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Ahmed M, Nudy M, Bussa R, Weigel F, Naccarelli G, Maheshwari A. Non-pharmacologic autonomic neuromodulation for treatment of heart failure: A systematic review and meta-analysis of randomized controlled trials. Trends Cardiovasc Med 2024; 34:101-107. [PMID: 36202286 DOI: 10.1016/j.tcm.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/08/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
Treatment strategies that modulate autonomic tone through interventional and device-based therapies have been studied as an adjunct to pharmacological treatment of heart failure with reduced ejection fraction (HFrEF). The main objective of this study was to perform a meta-analysis of randomized controlled trials which evaluated the efficacy of device-based autonomic modulation for treatment of HFrEF. All randomized-controlled trials testing autonomic neuromodulation device therapy in HFrEF were included in this trial-level analysis. Autonomic neuromodulation techniques included vagal nerve stimulation (VNS), baroreflex activation (BRA), spinal cord stimulator (SCS), and renal denervation (RD). The prespecified primary endpoints included mean change and 95% confidence intervals (CI) of left ventricular ejection fraction (LVEF), NT pro-B-type natriuretic peptide (NT-proBNP), and quality of life (QOL) measures including 6-minute hall walk distance (6-MHWD), and Minnesota Living with Heart Failure Questionnaire (MLHFQ). New York Heart Association (NYHA) functional class improvement was reported as odds ratios and 95% CI of improvement by at least 1 functional class. Eight studies were identified that included 1037 participants (2 VNS, 2 BRA, 1 SCS, and 3 RD trials). This included 6 open-label, 1 single-blind, and 1 sham-controlled, double-blind study. The mean age (±SD) was 61 (±9.3) years. The mean follow-up time was 7.9 months. Twenty percent of the total patients were female, and the mean BMI (±SD) was 29.86 (±4.12). Autonomic neuromodulation device therapy showed a statistically significant improvement in LVEF (4.02%; 95% CI 0.24,7.79), NT-proBNP (-219.80 pg/ml; 95% CI -386.56, -53.03), NYHA functional class (OR 2.32; 95% CI 1.76, 3.07), 6-MHWD (48.39 m; 95% CI 35.49, 61.30), and MLHFQ (-12.20; 95% CI -19.24, -5.16) compared to control. In patients with HFrEF, the use of autonomic neuromodulation device therapy is associated with improvement in LVEF, reduction in NT-proBNP, and improvement in patient-centered QOL outcomes in mostly small open-label trials. Large, double-blind, sham-controlled trials designed to detect differences in hard cardiovascular outcomes are needed before widespread use and adoption of autonomic neuromodulation device therapies in HFrEF.
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Affiliation(s)
- Mohammad Ahmed
- Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA 17033, United States of America
| | - Matthew Nudy
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA 17033, United States of America
| | - Rahul Bussa
- Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA 17033, United States of America
| | - Frank Weigel
- Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA 17033, United States of America
| | - Gerald Naccarelli
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA 17033, United States of America
| | - Ankit Maheshwari
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA 17033, United States of America.
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Molina‐Linde JM, Cordero‐Pereda D, Baños‐Álvarez E, Rosario‐Lozano MP, Blasco‐Amaro JA. Efficacy and safety of baroreflex activation therapy for heart failure with reduced ejection fraction: systematic review. ESC Heart Fail 2023; 10:2760-2772. [PMID: 37522644 PMCID: PMC10567643 DOI: 10.1002/ehf2.14473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 05/25/2023] [Accepted: 07/02/2023] [Indexed: 08/01/2023] Open
Abstract
Baroreflex activation therapy (BAT) is a possible adjuvant treatment for patients with heart failure with reduced ejection fraction (HFrEF) who remain symptomatic despite optimal medical therapy and may be an alternative therapy in patients with contraindications or drug intolerance. Our aim was to evaluate the efficacy and safety of BAT in patients with HFrEF. The protocol for this study was registered with PROSPERO (CRD42022349175). Searches were conducted using MEDLINE, preMedLine (via PubMed), EMBASE, Cochrane Library, Web of Science, Trip Medical Database, WHO International Clinical Trials Registry, and ClinicalTrials.gov. We included randomized controlled trials that compared the effects of BAT with pharmacological treatment. We assessed the risk of bias of each study using the Cochrane RoB2 tool and the certainty of the results using the GRADE approach. We performed a meta-analysis of treatment effects using a fixed-effects or random-effects model, depending on the heterogeneity observed. Two studies were included in the meta-analysis (HOPE4HF and BeAT-HF). The results showed that BAT led to statistically significant improvements in New York Heart Association functional class (relative risk 2.13; 95% confidence interval [CI, 1.65 to 2.76]), quality of life (difference in means -16.97; 95% CI [-21.87 to -12.07]), 6 min walk test (difference in means 56.54; 95% CI [55.67 to 57.41]) and N-terminal probrain natriuretic peptide (difference in means -120.02; 95% CI [-193.58 to -46.45]). The system- and procedure-related complication event-free rate varied from 85.9% to 97%. The results show that BAT is safe and improves functional class, quality of life and congestion in selected patients with HFrEF. Further studies and long-term follow-up are needed to assess efficacy in reducing cardiovascular events and mortality.
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Affiliation(s)
- Juan Máximo Molina‐Linde
- Health Technology Assessment Area‐AETSAAndalusian Public Foundation Progress and Health‐FPSSevilleSpain
| | - David Cordero‐Pereda
- Heart Failure and Cardiomyopathy UnitCardiology Service Ramón y Cajal HospitalMadridSpain
| | | | | | - Juan Antonio Blasco‐Amaro
- Health Technology Assessment Area‐AETSAAndalusian Public Foundation Progress and Health‐FPSSevilleSpain
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Vieira MC, Mendes FDSNS, da Silva PS, da Silva GMS, Mazzoli-Rocha F, de Sousa AS, Saraiva RM, Quintana MDSB, Costa HS, Paravidino VB, Rodrigues LF, Hasslocher-Moreno AM, Americano do Brasil PEA, Mediano MFF. The association between variables of cardiopulmonary exercise test and quality of life in patients with chronic Chagas cardiomyopathy (Insights from the PEACH STUDY). PLoS One 2022; 17:e0279086. [PMID: 36520825 PMCID: PMC9754173 DOI: 10.1371/journal.pone.0279086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Studies investigating the association between functional capacity and quality of life (QoL) in individuals with chronic Chagas cardiomyopathy (CCC) usually do not include a gold-standard evaluation of functional capacity, limiting the validity and the interpretation of the results. The present study is a cross-section analysis aiming to evaluate the association between functional capacity (quantified by cardiopulmonary exercise test [CPET]) and QoL in individuals with CCC. QoL was assessed using the SF-36 questionnaire. Sociodemographic, anthropometric, clinical, cardiac function and maximal progressive CPET variables were obtained from PEACH study. Generalized linear models adjusted for age, sex, and left ventricular ejection fraction were performed to evaluate the association between CPET variables and QoL. After adjustments, VO2 peak and VO2 AT were both associated with physical functioning (β = +0.05 and β = +0.05, respectively) and physical component summary (β = +0.03 and β = +0.03, respectively). Double product was associated with physical functioning (β = +0.003), general health perceptions (β = +0.003), physical component summary (β = +0.002), and vitality (β = +0.004). HRR≤12bpm was associated with physical functioning (β = -0.32), role limitations due to physical problems (β = -0.87), bodily pain (β = -0.26), physical component summary (β = -0.21), vitality (β = -0.38), and mental health (β = -0.19). VE/VCO2 slope presented association with all mental scales of SF-36: vitality (β = -0.028), social functioning (β = -0.024), role limitations due to emotional problems (β = -0.06), mental health (β = -0.04), and mental component summary (β = -0.02). The associations between CPET variables and QoL demonstrate the importance of CPET inclusion for a more comprehensive evaluation of individuals with CCC. In this setting, intervention strategies aiming to improve functional capacity may also promote additional benefits on QoL and should be incorporated as a treatment strategy for patients with CCC.
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Affiliation(s)
- Marcelo Carvalho Vieira
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
- Center for Cardiology and Exercise, Aloysio de Castro State Institute of Cardiology, Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
| | | | - Paula Simplício da Silva
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Flavia Mazzoli-Rocha
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrea Silvestre de Sousa
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roberto Magalhães Saraiva
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Henrique Silveira Costa
- Department of Physical Therapy, Federal University of Jequitinhonha and Mucuri Valleys, Diamantina, Minas Gerais, Brazil
| | - Vitor Barreto Paravidino
- Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Physical Education and Sports, Naval Academy, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luiz Fernando Rodrigues
- Department of Research and Education, National Institute of Cardiology, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Physiological Sciences, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Mauro Felippe Felix Mediano
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Research and Education, National Institute of Cardiology, Rio de Janeiro, Rio de Janeiro, Brazil
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Zafeiropoulos S, Doundoulakis I, Farmakis IT, Miyara S, Giannis D, Giannakoulas G, Tsiachris D, Mitra R, Skipitaris NT, Mountantonakis SE, Stavrakis S, Zanos S. Autonomic Neuromodulation for Atrial Fibrillation Following Cardiac Surgery: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:682-694. [PMID: 35177198 DOI: 10.1016/j.jacc.2021.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/12/2021] [Accepted: 12/07/2021] [Indexed: 12/17/2022]
Abstract
Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use.
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Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA.
| | - Ioannis Doundoulakis
- Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece; Athens Heart Center, Athens Medical Center, Athens, Greece
| | - Ioannis T Farmakis
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Santiago Miyara
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Raman Mitra
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Nicholas T Skipitaris
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | | | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Stavros Zanos
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA.
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Du X. Sympatho-adrenergic mechanisms in heart failure: new insights into pathophysiology. MEDICAL REVIEW (BERLIN, GERMANY) 2021; 1:47-77. [PMID: 37724075 PMCID: PMC10388789 DOI: 10.1515/mr-2021-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/02/2021] [Indexed: 09/20/2023]
Abstract
The sympathetic nervous system is activated in the setting of heart failure (HF) to compensate for hemodynamic instability. However, acute sympathetic surge or sustained high neuronal firing rates activates β-adrenergic receptor (βAR) signaling contributing to myocardial remodeling, dysfunction and electrical instability. Thus, sympatho-βAR activation is regarded as a hallmark of HF and forms pathophysiological basis for β-blocking therapy. Building upon earlier research findings, studies conducted in the recent decades have significantly advanced our understanding on the sympatho-adrenergic mechanism in HF, which forms the focus of this article. This review notes recent research progress regarding the roles of cardiac β2AR or α1AR in the failing heart, significance of β1AR-autoantibodies, and βAR signaling through G-protein independent signaling pathways. Sympatho-βAR regulation of immune cells or fibroblasts is specifically discussed. On the neuronal aspects, knowledge is assembled on the remodeling of sympathetic nerves of the failing heart, regulation by presynaptic α2AR of NE release, and findings on device-based neuromodulation of the sympathetic nervous system. The review ends with highlighting areas where significant knowledge gaps exist but hold promise for new breakthroughs.
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Affiliation(s)
- Xiaojun Du
- Faculty of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, 76 West Yanta Road, Xi’an710061, Shaanxi, China
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC3004, Australia
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Dyavanapalli J, Rodriguez J, Rocha Dos Santos C, Escobar JB, Dwyer MK, Schloen J, Lee KM, Wolaver W, Wang X, Dergacheva O, Michelini LC, Schunke KJ, Spurney CF, Kay MW, Mendelowitz D. Activation of Oxytocin Neurons Improves Cardiac Function in a Pressure-Overload Model of Heart Failure. ACTA ACUST UNITED AC 2020; 5:484-497. [PMID: 32478209 PMCID: PMC7251188 DOI: 10.1016/j.jacbts.2020.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/06/2020] [Accepted: 03/06/2020] [Indexed: 01/26/2023]
Abstract
Hypothalamic OXT neurons were chronically activated using a chemogenetic approach in an animal model of HF. Synaptic release of OXT onto parasympathetic autonomic targets was reduced in animals with HF but restored with daily treatment consisting of activation of OXT neurons. Long-term daily OXT neuron activation increased parasympathetic activity to the heart and reduced mortality, cardiac inflammation, and fibrosis and improved critical longitudinal in vivo indices of cardiac function. The benefits in cardiac function and autonomic balance in HF closely tracked the study-designed differences in initiation of OXT neuron activation in different groups.
This work shows long-term restoration of the hypothalamic oxytocin (OXT) network preserves OXT release, reduces mortality, cardiac inflammation, fibrosis, and improves autonomic tone and cardiac function in a model of heart failure. Intranasal administration of OXT in patients mimics the short-term changes seen in animals by increasing parasympathetic—and decreasing sympathetic—cardiac activity. This work provides the essential translational foundation to determine if approaches that mimic paraventricular nucleus (PVN) OXT neuron activation, such as safe, noninvasive, and well-tolerated intranasal administration of OXT, can be beneficial in patients with heart failure.
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Key Words
- ANOVA, analysis of variance
- CHO, Chinese hamster ovary
- CNO, clozapine-N-oxide
- CVN, cardiac vagal neuron
- ChR2, channelrhodopsin
- DMNX, dorsal motor nucleus of the vagus
- DREADD, designer receptors exclusively activated by designer drug
- HF, heart failure
- IL, interleukin
- LV, left ventricle
- LVDP, left ventricle- developed pressure
- OXT, oxytocin
- PVN, paraventricular nucleus of the hypothalamus
- SD, standard deviation
- TAC, transascending aortic constriction
- heart failure
- oxytocin
- parasympathetic
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Affiliation(s)
- Jhansi Dyavanapalli
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
| | - Jeannette Rodriguez
- Department of Biomedical Engineering, George Washington University, Washington, DC
| | | | - Joan B Escobar
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
| | - Mary Kate Dwyer
- Department of Biomedical Engineering, George Washington University, Washington, DC
| | - John Schloen
- Department of Biomedical Engineering, George Washington University, Washington, DC
| | - Kyung-Min Lee
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
| | - Whitney Wolaver
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
| | - Xin Wang
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
| | - Olga Dergacheva
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
| | - Lisete C Michelini
- Department of Physiology, Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo/SP, Brazil
| | - Kathryn J Schunke
- Department of Biomedical Engineering, George Washington University, Washington, DC
| | - Christopher F Spurney
- Children's National Heart Institute, Center for Genetic Medicine Research, Children's National Health System, Washington, DC
| | - Matthew W Kay
- Department of Biomedical Engineering, George Washington University, Washington, DC
| | - David Mendelowitz
- Department of Pharmacology and Physiology, George Washington University, Washington, DC
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Bendary A, Bendary M, Salem M. Autonomic regulation device therapy in heart failure with reduced ejection fraction: a systematic review and meta-analysis of randomized controlled trials. Heart Fail Rev 2020; 24:245-254. [PMID: 30317416 DOI: 10.1007/s10741-018-9745-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with reduced ejection fraction (HFrEF) represents a significant public health burden associated with incremental health care costs. Given the limitations associated with pharmacological autonomic regulation therapy (ART), device-based autonomic neuromodulation is on the horizon now for ART in those patients. This systematic review aimed primarily to determine the effect of ART by devices on functional status and quality of life (QOL) in patients with HFrEF. We performed a meta-analysis of five randomized controlled trials (1074 patients) comparing ART by devices versus optimal medical therapy (OMT) in HFrEF. We assessed pooled estimates of odds ratio (OR) for improvement in New York Heart Association (NYHA) class and mean differences (MD) in 6-minute hall walk distance (6-MHWD), Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, N-terminal pro b-type natriuretic peptide (NT-proBNP) levels, and left ventricular end-systolic volume index (LVESVi) with their 95% confidence intervals (CIs) at 6-month follow-up. Compared to OMT alone, ART by devices in HFrEF significantly improves NYHA class (OR 2.26, 95% CI 1.33 to 3.83, P = 0.003), increases 6-MHWD (MD 45.53 m, 95% CI 30.61 to 60.45, P < 0.00001), improves MLHFQ score (MD - 10.59, 95% CI - 20.62 to - 0.57, P = 0.04) with neutral effect on NT-proBNP levels (MD - 236.5 pg/ml, 95% CI - 523.86 to 50.87, P = 0.11) and LVESVi (MD - 1.01 ml/m2, 95% CI - 4.49 to 2.47, P = 0.57). We concluded that device-based neuromodulation therapy significantly improves functional status and quality of life in patients with HFrEF.
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Affiliation(s)
- Ahmed Bendary
- Cardiology Department, Benha Faculty of Medicine, Benha University, Benha, 13518, Egypt.
| | - Mohamed Bendary
- Department of Biostatistics, National Cancer Institute, Cairo University, Giza, Egypt
| | - Mohamed Salem
- Cardiology Department, Benha Faculty of Medicine, Benha University, Benha, 13518, Egypt
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