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Bellissima BL, Burns KE, Helsby NA, Kingston EL, Garavan F, Tingle MD. Clozapine metabolism and cardiotoxicity: A prospective longitudinal study. Int J Cardiol 2024; 403:131788. [PMID: 38244893 DOI: 10.1016/j.ijcard.2024.131788] [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: 08/26/2023] [Revised: 12/19/2023] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Clozapine-induced myocarditis and cardiomyopathy are difficult to detect clinically and may be fatal if not detected early. The current/routine biomarkers for clozapine-induced myocarditis are non-specific indicators of inflammation (C-reactive protein) or cardiomyocyte damage (troponins I and T) that lack sensitivity, and for which changes often arise too late to be clinically useful. METHODS The Clozapine Safety Study was a prospective, longitudinal, observational study to determine what, if any, the plasma concentrations of clozapine, N-desmethylclozapine, and clozapine-N-oxide in patients contribute to cardiotoxicity. Samples were collected and analysed using liquid chromatography mass spectrometry over a 41-month period from patients in the Auckland District Health Board. RESULTS Sixty-seven patients were included. Six patients were diagnosed with myocarditis; none were diagnosed with cardiomyopathy in the study period. In patients not undergoing dose titration, clozapine biotransformation may shift to the N-oxide pathway rather than the N-desmethyl pathway with increasing dose. During dose titration, the timeframe in which myocarditis occurs, the rate of increase in the plasma concentration of clozapine-N-oxide, as well as the ratio of N-oxidation relative to N-desmethylation, were significantly higher in patients diagnosed with myocarditis. CONCLUSIONS The assessment of clozapine-N-oxide formation, and N-oxidation relative to N-desmethylation ratios during treatment, may help identify a biomarker to aid the early detection of patients at risk of developing clozapine-induced cardiotoxicity.
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Affiliation(s)
- Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Kathryn E Burns
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Nuala A Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Ellen L Kingston
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Fintan Garavan
- Department of Forensic Pathology, Auckland District Health Board, LabPLUS, Auckland City Hospital, Gate 4, Grafton Road, PO Box 110031, Auckland, New Zealand.
| | - Malcom D Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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Mulla W, Segev A, Novak A, Yogev D, Abu-Much A, Fardman A, Massalha E, Goietin O, Kuperstein R, Matetzky S, Grupper A, Afel Y, Herscovici R, Peled-Potashnik Y, Chernomordik F, Brodov Y, Beigel R, Younis A. Significance of Anteroseptal Late Gadolinium Enhancement Among Patients With Acute Myocarditis. Am J Cardiol 2023; 199:18-24. [PMID: 37229967 DOI: 10.1016/j.amjcard.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/17/2023] [Accepted: 04/10/2023] [Indexed: 05/27/2023]
Abstract
Anteroseptal location of late gadolinium enhancement (LGE) in patients with acute myocarditis (AM) detected by cardiovascular magnetic resonance may indicate an independent marker of unfavorable outcomes according to recent data. We aimed to evaluate the clinical characteristics, management, and inhospital outcomes in patients with AM with positive LGE based on its presence in the anteroseptal location. We analyzed data from 262 consecutive patients hospitalized with a diagnosis of AM with positive LGE within 5 days of hospitalization (n = 425). Patients were divided into 2 groups: those with anteroseptal LGE (n = 25, 9.5%) and those with non-anteroseptal LGE (n = 237, 90.5%). Except for age that was higher in patients with anteroseptal LGE, the demographic and clinical characteristics did not differ significantly between both groups including past medical history, clinical presentation, electrocardiogram parameters, and lab values. Moreover, patients with anteroseptal LGE were more likely to present with reduced left ventricular ejection fraction and to receive congestive heart failure treatments. Although univariate analysis showed that patients with anteroseptal LGE were more likely to have inhospital major adverse cardiac events (28% vs 9%, p = 0.003), there was no difference inhospital outcomes on multivariable analysis between both groups (hazard ratio, 1.17 [95% confidence interval, 0.32 to 4.22], p = 0.81). A higher left ventricular ejection fraction in either echocardiography or cardiovascular magnetic resonance corresponded to better inhospital outcomes regardless of the presence or absence of anteroseptal LGE. In conclusion, the presence of anteroseptal LGE did not confer additional prognostic value for inhospital outcomes.
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Affiliation(s)
- Wesam Mulla
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Amitai Segev
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Amir Novak
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Dean Yogev
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Arsalan Abu-Much
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Alexander Fardman
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Eias Massalha
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Orly Goietin
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Raphael Kuperstein
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Shlomi Matetzky
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Avishay Grupper
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Yoav Afel
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Romana Herscovici
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Yael Peled-Potashnik
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Fernando Chernomordik
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Yafim Brodov
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Roy Beigel
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Anan Younis
- Department of Cardiovascular Medicine, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel.
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Yao Y, Bian W, Zhang H, Ji X, Wang Z. Quantitative cardiac MRI parameters for assessment of myocarditis in children and adolescents: a systematic review and meta-analysis. Clin Radiol 2023:S0009-9260(23)00230-1. [PMID: 37365114 DOI: 10.1016/j.crad.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023]
Abstract
AIM To evaluate the role of quantitative cardiac magnetic resonance imaging (CMRI) parameters in myocarditis, including acute and chronic myocarditis (AM and CM), for children and adolescents. MATERIALS AND METHODS PRISMA principles were followed. PubMed, EMBASE, Web of Science, Cochrane Library, and grey literature were searched. The Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) checklist were utilised for quality assessment. Quantitative CMRI parameters were extracted and a meta-analysis was performed in comparison with healthy controls. The overall effect size was measured as the weighted mean difference (WMD). RESULTS Ten quantitative CMRI parameters of seven studies were analysed. Compared with the control group, the myocarditis group reported longer native T1 relaxation time (WMD=54.00, 95% confidence interval [CI]: 33.21,74.79, p<0.001), longer T2 relaxation time (WMD=2.13, 95% CI: 0.98, 3.28, p<0.001), increased extracellular volume (ECV; WMD=3.13, 95% CI: 1.34,4.91, p=0.001), elevated early gadolinium enhancement (EGE) ratio (WMD=1.47, 95% CI: 0.65,2.28, p<0.001), and increased T2-weighted ratio (WMD=0.43, 95% CI: 0.21,0.64, p<0.001). The AM group had longer native T1 relaxation times (WMD=72.02, 95% CI: 32.78,111.27, p<0.001), increased T2-weighted ratios (WMD=0.52, 95% CI: 0.21,0.84 p=0.001), and impaired left ventricular ejection fractions (LVEF; WMD=-5.84, 95% CI: -9.69, -1.99, p=0.003). Impaired LVEF (WMD=-2.24, 95% CI: -3.32, -1.17, p<0.001) was observed in the CM group. CONCLUSION Statistical differences can be observed in some CMRI parameters between patients with myocarditis and healthy controls; however, apart from native T1 mapping, there were no large differences in other parameters between two groups, which may reveal the limited benefit of CMRI in assessing myocarditis in children and adolescents.
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Affiliation(s)
- Y Yao
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
| | - W Bian
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
| | - H Zhang
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
| | - X Ji
- Department of Pediatrics, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China.
| | - Z Wang
- Department of Radiology, Jiaxing Maternal and Child Health Hospital, Jiaxing, Zhejiang 314000, China
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Papalini EI, Polte CL, Bobbio E, Lagerstrand KM. Diagnosis of Acute Myocarditis Using Texture-Based Cardiac Magnetic Resonance, with CINE Imaging as a Novel Tissue Characterization Technique. Diagnostics (Basel) 2022; 12:diagnostics12123187. [PMID: 36553194 PMCID: PMC9777125 DOI: 10.3390/diagnostics12123187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/16/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Cardiac magnetic resonance (CMR) has emerged as a useful tool in the diagnostic work-up of patients with clinically suspected acute myocarditis (AM), yet the diagnosis remains challenging. The purpose of this proof-of-concept study was to evaluate if data-driven texture analysis has the feasibility to automatically distinguish between patients with and without CMR-verified AM using T2-weighted, late gadolinium enhancement, and CINE imaging. In particular, the present study investigated if functional CINE imaging could be used as a novel tissue characterization technique. Twenty patients with clinically suspected AM, separated into CMR-verified (n = 10) and non CMR-verified (n = 10) AM according to the Lake Louise criteria, were retrospectively included. Texture features were extracted from the images, compared on a group level, and correlated to the diagnostic outcome (CMR-verified versus non CMR-verified AM). Several features showed good to excellent reproducibility with very large differences between the groups, and moderate to strong correlation with the diagnostic outcome, suggesting that CMR texture analysis is a promising diagnostic tool for patients with clinically suspected AM. Furthermore, findings indicate that CINE imaging, which is currently used for the evaluation of cardiac function, might be a useful non-contrast-based technique for tissue characterization in patients with clinically suspected AM.
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Affiliation(s)
- Evin I. Papalini
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41390 Gothenburg, Sweden
- Correspondence: ; Tel.: +46-73-080-6717
| | - Christian L. Polte
- Department of Clinical Physiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41390 Gothenburg, Sweden
| | - Emanuele Bobbio
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41390 Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Kerstin M. Lagerstrand
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41390 Gothenburg, Sweden
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Emerging Role of Cardiac Magnetic Resonance Imaging in Diagnosing Myocarditis: A Blunder or The Way To Get the Problem Sorted? J Thorac Imaging 2022; 37:W12-W27. [PMID: 35191862 DOI: 10.1097/rti.0000000000000634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute myocarditis is a disease affecting the myocardial tissue, which is caused by infections, rheumatic diseases, especially sarcoidosis, or certain therapies. Its diagnosis may be difficult, owing to its variable clinical presentation. In this setting, cardiac magnetic resonance plays a pivotal role in detecting myocardial inflammation through qualitative, semiquantitative, and quantitative parameters, in particular with the new quantitative techniques such as T1 and T2 mapping, combined or not with late gadolinium enhancement evaluation. This is in accordance with the revised Lake Louise criteria. In this review, the emerging role of the new cutting-edge cardiac magnetic resonance imaging techniques in diagnosing myocarditis is extensively presented.
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Altered Phenotype of Circulating Dendritic Cells and Regulatory T Cells from Patients with Acute Myocarditis. J Immunol Res 2022; 2022:8873146. [PMID: 35265721 PMCID: PMC8901353 DOI: 10.1155/2022/8873146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/19/2022] [Accepted: 02/05/2022] [Indexed: 11/17/2022] Open
Abstract
Dendritic cells (DCs) and regulatory T cells (Tregs) play an essential role in myocarditis. However, a particular DC phenotype in this disease has not been assessed. Herein, we aim to evaluate myeloid (mDCs) and plasmacytoid DC (pDC) phenotype, as well as Treg levels from myocarditis patients and healthy controls. Using multiparametric flow cytometry, we evaluated the levels of myeloid DCs (mDCs), plasmacytoid DCs (pDCs), and Tregs in peripheral blood from myocarditis patients (n = 16) and healthy volunteers (n = 16) and performed correlation analysis with clinical parameters through Sperman test. DCs from myocarditis patients showed a higher expression of costimulatory molecules while a diminished expression of the inhibitory receptors, ILT2 and ILT4. Even more, Treg cells from myocarditis patients displayed higher levels of FOXP3 compared to controls. Clinically, the increased levels of mDCs and their higher expression of costimulatory molecules correlate with a worse myocardial function, higher levels of acute phase reactants, and higher cardiac enzymes. This study shows an activating phenotype of circulating DCs from myocarditis patients. This proinflammatory status may contribute to the pathogenesis and immune deregulation in acute myocarditis.
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Wieczorkiewicz P, Przybylak K, Supel K, Kidawa M, Zielinska M. Symptomatic Young Adults with ST-Segment Elevation-Acute Coronary Syndrome or Myocarditis: The Three-Factor Diagnostic Model. J Clin Med 2022; 11:jcm11040916. [PMID: 35207189 PMCID: PMC8877187 DOI: 10.3390/jcm11040916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Myocarditis may mimic myocardial infarction (MI) due to a similar clinical presentation, including chest pain, electrocardiography changes, and laboratory findings. The purpose of the study was to investigate the diagnostic value of clinical, laboratory, and electrocardiography characteristics of patients with acute coronary syndrome - like myocarditis and MI. We analysed 90 patients (≤45 years old) with an initial diagnosis of ST-segment elevation myocardial infarction; 40 patients (44.4%), through the use of cardiac magnetic resonance, were confirmed to have myocarditis, and 50 patients (55.6%) were diagnosed with MI. Patients with myocarditis were younger and had fewer cardiovascular risk factors than those with MI. The cutoff value distinguishing between myocarditis and MI was defined as the age of 36 years. The history of recent infections (82.5% vs. 6%) and C-reactive protein (CRP) levels on admission (Me 45.9 vs. 3.4) was more associated with myocarditis. Further, the QTc interval was inversely correlated with the echocardiographic ejection fraction in both groups but was significantly longer in patients with MI. Non-invasive diagnostics based on clinical features and laboratory findings are basic but still essential tools for differentiation between MI and myocarditis. The three-factor model including the criteria of age, abnormal CRP, and history of recent infections might become a valuable clinical indication.
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Piccirillo F, Watanabe M, Di Sciascio G. Diagnosis, treatment and predictors of prognosis of myocarditis. A narrative review. Cardiovasc Pathol 2021; 54:107362. [PMID: 34192559 DOI: 10.1016/j.carpath.2021.107362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/31/2022] Open
Abstract
Although it has been recognized for almost two centuries, myocarditis is still a challenging diagnosis due to the wide heterogeneity of its clinical manifestations and evolution. Moreover, the diagnostic gold standard, endomyocardial biopsy (EMB), is infrequently used, making hard to determine the exact incidence of myocarditis. Clinical presentation includes a wide range of symptoms, ranging from asymptomatic or subclinical disease with mild dyspnea and chest pain to sudden death, due to cardiogenic shock or malignant ventricular arrhythmias. Equally, the evolution of myocarditis largely varies: albeit short-term prognosis is usually good, with complete or partial recovery, dilated cardiomyopathy with chronic heart failure is the major long-term consequence of myocarditis, developing often several years after the acute onset. This narrative review aims to summarize the current knowledge about myocarditis, with a particular attention to predictors of short- and long-term prognosis, in order to provide a rational and practical approach to the diagnosis, evaluation and treatment of suspected myocarditis.
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Affiliation(s)
- Francesco Piccirillo
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy.
| | - Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Germano Di Sciascio
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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Abdelazeem B, Borcheni M, Alnaimat S, Mallikethi-Reddy S, Sulaiman A. Persistent Cardiac Magnetic Resonance Imaging Features of Myocarditis Detected Months After COVID-19 Infection. Cureus 2021; 13:e14250. [PMID: 33954066 PMCID: PMC8088400 DOI: 10.7759/cureus.14250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acute myocarditis is commonly caused by viral infections resulting from viruses such as adenovirus, enteroviruses, and, rarely, coronavirus. It presents with nonspecific symptoms like chest pain, dyspnea, palpitation, or arrhythmias and can progress to dilated cardiomyopathy or heart failure. Fulminant myocarditis is a potentially life-threatening form of the condition and presents as acute, severe heart failure with cardiogenic shock. In this report, we discuss a case of a 41-year-old female who presented with cough and chest pain of two days' duration. The patient had a new-onset atrial flutter. Her chest auscultation revealed bilateral crackles. Laboratory workup revealed elevated troponin levels, and the patient tested positive for coronavirus disease 2019 (COVID-19) by nasopharyngeal swab polymerase chain reaction (PCR). Transthoracic echocardiogram revealed a low left ventricular (LV) ejection fraction of 35-40% compared to 55% one year prior, as well as a granular appearance of LV myocardium. The patient's condition subsequently improved clinically and she was discharged home. Due to cardiac involvement and characteristic myocardial appearance on the echocardiogram, cardiac magnetic resonance (CMR) imaging was performed for further evaluation about two months from the date of admission. CMR showed extensive myocardial inflammation with a typical pattern of sub-epicardial and mid-wall delayed enhancement, confirming the diagnosis of myocarditis. This case highlights myocarditis as a potential complication of COVID-19 that requires early diagnosis and proper management to improve patients' quality of life. Additionally, we highlight the features of myocarditis on CMR in the acute phase and two months after clinical recovery.
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Affiliation(s)
- Basel Abdelazeem
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | - Mariem Borcheni
- Department of Internal Medicine, Sfax Faculty of Medicine, Sfax, TUN
| | - Saed Alnaimat
- Department of Cardiology, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | - Sagar Mallikethi-Reddy
- Department of Cardiology, McLaren Health Care, Flint/Michigan State University, Flint, USA
| | - Abdulbaset Sulaiman
- Department of Cardiology, McLaren Health Care, Flint/Michigan State University, Flint, USA
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