Возможности применения пероральной антикоагулянтной терапии у пациентов с фибрилляцией предсердий и хронической анемией: нарративный обзор

Дегтярева Т.С., Переверзева К.Г., Якушин С.С., Перегудова Н.Н. Возможности применения пероральной антикоагулянтной терапии у пациентов с фибрилляцией предсердий и хронической анемией // CardioСоматика. 2024. Т. 15, № 4. С. 365–374. DOI: https://doi.org/10.17816/CS635908

________________________________________________

Degtyareva TS, Pereverzeva KG, Yakushin SS, Peregudova NN. Prospects of oral anticoagulant therapy in patients with atrial fibrillation and chronic anemia: a narrative review. CardioSomatics. 2024;15(4):365–374. DOI: https://doi.org/10.17816/CS635908

Читать PDF

Аннотация

Назначение антикоагулянтной терапии при фибрилляции предсердий (ФП) играет важную роль в предотвращении тромбоэмболических осложнений. В обзорной статье рассматриваются вопросы назначения антикоагулянтной терапии пациентам с ФП в сочетании с хронической анемией различной степени тяжести. На основании анализа полнотекстовых литературных источников, затрагивающих тему антикоагулянтной терапии у пациентов с ФП и анемией и опубликованных в электронных библиотеках PubMed и eLibrary.ru за период 2010–2023 гг., авторы делают вывод о том, что целесообразность назначения оральных антикоагулянтов пациентам с ФП и хронической анемией лёгкой степени (Нb >90 г/л), а в отдельных работах и у пациентов с анемией средней степени тяжести с уровнем гемоглобина Нb >80 г/л подтверждена. У пациентов с ФП и анемией средней степени тяжести, особенно при уровне Нb=71–80 г/л, требуется индивидуальный подход к назначению оральных антикоагулянтов, так как в этой подгруппе пациентов польза от их назначения неочевидна, а риски геморрагических осложнений высоки. Тяжёлая анемия — противопоказание к приёму оральных антикоагулянтов у пациентов с ФП.

Ключевые слова: анемия, фибрилляция предсердий, пероральная антикоагулянтная терапия, апиксабан, дабигатран этексилат, ривароксабан, эдоксабан, оральные антикоагулянты

________________________________________________

Anticoagulant therapy for atrial fibrillation (AF) plays an important role in preventing thromboembolic events. This review discusses anticoagulant therapy in patients with AF and chronic anemia of varying severity. The search was carried out in PubMed and Library electronic databases from 2010 to 2023. Based on the analysis of full text literature, the authors concluded that currently oral anticoagulants in patients with AF and mild chronic anemia (Hb >90 g/L) and, according to some studies, in patients with moderate anemia (Hb >80 g/L) are considered reasonable. Patients with AF and moderate anemia (Hb 71–80 g/L) require an individualized approach to therapy with oral anticoagulants, since its benefit is not obvious in this subgroup, and the risk of hemorrhagic complications is high. Currently, severe anemia is a contraindication to oral anticoagulants in patients with AF.

Keywords: anemia, atrial fibrillation, oral anticoagulant therapy, apixaban, dabigatran etexilate, rivaroxaban, edoxaban, oral anticoagulants

Полный текст

Материалы доступны только для специалистов сферы здравоохранения. Авторизуйтесь или зарегистрируйтесь.

Список литературы

1. McLean E., Cogswell M., Egli I., et al. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005 // Public Health Nutrition. 2009. Vol. 12, N 4. P. 444–454. doi: 10.1017/S1368980008002401
2. Patel K.V. Epidemiology of anemia in older adults // Semin Hematol. 2008. Vol. 45, N 4. P. 210–217. doi: 10.1053/j.seminhematol.2008.06.006
3. Zhang Z., Jiang C., He L., et al. Associations of anemia with death and major bleeding in patients with atrial fibrillation: A report from the Chinese Atrial Fibrillation Registry Study // Clin Cardiol. 2022. Vol. 45, N 1. P. 91–100. doi: 10.1002/clc.23764
4. Андреичев Н.А., Балеева Л.В. Анемия хронических заболеваний // Российский медицинский журнал. 2014. № 2. С. 50–55. EDN: SCFEDH
5. Чеснокова Н.П., Невважай Т.А., Бизенкова М.Н. Моррисон В.В. Лекция 3. Дизэритропоэтические анемии. Классификация. Этиология и патогенез железодефицитной анемии // Международный журнал прикладных и фундаментальных исследований. 2015. Т. 6, № 1. С. 155–159. EDN: TTJCUZ
6. Hu W.S., Sung F.C., Lin C.L. Aplastic Anemia and Risk of Incident Atrial Fibrillation - A Nationwide Cohort Study // Circ J. 2018. Vol. 82, N 5. P. 1279–1285. doi: 10.1253/circj.CJ-17-0519
7. Kline J.A., Jimenez D., Courtney D.M., et al. Comparison of Four Bleeding Risk Scores to Identify Rivaroxaban-treated Patients with Venous Thromboembolism at Low Risk for Major Bleeding // Acad Emerg Med. 2016. Vol. 23, N 2. P. 144–150. doi: 10.1111/acem.12865
8. Westenbrink B.D., Alings M., Granger C.B., et al. Anemia is associated with bleeding and mortality, but notstroke, in patients with atrial fibrillation: Insights from the Apixaban for Reduction in Stroke and OtherThromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial // Am Heart J. 2017. Vol. 185. P. 140–149. doi: 10.1016/j.ahj.2016.12.008
9. Lee W.H., Hsu P.C., Chu C.Y., et al. Anemia as an Independent Predictor of Adverse Cardiac Outcomes in Patients with Atrial Fibrillation // Int J Med Sci. 2015. Vol. 12, N 8. P. 618–624. doi: 10.7150/ijms.11924
10. Tu S.J., Hanna-Rivero N., Elliott A.D., et al. Associations of anemia with stroke, bleeding, and mortality in atrial fibrillation: A systematic review and meta-analysis // J Cardiovasc Electrophysiol. 2021. Vol. 32, N 3. P. 686–694. doi: 10.1111/jce.14898
11. Keskin M., Ural D., Altay S., et al. Iron deficiency and hematinic deficiencies in atrial fibrillation: A new insight into comorbidities // Turk Kardiyol Dern Ars. 2018. Vol. 46, N 2. P. 103–110. doi: 10.5543/tkda.2018.51001
12. Sharma S., Gage B.F., Deych E., Rich M.W. Anemia: an independent predictor of death and hospitalizations among elderly patients with atrial fibrillation // Am Heart J. 2009. Vol. 157, N 6. P. 1057–63. doi: 10.1016/j.ahj.2009.03.009
13. Полякова О.А., Дубинина А.В., Телкова С.С., и др. Фибрилляция предсердий и анемия: что нам известно и как подходить к терапии? // Фарматека. 2023. Т. 30, № 1–2. С. 84–93. EDN: GEVZVW doi: 10.18565/pharmateca.2023.1-2.84-93
14. Лукьянов М.М., Андреенко Е.Ю., Марцевич С.Ю., и др. Больные с фибрилляцией предсердий в клинической практике: коморбидность, медикаментозное лечение и исходы (данные регистров РЕКВАЗА) // Рациональная Фармакотерапия в Кардиологии. 2020. Т. 16, № 6. С. 888–898. EDN: FHUNAV doi: 10.20996/1819-6446-2020-12-01
15. Westenbrink B.D., Alings M., Connolly S.J., et al. Anemia predicts thromboembolic events, bleeding complications and mortality in patients with atrial fibrillation: insights from the RE-LY trial // J Thromb Haemost. 2015. Vol. 13, N 5. P. 699–707. doi: 10.1111/jth.12874
16. Yeh Y.H., Chan Y.H., Chen S.W., et al. Oral anticoagulant use for patients with atrial fibrillation with concomitant anemia and/or thrombocytopenia // Am J Med. 2022. Vol. 135, N 8. P. e248–e256. doi: 10.1016/j.amjmed.2022.03.011
17. Bonde A.N., Blanche P., Staerk L., et al. Oral anticoagulation among atrial fibrillation patients with anaemia: an observational cohort study // Eur Heart J. 2019. Vol. 40, N 46. P. 3782–3790. doi: 10.1093/eurheartj/ehz155
18. Kodani E., Inoue H., Atarashi H., et al. J-RHYTHM Registry Investigators. Impact of hemoglobin concentration and platelet count on outcomes of patients with non-valvular atrial fibrillation: A subanalysis of the J-RHYTHM Registry // Int J Cardiol. 2020. Vol. 302. P. 81–87. doi: 10.1016/j.ijcard.2019.11.127
19. Park J., Cha M.J., Choi Y.J., et al. Prognostic efficacy of platelet count in patients with nonvalvular atrial fibrillation // Heart Rhythm. 2019. Vol. 16, N 2. P. 197–203. doi: 10.1016/j.hrthm.2018.08.023
20. Connolly S.J., Ezekowitz M.D., Yusuf S., et al. Dabigatran versus warfarin in patients with atrial fibrillation // N Engl J Med. 2009. Vol. 361, N 12. P. 1139–1151. doi: 10.1056/NEJMoa0905561
21. Giugliano R.P., Ruff C.T., Braunwald E., et al. Edoxaban versus warfarin in patients with atrial fibrillation // N Engl J Med. 2013. Vol. 369, N 22. P. 2093–2104. doi: 10.1056/NEJMoa1310907
22. Patel M.R., Mahaffey K.W., Garg J., et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation // N Engl J Med. 2011. Vol. 365, N 10. P. 883–91. doi: 10.1056/NEJMoa1009638
23. Granger C.B., Alexander J.H., McMurray J.J., et al. Apixaban versus warfarin in patients with atrial fibrillation // N Engl J Med. 2011. Vol. 365, N 11. P. 981–992. doi: 10.1056/NEJMoa1107039
24. Eikelboom J.W., O'Donnell M., Yusuf S., et al. Rationale and design of AVERROES: apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment // Am Heart J. 2010. Vol. 159, N 3. P. 348–353.e1. doi: 10.1016/j.ahj.2009.08.026
25. Yabeyu A.B., Mohammed S.Y., Legesse E.S., et al. The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting // Biomed Res Int. 2023. Vol. 2023. P. 6673397. doi: 10.1155/2023/6673397
26. Баранова Е.И., Ионин В.А., Близнюк О.И., и др. Причины отказа от назначения антикоагулянтов в стационаре больным с фибрилляцией предсердий и высоким риском инсульта: какой должна быть оптимальная тактика ведения этих пациентов? // Ученые записки СПбГМУ им. акад. И. П. Павлова. 2022. Т. 29, № 2. С. 58–67. EDN: PERWRG doi: 10.24884/1607-4181-2022-29-2-58-67
27. Hindricks G., Potpara T., Dagres N., et al. Рекомендации ESC 2020 по диагностике и лечению пациентов с фибрилляцией предсердий, разработанные совместно с европейской ассоциацией кардиоторакальной хирургии (EACTS) // Российский кардиологический журнал. 2021. Т. 26. № 9. С. 234–329. doi: 10.15829/1560-4071-2021-4701
28. Pandya E.Y., Anderson E., Chow C., et al. Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting // Ther Adv Drug Saf. 2018. Vol. 9, N 2. P. 97–111. doi: 10.1177/2042098617744926
29. Bonde A.N., Blanche P., Staerk L., et al. Oral anticoagulation among atrial fibrillation patients with anaemia: an observational cohort study // Eur Heart J. 2019. Vol. 40, N 46. P. 3782–3790. doi: 10.1093/eurheartj/ehz155
30. Krarup L.H., Boysen G., Janjua H., et al. Validity of stroke diagnoses in a National Register of Patients // Neuroepidemiology. 2007. Vol. 28, N 3. P. 150–154. doi: 10.1159/000102143
31. Al-Hussainy N., Kragholm K.H., Lundbye-Christensen S., et al. Safety and efficacy of direct oralanticoagulants in patients with anaemia and atrial fibrillation: an observational nationwide Danish cohort study // Eur Heart J Qual Care Clin Outcomes. 2022. Vol. 8, N 8. P. 840–851. doi: 10.1093/ehjqcco/qcab095
32. Xu W., Chen J., Wu S., et al. Safety and efficacy of direct oral anticoagulants in stroke prevention in patients with atrial fibrillation complicated with anemia and/or thrombocytopenia: a retrospective cohort study // Thromb J. 2023. Vol. 21, N 1. P. 118. doi: 10.1186/s12959-023-00563-7
33. Чашкина М.И., Андреев Д.А., Козловская Н.Л., и др. Показатели безопасности ривароксабана по сравнению с варфарином у пациентов с фибрилляцией предсердий и хронической болезнью почек поздних стадий // Кардиология. 2020. Т. 60, № 11. С. 94–100. EDN: XXRRNI doi: 10.18087/cardio.2020.11.n1322
34. Tanaka N., Inoue K., Okada M., et al. Impact of anemia on the clinical outcomes in elderly patients with atrial fibrillation receiving apixaban: J-ELD AF registry subanalysis // Int J Cardiol Heart Vasc. 2022. Vol. 40. P. 100994. doi: 10.1016/j.ijcha.2022.100994
35. Suzuki S., Yamashita T., Otsuka T., et al. Identifying risk patterns in older adults with atrial fibrillation by hierarchical cluster analysis: A retrospective approach based on the risk probability for clinical events // Int J Cardiol Heart Vasc. 2021. Vol. 37. P. 100883. doi: 10.1016/j.ijcha.2021.100883
36. Wang C.L., Wu V.C., Huang Y.T., et al. Safety and Effectiveness of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation and Anemia: A Retrospective Cohort Study // J Am Heart Assoc. 2019. Vol. 8, N 9. P. e012029. doi: 10.1161/JAHA.119.012029
37. Apostolou C., Klonizakis P., Mainou M., et al. Rivaroxaban Use in Patients with Hemoglobinopathies // Hemoglobin. 2017. Vol. 41, N 3. P. 223–224. doi: 10.1080/03630269.2017.1374969

________________________________________________

1. McLean E, Cogswell M, Egli I, et al. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005. Public Health Nutrition. 2009;12(4):444–454. doi: 10.1017/S1368980008002401
2. Patel KV. Epidemiology of anemia in older adults. Semin Hematol. 2008;45(4):210–217. doi: 10.1053/j.seminhematol.2008.06.006
3. Zhang Z, Jiang C, He L, et al. Associations of anemia with death and major bleeding in patients with atrial fibrillation: A report from the Chinese Atrial Fibrillation Registry Study. Clin Cardiol. 2022;45(1):91–100. doi: 10.1002/clc.23764
4. Andreitchev NA, Baleyeva LV. Anemia of chronic diseases. Russian Medicine. 2014;(2):50–55. EDN: SCFEDH
5. Chesnokova NP, Nevvazhay TA, Bizenkova MN, Morrison VV. Lecture 3. Dyserythropoietic anemia. Classifi cation. Etiology and pathogenesis of iron defi ciency anemia. Mezhdunarodnyy zhurnal prikladnykh i fundamentalnykh issledovaniy. 2015;(6-1):155–159. EDN: TTJCUZ
6. Hu WS, Sung FC, Lin CL. Aplastic Anemia and Risk of Incident Atrial Fibrillation - A Nationwide Cohort Study. Circ J. 2018;82(5):1279–1285. doi: 10.1253/circj.CJ-17-0519
7. Kline JA, Jimenez D, Courtney DM, et al. Comparison of Four Bleeding Risk Scores to Identify Rivaroxaban-treated Patients with Venous Thromboembolism at Low Risk for Major Bleeding. Acad Emerg Med. 2016;23(2):144–150. doi: 10.1111/acem.12865
8. Westenbrink BD, Alings M, Granger CB, et al. Anemia is associated with bleeding and mortality, but notstroke, in patients with atrial fibrillation: Insights from the Apixaban for Reduction in Stroke and OtherThromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J. 2017;185:140–149. doi: 10.1016/j.ahj.2016.12.008
9. Lee WH, Hsu PC, Chu CY, et al. Anemia as an Independent Predictor of Adverse Cardiac Outcomes in Patients with Atrial Fibrillation. Int J Med Sci. 2015;12(8):618–24. doi: 10.7150/ijms.11924
10. Tu SJ, Hanna-Rivero N, Elliott AD, et al. Associations of anemia with stroke, bleeding, and mortality in atrial fibrillation: A systematic review and meta-analysis. J Cardiovasc Electrophysiol. 2021;32(3):686–694. doi: 10.1111/jce.14898
11. Keskin M, Ural D, Altay S, et al. Iron deficiency and hematinic deficiencies in atrial fibrillation: A new insight into comorbidities. Turk Kardiyol Dern. Ars. 2018;46(2):103–110. doi: 10.5543/tkda.2018.51001
12. Sharma S, Gage BF, Deych E, Rich MW. Anemia: an independent predictor of death and hospitalizations among elderly patients with atrial fibrillation. Am Heart J. 2009;157(6):1057–1063. doi: 10.1016/j.ahj.2009.03.009
13. Polyakova OA, Dubinina AV, Telkova SS, et. al. Atrial fibrillation and anemia: what do we know and how to approach therapy? Farmateka. 2023;30(1–2):84–93. EDN: GEVZVW doi: 10.18565/pharmateca.2023.1-2.84-93
14. Loukianov MM, Andreenko EYu, Martsevich SYu, et al. Patients with Atrial Fibrillation in Clinical Practice: Comorbidity, Drug Treatment and Outcomes (Data from RECVASA Registries). Rational Pharmacotherapy in Cardiology. 2020;16(6):888–898. EDN: FHUNAV doi: 10.20996/1819-6446-2020-12-01
15. Westenbrink BD, Alings M, Connolly SJ, et al. Anemia predicts thromboembolic events, bleeding complications and mortality in patients with atrial fibrillation: insights from the RE-LY trial. J Thromb Haemost. 2015;13(5):699–707. doi: 10.1111/jth.12874
16. Yeh YH, Chan YH, Chen SW, et al. Oral anticoagulant use for patients with atrial fibrillation with concomitant anemia and/or thrombocytopenia. Am J Med. 2022;135(8):e248–e256. doi: 10.1016/j.amjmed.2022.03.011
17. Bonde AN, Blanche P, Staerk L, et al. Oral anticoagulation among atrial fibrillation patients with anaemia: an observational cohort study. Eur Heart J. 2019;40(46):3782–3790. doi: 10.1093/eurheartj/ehz155
18. Kodani E, Inoue H, Atarashi H, et al. J-RHYTHM Registry Investigators. Impact of hemoglobin concentration and platelet count on outcomes of patients with non-valvular atrial fibrillation: A subanalysis of the J-RHYTHM Registry. Int J Cardiol. 2020;302:81–87. doi: 10.1016/j.ijcard.2019.11.127
19. Park J, Cha MJ, Choi YJ, et al. Prognostic efficacy of platelet count in patients with nonvalvular atrial fibrillation. Heart Rhythm. 2019;16(2):197–203. doi: 10.1016/j.hrthm.2018.08.023
20. Connolly SJ, Ezekowitz MD, Yusuf S, et al Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–1151. doi: 10.1056/NEJMoa0905561
21. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369(22):2093–2104. doi: 10.1056/NEJMoa1310907
22. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–891. doi: 10.1056/NEJMoa1009638
23. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–992. doi: 10.1056/NEJMoa1107039
24. Eikelboom JW, O'Donnell M, Yusuf S, et al. Rationale and design of AVERROES: apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment. Am Heart J. 2010;159(3):348–353.e1. doi: 10.1016/j.ahj.2009.08.026
25. Yabeyu AB, Mohammed SY, Legesse ES, et al. The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting. Biomed Res Int. 2023;2023:6673397. doi: 10.1155/2023/6673397
26. Baranova EI, Ionin VA, Bliznyuk OI, et al. Reasons for not prescribing anticoagulants in hospitalized patients with atrial fibrillation and high risk of stroke: what should be the optimal management tactics for these patients? The Scientific Notes of Pavlov University. 2022;29(2):58–67. EDN: PERWRG doi: 10.24884/1607-4181-2022-29-2-58-67
27. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Russian Journal of Cardiology. 2021;26(9):4701. doi: 10.15829/1560-4071-2021-4701
28. Pandya EY, Anderson E, Chow C, et al. Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting. Ther Adv Drug Saf. 2018;9(2):97–111. doi: 10.1177/2042098617744926
29. Bonde AN, Blanche P, Staerk L, et al. Oral anticoagulation among atrial fibrillation patients with anaemia: an observational cohort study. Eur Heart J. 2019;40(46):3782–3790. doi: 10.1093/eurheartj/ehz155
30. Krarup LH, Boysen G, Janjua H, et al. Validity of stroke diagnoses in a National Register of Patients. Neuroepidemiology. 2007;28(3):150–154. doi: 10.1159/000102143
31. Al-Hussainy N, Kragholm KH, Lundbye-Christensen S, et al. Safety and efficacy of direct oralanticoagulants in patients with anaemia and atrial fibrillation: an observational nationwide Danish cohort study. Eur Heart J Qual Care Clin Outcomes. 2022;8(8):840–851. doi: 10.1093/ehjqcco/qcab095
32. Xu W, Chen J, Wu S., et al. Safety and efficacy of direct oral anticoagulants in stroke prevention in patients with atrial fibrillation complicated with anemia and/or thrombocytopenia: a retrospective cohort study. Thromb J. 2023;21(1):118. doi: 10.1186/s12959-023-00563-7
33. Chashkina MI, Andreev DA, Kozlovskaya NL, et al. Safety performance of rivaroxaban versus warfarin in patients with atrial fibrillation and advanced chronic kidney disease. Kardiologiia. 2020;60(11):94–100. EDN: XXRRNI doi: 10.18087/cardio.2020.11.n1322
34. Tanaka N, Inoue K, Okada M., et al. Impact of anemia on the clinical outcomes in elderly patients with atrial fibrillation receiving apixaban: J-ELD AF registry subanalysis. Int J Cardiol Heart Vasc. 2022;40:100994. doi: 10.1016/j.ijcha.2022.100994
35. Suzuki S, Yamashita T, Otsuka T, et al. Identifying risk patterns in older adults with atrial fibrillation by hierarchical cluster analysis: A retrospective approach based on the risk probability for clinical events. Int J Cardiol Heart Vasc. 2021;37:100883. doi: 10.1016/j.ijcha.2021.100883
36. Wang CL, Wu VC, Huang YT, et al. Safety and Effectiveness of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation and Anemia: A Retrospective Cohort Study. J Am Heart Assoc. 2019;8(9):e012029. doi: 10.1161/JAHA.119.012029
37. Apostolou C, Klonizakis P, Mainou M, et al. Rivaroxaban Use in Patients with Hemoglobinopathies. Hemoglobin. 2017;41(3):223–224. doi: 10.1080/03630269.2017.1374969

Авторы

Т.С. Дегтярева, К.Г. Переверзева*, С.С. Якушин, Н.Н. Перегудова

Рязанский государственный медицинский университет им. акад. И.П. Павлова, Рязань, Россия
*pereverzevakg@gmail.com

________________________________________________

Tatyana S. Degtyareva, Kristina G. Pereverzeva*, Sergey S. Yakushin, Natalia N. Peregudova

Ryazan State Medical University, Ryazan, Russia
*pereverzevakg@gmail.com

Назад к списку

Цель портала OmniDoctor – предоставление профессиональной информации врачам, провизорам и фармацевтам.