0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

Microalbuminuria in Ischemic Stroke FREE

Nancy B. Beamer, MS; Bruce M. Coull, MD; Wayne M. Clark, MD; Mike Wynn, DO
[+] Author Affiliations

From the Departments of Neurology, Arizona Health Sciences Center, Tucson (Ms Beamer and Dr Coull), and Oregon Health Sciences University, Portland (Drs Clark and Wynn).


Arch Neurol. 1999;56(6):699-702. doi:10.1001/archneur.56.6.699.
Text Size: A A A
Published online

Objectives  To determine (1) the incidence of microalbuminuria in patients with recent ischemic stroke, (2) its relationship to risk factors for stroke, (3) its prevalence in the major subtypes of ischemic stroke, and (4) its potential for identifying patients at increased risk for recurrent stroke, myocardial infarction, or vascular death.

Design  Prospective case-control study.

Setting  Outpatient clinics at the medical centers affiliated with the Department of Veterans Affairs and Oregon Health Sciences University in Portland, Ore.

Patients  A total of 186 older men and women (median age, 65 years) who were enrolled in a prospective study of risk factors for recurrent stroke, including 97 patients with recent (6-8 weeks) ischemic stroke, 51 with similar clinical risk factors for stroke, including 24 with a history of remote stroke or transient ischemic attack, and 38 community-dwelling volunteers.

Results  Microalbuminuria was 3 times more prevalent in patients with recent stroke (29%) than in those with clinical risk factors for stroke (10%), and was undetectable in healthy elderly controls (P<.001). The presence of microalbuminuria in recent stroke as well as in the combined recent and remote stroke or transient ischemic attack group (n=121) was predicted by diabetes (odds ratio [OR], 8.4; 95% confidence interval [CI], 2.6-27.0; P<.001; serum albumin levels (OR, 0.12; 95% CI, 0.03-0.50; P<.005); age (OR, 1.1; 95% CI, 1.0-1.2; P<.01), and ischemic heart disease (OR, 3.0; 95% CI, 1.0-9.1; P.05). Among patients with recent stroke the prevalence of microalbuminuria did not differ among major ischemic stroke subtypes, ie, atheroembolic, 23%; cardioembolic, 30%; and lacunar, 33%. During a mean±SD of 1.5±0.9 years of follow-up, 20% of patients with recent stroke, 14% with risk factors for stroke, and 0% of healthy elderly volunteers had vascular end points (P<.004), with events being as frequent in patients with microalbuminuria (32%) as in patients with macroalbuminuria (33%). After controlling for major clinical risk factors, microalbuminuria remained an independently significant predictor of future stroke in the combined recent stroke and remote stroke or transient ischemic attack group (Cox proportional hazard ratio, 4.9; 95% CI, 1.4-17.6; P<.01).

Conclusions  Microalbuminuria is a common finding in patients with cerebrovascular disease and is associated with increased risk for stroke even after correction for the presence of confounding clinical risk factors. These data suggest that microalbuminuria merits further examination as a potentially inexpensive and easily measured marker of increased risk for stroke.

Figures in this Article

ALTHOUGH microalbuminuria is associated with clinical risk factors for stroke, including diabetes, hypertension, aging, history of myocardial infarction, and left ventricular hypertrophy, there is surprisingly little information regarding it as an independent risk factor for stroke or as a predictor of stroke outcome. A large prospective study1 has reported that microalbuminuria is a risk factor for stroke in men, and a limited case-control study2 found that the highest quintile of microalbuminuria values was associated with a 13-fold increased risk for stroke. Although microalbuminuria is more prevalent in diabetes and/or hypertension, 2 classic risk factors associated with intracranial arteriosclerosis, reduced microvascular perfusion, and lacunar infarcts, there is scant data regarding the incidence of microalbuminuria in lacunar stroke. More recently, a highly significant association between microalbuminuria and carotid artery intima-media thickness has been reported, a finding which suggests that microalbuminuria may be a a marker for early development of carotid artery atherosclerosis and points to a possible linkage between microalbuminuria and atherothrombotic stroke mechanism.3 With the introduction of more sensitive and relatively inexpensive dipstick methods, patients can now be readily screened for microalbuminuria, commonly defined as a urinary albumin concentration higher than 20 but not exceeding 200 mg/L.4 Our study was designed, therefore, to determine (1) the incidence of microalbuminuria in ischemic stroke, (2) its relationship to risk factors for stroke, (3) its prevalence in major subtypes of ischemic stroke, and (4) its potential use as a marker for stroke recurrence.

Patients with recent ischemic stroke (≤7 days), patients with multiple clinical risk factors for stroke such as hypertension, diabetes, and ischemic heart disease (IHD), and healthy elderly controls were recruited from the wards and clinics of the Portland Veterans Administration and Oregon Health Sciences University hospitals in Portland after giving informed consent according to institutional guidelines. Patients with a history of stroke and/or transient ischemic attack were eligible for the risk group provided they had experienced no cerebrovascular symptoms for at least 6 months prior to enrollment. Patients with urinary tract infection, chronic renal failure, malignancy, and vasculitis were excluded. A detailed description of additional exclusions, diagnostic criteria for risk factor assessment, and definition of vascular end points has been published.5 Vascular end points included recurrent stroke, myocardial infarction, and vascular death; transient ischemic attacks were noted but not counted as end points. Participants in all groups were examined at enrollment, 6 to 8 weeks, 6 months, 1 year, and once a year thereafter until termination of the study or the occurrence of a vascular event.

To minimize potentially confounding factors present at onset of stroke, urinary albumin levels in the recent stroke group were studied at the first outpatient clinic visit 6 to 8 weeks after the indexing infarction. Collection kits and instructions for obtaining first morning void urine samples on 2 consecutive days were mailed to patients prior to clinic. Urine samples were kept at 4°C for a maximum of 5 days for batch analysis by rate nephelometry at the Oregon Health Sciences University clinical laboratory (Beckman-Coulter Instruments, Fullerton, Calif). Duplicate determinations were performed on samples from each day and the results averaged. Normoalbuminuria was defined as a urinary albumin concentration 20 mg/L or lower, microalbuminuria as higher than 20 mg/L but lower than 200 mg/L, and macroalbuminuria as higher than 200 mg/L). Statistical analysis, including analysis of variance with Bonferroni post hoc correction or Kruskal-Wallis for evaluating intergroup differences, c2 or Fisher exact test for assessing differences in frequency distributions, as well as Kaplan-Meier survival curves, was performed with Stata software (Stata 5.0; Stata Corporation, College Station, Tex). Except when stated otherwise, summary statistics are expressed as the mean±SD.

As shown in Table 1, the recent stroke (n=97) and risk (n=51) groups had similar percentages of patients with hypertension, diabetes, IHD, and other classic risk factors for stroke, except for more current smokers in the recent stroke group (P<.003). More than half (54 [56%]) of the patients with recent stroke had experienced a lacunar infarction, followed by 22 (23%) with atheroembolic and 20 (21%) with cardioembolic mechanisms. Since nearly half (24 [47%]) of the patients in the risk group had a history of remote stroke or transient ischemic attack, they were combined with patients with recent stroke into a cerebrovascular disease (CVD) group (n=121) for additional analysis. The clinical characteristics of the combined CVD group (Table 1) did not differ significantly from those of the parent groups. The 38 healthy controls were age balanced (average age, 66±8 years) with the patients with recent stroke and risk factors, and the racial composition of all groups was predominantly white (97%).

Microalbuminuria was more prevalent in the stroke (29%) compared with the risk (10%) or healthy elderly groups (0%) (P<.001). An additional 10% of patients with recent stroke and 10% of patients with risk factors had macroalbuminuria. In the combined CVD group, 26% were microalbuminuric and 8% were macroalbuminuric. Diabetes and IHD, but not hypertension (Table 2) were twice as common in both the microalbuminuric and macroalbuminuric groups as in the normoalbuminuric group. Approximately 40% of patients with microalbuminuria and macroalbuminuria were insulin-dependent diabetics, but with the exception of insulin (P<.006), no relationship was observed between patterns of medication use and urinary albumin levels. Fasting blood glucose was elevated in both albuminuric subgroups, but glycosylated hemoglobin, although elevated, did not differ significantly by albumin status (glycosylated hemoglobin available for 69% of patients with normoalbuminuria, 58% with microalbuminuria, and 80% with macroalbuminuria). Neither glucose nor glycosylated hemoglobin levels correlated with absolute levels or urinary albumin (data not shown), nor did serum creatinine levels differ significantly among albumin subgroups. Finally, the prevalence of microalbuminuria did not differ among the 3 major subtypes of ischemic stroke, ie, atheroembolic mechanisms, 23%; cardioembolic mechanism, 30%; or lacunar infarction, 32%, even though patients with lacunar infarction had a higher incidence of diabetes, hypertension, or both (90%), than patients with cardioembolic (63%) or atheroembolic (72%) stroke mechanism (P<.03).

Table Graphic Jump LocationTable 2. Urinary Albumin Status in Combined CVD Group*

Both in the recent stroke and the combined CVD groups the presence of the same 4 risk factors independently predicted microalbuminuria: diabetes, serum albumin, age, and IHD. For the combined group the odd ratios for diabetes was 8.4 (95% confidence interval [CI], 2.6-27.0; P<.001); for albumin, 0.12 (95% CI, 0.03-0.50; P<.005); age, 1.1 (95% CI, 1.0-1.2; P<.01); and for IHD, 3.0 (95% CI, 1.0-9.1; P<.05). Although it was not an independent predictor, the degree of carotid stenosis detectable by ultrasonography performed on 76% of the combined CVD group was positively related (P<.04) to urinary albumin levels, ie, in patients with normoalbuminuria, microalbuminuria, or macroalbuminuria.

During 1.5±0.9 years of follow-up, 20% of the patients with recent stroke, 14% with risk factors for stroke, and 0% of the healthy elderly controls had new vascular end points (P<.004). As shown in Figure 1, vascular events were common among patients with recent stroke who had microalbuminuria (32%) and macroalbuminuria (33%), with both groups having 3 times more events than patients with normoalbuminuria (12%) (P<.04). After controlling for the presence of diabetes, hypertension, and smoking status, microalbuminuria was not an independent predictor of recurrent stroke (P<.06) in those with recent stroke. In the combined CVD group, however, microalbuminuria remained a significant marker for future stroke, after correction for the same 3 risk factors: hazard ratio (Cox proportional model), 4.9 (95% CI, 1.4-17.6; P<.01).The Kaplan-Meier plot (Figure 2) illustrates the reduced survival probability for patients with CVD plus microalbuminuria compared with their counterparts with normoalbuminuria (P<.03, Mantel-Haenszel). Notably, macroalbuminuria was not predictive for stroke in either group, since all vascular events in patients with macroalbuminuria consisted of myocardial infarction or death.

Place holder to copy figure label and caption
Figure 1.

Compared with patients with normoalbuminuria, both patients with microalbuminuria and macroalbuminuria with recent stroke had significantly more new vascular events (stroke, myocardial infarction, or vascular death) during the mean±SD of 1.5±0.9 years of follow-up.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Patients with cerebrovascular disease (either recent stroke or remote stroke or transient ischemic attack) with microalbuminuria had significantly lower probability of surviving free of a recurrent vascular event (those with macroalbuminuria excluded).

Graphic Jump Location

Although rare (0%-4%) in clinically healthy population-based samples, microalbuminuria may be present in up to one fourth of patients with cardiovascular risk factors, most notably those with diabetes, hypertension, coronary artery disease, and/or smoking habit.611 Consistent with this literature, microalbuminuria was not found in healthy elderly subjects but was present in 10% of those with risk factors for stroke. However, the high prevalence (29%) of microalbuminuria in patients with recent stroke compared with those with a similar risk profile (10%) is a new and unexpected finding. Although microalbuminuria is thought to be a marker for vascular endothelial damage due to the severity and/or duration of numerous pathophysiological insults, especially the injurious effects of poorly controlled diabetes and hypertension, this view fails to account for increased microalbuminuria in recent stroke.12 Specifically, the patients with recent stroke and those with risk factors for stroke did not differ with respect to the percentages of patients with hypertension or diabetes (Table 1), the proportion of insulin-dependent patients with diabetes (56% in each group), glycemic control (8.2±2.7 vs 7.3±2.0% glycosylated hemoglobin), or the duration of hypertension (11±12 vs 12±10 years). Although creatinine clearance was not assessed, serum creatinine levels did not differ significantly between the groups with recent stroke (1.3±0.6 mg/dL) and risk factors for stroke (1.1±0.2 mg/dL). As noted earlier, the group with recent stroke included more current smokers (34% vs 12%; P<.003) than the group with risk factors; although smoking status was not an independent predictor of urinary albumin levels in this study, current smoking may have contributed to the higher prevalence of microalbuminuria in recent stroke.13

Diabetes was clearly the clinical factor most closely related to microalbuminuria in both patients with recent stroke and the combined group with CVD; however, age and IHD were also significant, as has been reported.14 Yet even though microalbuminuria was significantly related to IHD, we could not confirm the relationship between microalbuminuria and left ventricular hypertrophy observed by others.1517 Serum albumin levels were also an independent (negative) predictor of microalbuminuria in the population with stroke, a finding which agrees with some studies18,19 showing increased transcapillary escape of albumin in patients with albuminuria. Moreover, the association between microalbuminuria and carotid stenosis in this article provides additional indirect support for the reported correlation between microalbuminuria and increased carotid artery intima-media thickness or carotid wall thickness in both patients with and without diabetes .3,16

Although direct comparison with earlier studies is difficult due to methodological differences, our data are in overall agreement with findings on 38 patients with mixed ischemic and hemorrhagic stroke, as well as with results of a large (n=2302) prospective study1 of first-ever stroke in Japan, which found that urinary albumin (dipstick method for macroalbuminuria) represented an increased risk for stroke (relative risk, 3.33; odds ratio, 1.38-8.02) in men but not women.1,2 Although we had speculated that microalbuminuria might be a marker for lacunar infarcts, given this group's higher combined incidence of diabetes and/or hypertension, the results of our study confirm an earlier report of no significant difference in the prevalence of microalbuminuria among different subtypes of stroke.

This study is, to our knowledge, the first to examine the relationship between urinary albumin levels and recurrent vascular events in patients with CVD. Patients with recent stroke with microalbuminuria were more likely to experience a recurrent stroke; yet, as noted earlier, after adjusting for diabetes, smoking, and hypertension, microalbuminuria was only weakly prognostic (P<.06). However, in patients with a history of recent or remote stroke or transient ischemic attack, microalbuminuria was an independent marker for future stroke (P<.01), even after correction for the above risk factors. Thus, although identification of markers for individuals at increased risk for stroke has been problematic, these data support the view that microalbuminuria merits further scrutiny as a potentially inexpensive and easily measured marker for heightened risk of stroke in patients who have CVD.

Accepted for publication August 8, 1998.

Corresponding author: Bruce M. Coull, MD, Department of Neurology, Arizona Health Sciences Center, 1501 N Campbell Ave, Tucson AZ 85724-5023 (e-mail: coullb@aruba.ccit.arizona.edu).

Nakayama  TDate  CYokoyama  TYoshiike  NYamaguchi  MTanaka  H A 15.5-year follow-up study of stroke in a Japanese provincial city: The Shibata Study. Stroke. 1997;2845- 52
Link to Article
Woo  JLau  EKay  R  et al.  A case control study of some hematological and biochemical variables in acute stroke and their prognostic value. Neuroepidemiology. 1990;9315- 320
Link to Article
Mykkanen  LZaccaro  DJO'Leary  DHHoward  GRobbins  DCHaffner  SM Microalbuminuria and carotid artery intima-media thickness in nondiabetic and NIDDM subjects: The Insulin Resistance Atherosclerosis Study (IRAS). Stroke. 1997;281710- 1716
Link to Article
Tiu  SCLee  SSCheng  MW Comparison of six commercial techniques in the measurement of microalbuminuria in diabetic patients. Diabetes Care. 1993;16616- 620
Link to Article
Beamer  NBCoull  BMClark  WMBriley  DPWynn  MSexton  G Persistent inflammatory response in stroke survivors. Neurology. 1998;501722- 1728
Link to Article
Metcalf  PABaker  JRScragg  RKRDryson  EScott  AJWild  CJ Microalbuminuria in a middle-aged workforce: effect of hyperglycemia and ethnicity. Diabetes Care. 1993;161485- 1493
Link to Article
Jensen  JSFeldt-Rasmussen  BBorch-Johnsen  KJensen  Gand the Copenhagen City Heart Study Group, Urinary albumin excretion in a population based sample of 1011 middle aged non-diabetic subjects. Scand J Clin Lab Invest. 1993;53867- 872
Link to Article
Jensen  JSBorch-Johnsen  KJensen  GFeldt-Rasmussen  B Atherosclerotic risk factors are increased in clinically healthy subjects with microalbuminuria. Atherosclerosis. 1995;112245- 252
Link to Article
Winocour  PHHarland  JOEMillar  JPLaker  MFAlberti  KGMM Microalbuminuria and associated cardiovascular risk factors in the community. Atherosclerosis. 1992;9371- 81
Link to Article
Chase  HPGarg  SKMarshall  G  et al.  Cigarette smoking increases the risk of albuminuria among subjects with type diabetes. JAMA. 1991;265614- 617
Link to Article
Janssen  WMTde Jong  PEde Zeeuw  D Hypertension and renal disease: role of microalbuminuria. Hypertension. 1996;14(suppl 5)S173- S177
Link to Article
Deckert  TFeldt-Rasmussen  BBorch-Johnsen  KJensen  TKofoed-Enevoldsen  A Albuminuria reflects widespread vascular damage: the Steno hyptothesis. Diabetologia. 1989;32219- 226
Link to Article
Gosling  PShearman  CPBeevers  DG Urinary albumin excretion in smokers and non-smokers. Contrib Nephrol. 1990;83151- 155
Yudkin  JSForrest  RDJackson  CA Microalbuminuria as predictor of vascular disease in non-diabetic subjects. Lancet. 1988;2530- 533
Link to Article
Pedrinelli  RDi Bello  VCatapano  G  et al.  Microalbuminuria is a marker of left ventricular hypertrophy but not hyperinsulinemia in nondiabetic atherosclerotic patients. Arterioscler Thromb. 1993;13900- 906
Link to Article
Pontremolli  RViazzi  FSofia  A  et al.  Microalbuminuria: a marker of cardiovascular risk and organ damage in essential hypertension. Kidney Int. l998;52(suppl 63)S163- S165
Tomiyama  HDoba  NKushiro  T  et al.  The relationship of hyperinsulinemic state to left ventricular hypertrophy, microalbuminuria, and physical fitness in borderline and mild hypertension. Am J Hypertens. 1997;10587- 591
Link to Article
Jensen  EWEspersen  KKnudsen  JHNielsen  SL Increased transcapillary escape rate of albumin in elderly subjects due to long-term smoking habits. Clin Physiol. 1995;15159- 167
Link to Article
Jensen  JSBorch-Johnsen  KJensen  GFeldt-Rasmussen  B Microalbuminuria reflects a generalized transvascular albumin leakiness in clinically healthy subjects. Clin Sci. 1995;88629- 633

Figures

Place holder to copy figure label and caption
Figure 1.

Compared with patients with normoalbuminuria, both patients with microalbuminuria and macroalbuminuria with recent stroke had significantly more new vascular events (stroke, myocardial infarction, or vascular death) during the mean±SD of 1.5±0.9 years of follow-up.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Patients with cerebrovascular disease (either recent stroke or remote stroke or transient ischemic attack) with microalbuminuria had significantly lower probability of surviving free of a recurrent vascular event (those with macroalbuminuria excluded).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Urinary Albumin Status in Combined CVD Group*

References

Nakayama  TDate  CYokoyama  TYoshiike  NYamaguchi  MTanaka  H A 15.5-year follow-up study of stroke in a Japanese provincial city: The Shibata Study. Stroke. 1997;2845- 52
Link to Article
Woo  JLau  EKay  R  et al.  A case control study of some hematological and biochemical variables in acute stroke and their prognostic value. Neuroepidemiology. 1990;9315- 320
Link to Article
Mykkanen  LZaccaro  DJO'Leary  DHHoward  GRobbins  DCHaffner  SM Microalbuminuria and carotid artery intima-media thickness in nondiabetic and NIDDM subjects: The Insulin Resistance Atherosclerosis Study (IRAS). Stroke. 1997;281710- 1716
Link to Article
Tiu  SCLee  SSCheng  MW Comparison of six commercial techniques in the measurement of microalbuminuria in diabetic patients. Diabetes Care. 1993;16616- 620
Link to Article
Beamer  NBCoull  BMClark  WMBriley  DPWynn  MSexton  G Persistent inflammatory response in stroke survivors. Neurology. 1998;501722- 1728
Link to Article
Metcalf  PABaker  JRScragg  RKRDryson  EScott  AJWild  CJ Microalbuminuria in a middle-aged workforce: effect of hyperglycemia and ethnicity. Diabetes Care. 1993;161485- 1493
Link to Article
Jensen  JSFeldt-Rasmussen  BBorch-Johnsen  KJensen  Gand the Copenhagen City Heart Study Group, Urinary albumin excretion in a population based sample of 1011 middle aged non-diabetic subjects. Scand J Clin Lab Invest. 1993;53867- 872
Link to Article
Jensen  JSBorch-Johnsen  KJensen  GFeldt-Rasmussen  B Atherosclerotic risk factors are increased in clinically healthy subjects with microalbuminuria. Atherosclerosis. 1995;112245- 252
Link to Article
Winocour  PHHarland  JOEMillar  JPLaker  MFAlberti  KGMM Microalbuminuria and associated cardiovascular risk factors in the community. Atherosclerosis. 1992;9371- 81
Link to Article
Chase  HPGarg  SKMarshall  G  et al.  Cigarette smoking increases the risk of albuminuria among subjects with type diabetes. JAMA. 1991;265614- 617
Link to Article
Janssen  WMTde Jong  PEde Zeeuw  D Hypertension and renal disease: role of microalbuminuria. Hypertension. 1996;14(suppl 5)S173- S177
Link to Article
Deckert  TFeldt-Rasmussen  BBorch-Johnsen  KJensen  TKofoed-Enevoldsen  A Albuminuria reflects widespread vascular damage: the Steno hyptothesis. Diabetologia. 1989;32219- 226
Link to Article
Gosling  PShearman  CPBeevers  DG Urinary albumin excretion in smokers and non-smokers. Contrib Nephrol. 1990;83151- 155
Yudkin  JSForrest  RDJackson  CA Microalbuminuria as predictor of vascular disease in non-diabetic subjects. Lancet. 1988;2530- 533
Link to Article
Pedrinelli  RDi Bello  VCatapano  G  et al.  Microalbuminuria is a marker of left ventricular hypertrophy but not hyperinsulinemia in nondiabetic atherosclerotic patients. Arterioscler Thromb. 1993;13900- 906
Link to Article
Pontremolli  RViazzi  FSofia  A  et al.  Microalbuminuria: a marker of cardiovascular risk and organ damage in essential hypertension. Kidney Int. l998;52(suppl 63)S163- S165
Tomiyama  HDoba  NKushiro  T  et al.  The relationship of hyperinsulinemic state to left ventricular hypertrophy, microalbuminuria, and physical fitness in borderline and mild hypertension. Am J Hypertens. 1997;10587- 591
Link to Article
Jensen  EWEspersen  KKnudsen  JHNielsen  SL Increased transcapillary escape rate of albumin in elderly subjects due to long-term smoking habits. Clin Physiol. 1995;15159- 167
Link to Article
Jensen  JSBorch-Johnsen  KJensen  GFeldt-Rasmussen  B Microalbuminuria reflects a generalized transvascular albumin leakiness in clinically healthy subjects. Clin Sci. 1995;88629- 633

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 43

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Table 9.2-3 Refuted Evidence From Observational Studiesa

The Rational Clinical Examination
Quick Reference