Warning signs and symptoms of heart disease: MedlinePlus Medical Encyclopedia

Heart disease often develops over time. You may have early signs or symptoms long before you have serious heart problems. Or, you may not realize you are developing heart disease. The warning signs of heart disease may not be obvious. Also, not every person has the same symptoms.

Certain symptoms, such as chest pain, ankle swelling, and shortness of breath may be signals that something is wrong. Learning the warning signs can help you get treatment and help prevent a heart attack or stroke.

Chest pain is discomfort or pain that you feel along the front of your body, between (and including) your neck and upper abdomen. There are many causes of chest pain that have nothing to do with your heart.

But chest pain is still the most common symptom of poor blood flow to the heart or a heart attack. This type of chest pain is called angina.

Chest pain can occur when the heart is not getting enough blood or oxygen. The amount and type of pain can vary from person to person. The intensity of the pain does not always relate to how severe the heart problem is.

• Some people may feel a crushing pain, while others feel only mild discomfort.
• Your chest may feel heavy or like someone is squeezing your chest or heart. You may also feel a sharp, burning pain in your chest.
• You may feel the pain under your breastbone (sternum, so the pain is called substernal) or in your neck, arms, stomach, jaw, or upper back.
• Chest pain from angina often occurs with activity or emotion, and goes away with rest or a medicine called nitroglycerin.
• Bad indigestion can also cause chest pain.

Women, older adults, and people with diabetes may have little or no chest pain. Some people have symptoms other than chest pain, such as:

• Fatigue
• Shortness of breath
• General weakness
• Change in skin color or greyish pallor (episodes of change in skin color associated with weakness)

Other symptoms of a heart attack can include:

• Extreme anxiety
• Fainting or loss of consciousness
• Lightheadedness or dizziness
• Nausea or vomiting
• Palpitations (feeling like your heart is beating too fast, too strongly, or irregularly)
• Shortness of breath
• Sweating, which may be very heavy

When the heart can’t pump blood as well as it should, blood backs up in the veins that go from the lungs to the heart. Fluid leaks into the lungs and causes shortness of breath. This is a symptom of heart failure.

You may notice shortness of breath:

• During activity
• While you’re resting
• When you’re lying flat on your back — it may even wake you from sleep

Coughing or wheezing that doesn’t go away can be another sign that fluid is building up in your lungs. You may also cough up mucus that is pink or bloody.

Swelling (edema) in your lower legs is another sign of a heart problem. When your heart doesn’t work as well, blood flow slows and backs up in the veins in your legs. This causes fluid to build up in your tissues.

You may also have swelling in your stomach or notice some weight gain.

Narrowing of the blood vessels that bring blood to other parts of the body is not the same as heart disease but it may mean you have a much higher risk for heart attack than you otherwise would. It can occur when cholesterol and other fatty material (plaque) build up on the walls of your arteries.

Poor blood supply to the legs may lead to:

• Pain, achiness, fatigue, burning, or discomfort in the muscles of your feet, calves, or thighs.
• Symptoms that often appear during walking or exercise, and go away after several minutes of rest.
• Numbness in your legs or feet when you are at rest. Your legs may also feel cool to the touch, and the skin may look pale.

A stroke occurs when blood flow to a part of the brain stops. A stroke is sometimes called a “brain attack.” Symptoms of stroke can include difficulty moving the limbs on one side of your body, one side of the face drooping, loss of sensation on one side of your body, difficulty with speaking or understanding language.

Tiredness can have many causes. Sometimes it simply means that you need more rest. But feeling run down can be a sign of a more serious problem. Fatigue may be a sign of heart trouble when:

• You feel much more tired than normal. It’s common for women to feel severely tired before or during a heart attack.
• You feel so tired that you can’t do your normal daily activities.
• You have sudden, severe weakness.

If your heart can’t pump blood as well, it may beat faster to try to keep up. You may feel your heart racing or throbbing. A fast or uneven heartbeat can also be the sign of an arrhythmia. This is a problem with your heart rate or rhythm.

If you have any signs of heart disease, call your health care provider right away. Don’t wait to see if the symptoms go away or dismiss them as nothing.

Call 911 or the local emergency number if:

• You have chest pain or other symptoms of a heart attack
• You know you have angina and have chest pain that doesn’t go away after 5 minutes of rest or after taking nitroglycerin
• You think you may be having a heart attack
• You become extremely short of breath
• You think you may have lost consciousness

Angina – heart disease warning signs; Chest pain – heart disease warning signs; Dyspnea – heart disease warning signs; Edema – heart disease warning signs; Palpitations – heart disease warning signs

Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S49-S73. PMID: 24222018 pubmed.ncbi.nlm.nih.gov/24222018/.

Gulati M, Bairey Merz CN. Cardiovascular disease in women. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 91.

Morrow DA, de Lemos J. Stable ischemic heart disease. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 40.

Writing Committee Members; Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. J Am Coll Cardiol. 2022,79 (2):e21–e129. PMID: 34895950 pubmed. ncbi.nlm.nih.gov/34895950/.

Updated by: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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What is your swollen leg telling you?

If you’re over 60 and your legs are painful and swollen, chances are it’s not related to a heart condition. A more likely explanation is that it’s linked to reduced blood flow through the veins in your legs, said an HonorHealth interventional cardiologist.

“Essentially the right side of the heart fails because that side isn’t built to withstand high blood pressures,” said Dr. Bhakta. “The pressures in the lung can climb so high that the right side of the heart can no longer push blood through the lungs’ circulatory system.”

Other heart problems that can be related to leg swelling include:

• Atrial and ventricular septal defects — holes in the heart that are typically diagnosed at birth
• Certain abnormal heart rhythms
• Issues with heart valves
• Left heart failure: Swollen ankles and legs can be a symptom

Is this an emergency?

Chronic swelling in the legs as a symptom by itself isn’t typically a medical emergency. “Call and make an appointment with your primary care physician or cardiologist,” said Dr. Bhakta. The biggest concern with vein-related leg swelling is that the signs could also be connected to pulmonary hypertension.

The first thing your primary care physician or cardiologist likely will do is perform an ultrasound examination of your leg veins and an ultrasound of your heart, or an echocardiogram, according to Dr. Bhakta.

The most often recommended non-medical treatment is compression stockings, which compress the veins and ensure that blood continues to flow.

If the exam shows that the valve in a leg vein is deteriorating to a significant degree, your doctor may recommend venous ablation. In this procedure, a medical-grade adhesive seals off the damaged vein.

If your doctor determines that your leg swelling is related to pulmonary hypertension or heart failure (when the heart isn’t pumping like it should be), you’ll probably undergo additional tests to determine the best treatment. Treatments for both pulmonary hypertension and heart failure include medications and surgery.

Leg pain and weakness

If you’re experiencing pain or weakness in your legs and have difficulty walking, you may have peripheral vascular disease. Other PVD symptoms include:

• Numbness in your legs
• A sense of cold in the calf or foot, especially compared to the other side
• A change in the color of your legs
• Sores that won’t heal on your feet or legs
• If you’re experiencing these signs of PVD, see your doctor

Leg swelling as a single symptom that lasts more than a few days requires an office visit with a primary care physician or cardiologist, Dr. Bhakta emphasized. There’s about an 85% chance that leg swelling is related to chronic venous insufficiency or side effects from medications, such as calcium channel blockers or corticosteroids (used to treat high blood pressure). But you’ll need a healthcare provider’s direction to determine the cause.

If leg swelling is accompanied by shortness of breath or chest pain, go to the ER.

causes, symptoms and treatments

Contents

• 1 Swelling of the legs in heart failure: symptoms, causes and treatment
  • 1.1 Heart failure: an explanation of the concept
  • 1.2 How are heart failure and swelling of the legs related?
  • 1.3 Swelling of the legs in heart failure: causes, symptoms and treatment
    • 1.3.1 What factors can lead to swelling of the legs in heart failure?
  • 1.4 What symptoms accompany swelling of the legs in heart failure?
  • 1.5 Diagnosis of leg swelling in heart failure
  • 1.6 Treatment of leg swelling in heart failure
  • 1.7 Medication for leg swelling in heart failure
  • 1.8 How can I change my lifestyle to reduce leg swelling in heart failure?
    • 1.8.1 Exercise and physical activity:
    • 1.8.2 Nutrition:
    • 1.8.3 Weight control:
    • 1. 8.4 Stress avoidance:
    • 1.8.5 Take medication:
  • 1.9 Physical therapy for heart failure leg swelling
  • 1.10 Heart failure leg swelling diet 90 004
  • 1.10.1 Avoid excessive sodium intake
  • 1.10.2 Increase your protein intake
  • 1.10.3 Drink enough water
  • 1.10.4 Reduce your fluid intake
  • 1.10.5 Eat regularly
  • 1.10.6 Control your weight
• 1.11 Operations and procedures for the treatment of leg swelling in heart failure
• 1.12 Related videos:
• 1.13 Q&A:
  • • 1.13.0.1 What are the symptoms may indicate swelling of the legs in heart failure?
    • 1.13.0.2 What medicines can help with leg swelling?
    • 1.13.0.3 What methods can be applied independently to reduce swelling of the legs?
    • 1.13.0.4 How can leg edema be diagnosed in heart failure?
    • 1.13.0.5 What are the causes of leg swelling in heart failure?
    • 1.13. 0.6 How often should I seek medical attention for swelling of the legs due to heart failure?

Edema of the legs in heart failure is a symptom that indicates a violation of blood circulation in the body. Find out the causes and treatments for leg swelling in people with heart failure on our website.

Heart failure is a condition in which the heart is unable to pump enough blood throughout the body. One of the most common symptoms of heart failure is leg swelling. They occur due to impaired blood circulation and accumulation of fluid in the tissues of the legs.

Swelling of the legs may be the first sign of heart failure. They appear as swelling of the outer and inner parts of the legs. In addition, there may be swelling in the ankles, feet, and toes. This disease can occur in people of any age: from youth to the older age category.

If you do not pay timely attention to the swelling that has appeared, the development of dangerous consequences is possible. Therefore, it is important to know the causes of edema and methods of their treatment, which will help prevent serious complications. In this article, you will learn what factors can cause leg swelling in heart failure, as well as how to properly diagnose and treat this disease.

Heart failure: an explanation of the concept

Heart failure (HF) is a pathological condition that develops as a result of a malfunction of the heart. In the human body, a certain blood supply to organs and tissues is necessary, and this is achieved through the work of the heart muscle.

There are many causes of heart failure, such as valvular disorders, obesity, diabetes, hypertension, radiation therapy, and hereditary heart disease.

How are heart failure and leg swelling related?

Heart failure is a serious heart disorder that causes an uncontrolled accumulation of fluid in body tissues, including the legs. That is why swelling of the legs is one of the most characteristic symptoms of heart failure.

When the heart is not working properly, the blood cannot circulate efficiently through the body. This leads to fluid retention in the tissues, which accumulates primarily in the lower extremities and causes edema. The formation of edema in the legs is the result of a reduced efficiency of the pumping function of the heart, which leads to a congestive state.

The fight against leg edema associated with heart failure is an important part of complex therapy and is highly effective together with conventional methods of treating heart failure.

Swelling of the legs in heart failure: causes, symptoms and treatment

What factors can lead to swelling of the legs in heart failure?

Swelling in the legs can be one of the first signs of heart failure because the heart cannot supply enough blood to the body. Factors that can lead to leg swelling include:

• Circulatory failure in the heart: the heart cannot contract effectively and pump blood, which leads to the accumulation of fluid in the tissues.
• Veins full of blood: in heart failure, blood can accumulate in the veins, resulting in swelling of the legs.
• Increased capillary pressure: in heart failure, the level of fluid in the blood vessels may be insufficient, which leads to increased pressure in the capillaries and edema.
• Problems with the lymphatic system: some cases of leg swelling may be due to problems with the lymphatic system, which removes excess fluid from the tissues.

If swelling of the legs occurs, see a doctor to determine possible heart failure and treat accordingly.

What symptoms accompany swelling of the legs in heart failure?

Heart failure is a condition where the heart cannot pump blood efficiently throughout the body. Swelling of the legs is one of the symptoms of heart failure, which manifests itself in the later stages of the disease.

With prolonged heart failure, edema may spread to other parts of the body, such as the lungs, abdomen, face. In such cases, urgent medical attention is needed, as the patient’s condition may worsen to critical levels.

If you notice such symptoms, you should not postpone a visit to the doctor for a long time. Timely diagnosis and treatment of heart failure will avoid serious complications and improve the patient’s quality of life.

Diagnosis of leg swelling in heart failure

Leg swelling is often one of the first signs of heart failure. In order to establish that edema is associated specifically with heart failure and determine its degree, various diagnostic methods are used.

1. Physical Exam – The doctor examines the legs and looks for signs of swelling, such as swelling in the legs, sock marks on the skin, dry skin, and ulcers.
2. Ultrasound examination – allows you to assess the functional state of the heart, determine the presence and degree of impaired blood flow and blood volume in the legs. This method is prescribed by doctors only if necessary, after evaluating the results of previous studies.
3. Blood tests – can help doctors determine the cause of swelling, such as determining the level of electrolytes in the blood. If the level of sodium in the blood is low, this may indicate the presence of heart failure.

Depending on the results of the diagnosis, the doctor may prescribe additional tests to clarify the diagnosis and decide on treatment. Treatment of leg edema in heart failure should be carried out by a doctor and will depend on the severity of the disease and the presence of other concomitant diseases.

Treatments for swelling of the legs in heart failure

Swelling of the legs can be a sign of heart failure. The treatment of edema is aimed at improving the function of the heart and reducing the load on it. To start treatment, you need to contact a cardiologist to determine the exact cause of edema.

• Medicines that improve heart function. They help to improve the contractility of the heart, reduce the load and reduce swelling. They must be prescribed by a doctor.
• Treatment of concomitant diseases. If there are comorbidities such as hypertension or diabetes, these should also be treated.
• Restriction of fluid and salt intake. Limiting fluid and salt intake may help reduce the workload on the heart and reduce swelling.
• Compression therapy. Performing compression therapy with elastic bandages or socks may help reduce leg swelling.
• Diuretics. Diuretics may help remove fluid from the body and reduce swelling.

Treatment of leg edema in heart failure is a process that requires an individual approach and regular monitoring by a doctor. Following the doctor’s recommendations will help reduce the risk of complications and improve the patient’s quality of life.

Drug treatment for leg swelling due to heart failure

Various drugs are used to treat leg swelling due to heart failure. In most cases, drug therapy is given in combination with other therapies such as diet, exercise, and compression therapy.

Drugs used to treat swelling in the legs help to reduce the load on the heart muscle and improve blood circulation in the vessels. These include:

• Diuretics. These are drugs that increase the excretion of fluid from the body by increasing the volume of urine. Among them are furosemide and hydrochlorothiazide.
• Angiotensin converting enzyme (ACE) and ACE inhibitors. They help lower blood pressure, reduce stress on the heart and blood vessels, and improve blood circulation in the legs. These include captopril, enalapril and others.
• Angiotensin II receptor blockers. These drugs help lower blood pressure, reduce the workload on the heart, and improve blood circulation in the legs. These include losartan, candesartan, and others.

The doctor prescribes the dosage and duration of taking medications based on the general condition of the patient and the diseases present in him.

How can I make lifestyle changes to reduce leg swelling in heart failure?

Exercise and physical activity:

Regular exercise is one way to reduce leg swelling. Simple exercises such as walking, swimming or cycling improve blood circulation, which leads to a reduction in swelling.

Diet:

Excessive fluid and salt intake should be avoided as this can aggravate leg swelling. It is recommended to increase the intake of protein and vitamins, as well as reduce the intake of fats and carbohydrates.

Weight control:

Being overweight can impair heart function and increase leg swelling. Therefore, weight control can help reduce swelling and improve heart health.

Stress avoidance:

Stress can worsen the condition of the heart, increase blood pressure and increase swelling in the legs. Avoid stressful situations and practice relaxing exercises like yoga or meditation.

Take your medicine:

If you have heart failure, take your medicine as prescribed by your doctor. It is also possible to use diuretics, which help remove excess fluid from the body, thereby reducing leg swelling.

Physical Therapy for Leg Swelling in Heart Failure

Leg Swelling in Heart Failure can be effectively treated through physical therapy. It includes various exercises to strengthen the lower body and increase blood circulation.

Physical exercises are also widely used to strengthen the muscles and increase blood circulation in the legs. It can be both moderate walking and special exercises designed for specific muscle groups.

Individual approach is very important in physical therapy in the treatment of leg edema in heart failure. It is best to work with a professional physical therapist who can develop the best exercise plan and monitor your progress.

• Compression therapy
• Moderate walking
• Exercises to strengthen muscles and increase blood circulation in the legs

Diet for swollen legs due to heart failure

Avoid excessive sodium intake 9010 9

Sodium, or salt, can retain fluid in the body, which may lead to edema. Therefore, it is necessary to reduce the amount of salt in the diet. Avoid ready meals, marinades, cold cuts and cheese.

Increase your protein intake

Protein helps keep the body hydrated and prevents fluid retention in the tissues. Include protein foods such as fish, chicken, seafood, eggs, and legumes in your diet.

Drink enough water

Controversial, but you need to drink plenty of water to reduce the risk of edema. Insufficient water intake can lead to fluid retention in the body. Drink at least 8 glasses of water a day.

Reduce fluid intake

If you have heart failure, it may be helpful to reduce your fluid intake. Do not reduce water, but stop drinking sugary drinks, strong tea, coffee and alcohol.

Eat regularly

Diet is important in heart failure. Eat regularly and eat less but more often. Avoid overeating, which can lead to swelling.

Watch your weight

Watch your weight. Avoid rapid weight loss or gain, which can lead to edema and aggravation.

Recommended foods for edema Foods to avoid

Operations and procedures for the treatment of swelling of the legs in heart failure

Swelling of the legs often occurs in heart failure, when the heart is not able to pump blood efficiently. Most cases of leg swelling can be treated conservatively, but some cases may require surgery.

One possible procedure is sclerotherapy, which involves injecting salt or a special drug into the affected vein to narrow its walls. It helps reduce swelling and improve blood circulation.

Endovenous laser treatment may also be an effective procedure in the treatment of leg edema due to heart failure. This method involves using laser light to close off the affected veins, resulting in less swelling and more efficient blood circulation.

If conservative methods fail, surgery may be required. One of the commonly used methods is to normalize blood flow in the legs. This includes creating new channels for blood flow in the legs.

Some types of edema may require the use of a stent. A stent is a metal or plastic mesh that is inserted into an affected vein to keep it from expanding and losing its shape.

• Conclusion: In the treatment of leg edema in heart failure, both conservative methods and surgical interventions can be used, including sclerotherapy, endovenous laser photocoagulation, normalization of blood flow in the legs and stenting.

Video on the topic:

Q&A:

What symptoms may indicate swelling of the legs in heart failure?

Swelling of the legs may be accompanied by a feeling of heaviness and tension in the legs, pain when walking, inability to put on ordinary shoes, swelling of the ankles and feet. It is also possible for swelling to appear on other parts of the body, for example, on the ankles, abdomen, lungs.

What medicines can help with leg swelling?

Diuretics can be used to treat swelling in the legs due to heart failure, which increases the excretion of excess water from the body, reducing swelling. Drugs that reduce the workload on the heart and increase its efficiency, such as angiotensin-converting enzyme (ACE) inhibitors, may also be used.

What methods can be applied independently to reduce swelling of the legs?

To reduce swelling of the legs, it is recommended to monitor the diet, limiting the intake of salt and liquid, control your weight, avoid prolonged stay in one position, sit or lie with your legs up, if this is not contraindicated, use compression stockings or stockings.

How can leg edema be diagnosed in heart failure?

For the diagnosis of leg edema in heart failure, such research methods as electrocardiogram (ECG), cardiac ultrasound (ultrasound), chest x-ray, vascular dopplerography, cardiac catheterization are carried out. It is also necessary to conduct tests to determine the level of salt and fluid in the blood.

What are the causes of leg swelling in heart failure?

Heart problems can lead to poor circulation, which in turn causes swelling in the legs. Experiencing weakness of the heart, it cannot effectively pump blood from the lower extremities, while fluid begins to accumulate in the tissues. In addition, edema can be caused by impaired kidney function, hormonal disruptions, and taking certain medications.

How often should I seek medical attention for swelling of the legs due to heart failure?

At the first sign of swelling of the legs due to heart failure, you should consult a doctor for a profile examination and consultation. Further, the frequency of visits will be determined by a specialist individually, depending on the symptoms of the disease and the effectiveness of treatment.

treatment, diagnosis, prevention, signs — 8(495)120-02-05

In heart failure, edema is observed quite often. They are localized depending on the characteristics of the disease that caused heart failure, and on the specifics of the pathology of the functioning of the heart muscle.

Signs of cardiac edema

At the initial stages of chronic heart failure, the legs begin to swell in the evenings or after prolonged exertion on the limbs in an upright position. They pass after a short rest or when changing the position of the body. But subsequently, as the disease progresses, edematous phenomena also progress. Not even a long rest helps.

Initially, swelling is localized on the legs, from the toes and feet, the swelling gradually spreads higher and higher, to the hips and lower abdomen, while the swelling zone also increases. At the same time, the legs swell symmetrically. Often in the area of ​​​​edema, cyanosis is observed.

Edemas appear regularly, and their manifestations only get worse with time. On palpation, the edema area is dense to the touch. If you press on the edema, then a hole appears in its place, which soon disappears. For cardiac edema, their symmetrical arrangement is characteristic. In the later stages of the development of the disease, edema is accompanied by shortness of breath. In bedridden patients, swelling appears in the pelvis and lower back. Acute heart failure can lead to pulmonary edema.

Often, edema is accompanied by tachycardia, pallor, blue lips, swelling of the face, fatigue, chronic fatigue syndrome. In the later stages, the liver increases in size, abdominal dropsy appears.

Prevention of edema

In case of edema, it is very important to be in a state of physical and mental rest. It is necessary to observe the regime of the day, sleep about 9-10 hours a day. Useful daily therapeutic exercises, walks in the fresh air. Wearing elastic bandages or stockings can also be effective.

Nutrition should be fortified and balanced. It is necessary to follow a salt-free diet and limit fluid intake to 1 liter per day. In the diet, foods with a high content of potassium are required: potatoes, cabbage, cucumbers, eggplants, parsley, onions, buckwheat, raisins, dried apricots, nuts. Additionally, a cardiologist may recommend nutritional supplements: magnesium, thiamine, amino acids, and the like.

If your legs are swollen and your heart hurts

These could be signs of heart failure! Sign up for an examination at our clinic! Timely diagnosis will prevent the development of a dangerous disease.

Treatment

To get rid of edema, first of all, it is necessary to remove the symptoms of heart failure and achieve their compensation.

If the edema is not yet very pronounced, massage, foot baths, compresses, and rest with legs held high are useful. After consulting a doctor, it is possible to use diuretics of plant origin: infusion of birch leaves, lingonberry leaves, infusion of cornflower flowers, horsetail decoction. But they are effective only at the initial stage of edema.

When “home” remedies do not help, drug treatment is prescribed: diuretics, ACE inhibitors, cardiac glycosides are prescribed. In severe forms of edema, the patient is hospitalized.

In severe cases, surgical treatment is performed: fluid from the abdominal cavity is removed by laparocentesis, and pleural puncture helps to remove fluid from the lungs.

It is very important to see a doctor and be examined at the first sign of swelling. Properly selected treatment relieves the symptoms of heart failure, normalizes the work of the heart and contributes to the rapid removal of excess fluid from the body.

However, edema cannot be cured at one time. It is necessary to undergo several courses of treatment, usually they are prescribed once every three months. In more complex cases, constant medical supervision and regular treatment are necessary.

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