1
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a Difference: 5 Years of Cardiac Surgery Intersociety Alliance (CSIA). Ann Thorac Surg 2024; 118:338-351. [PMID: 38864803 DOI: 10.1016/j.athoracsur.2024.04.011] [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] [Accepted: 02/15/2024] [Indexed: 06/13/2024]
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, New York
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand and, Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria; Department of Cardiothoracic Surgery, University Hospital St. Pölten, St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women's Hospital and Mass General Hospital, Harvard University, Boston, Massachusetts
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2
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Karthikeyan G, Ntsekhe M, Islam S, Rangarajan S, Avezum A, Benz A, Cabral TTJ, Changsheng M, Chillo P, Gonzalez-Hermosillo JA, Gitura B, Damasceno A, Dans AML, Davletov K, Elghamrawy A, ElSayed A, Fana GT, Gondwe L, Haileamlak A, Kayani AM, Lwabi P, Maklady F, Molefe-Baikai OJ, Musuku J, Ogah OS, Paniagua M, Rusingiza E, Sharma SK, Zuhlke L, Connolly S, Yusuf S. Mortality and Morbidity in Adults With Rheumatic Heart Disease. JAMA 2024; 332:133-140. [PMID: 38837131 PMCID: PMC11154374 DOI: 10.1001/jama.2024.8258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/18/2024] [Indexed: 06/06/2024]
Abstract
Importance Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries. Objective To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Design, Setting, and Participants Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs. Main Outcomes and Measures The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models. Results Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors. Conclusions and Relevance Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi
- Translational Health Science and Technology Institute, Faridabad, India
| | - Mpiko Ntsekhe
- Division of Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Shofiqul Islam
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexander Benz
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | | | - Philly Chillo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Bernard Gitura
- Kenyatta National Teaching & Referral Hospital, Department of Cardiology, Nairobi, Kenya
| | | | | | - Kairat Davletov
- Asfendiyarov Kazakh National Medical University, Health Research Institute, Almaty, Kazakhstan
| | | | | | | | | | - Abraham Haileamlak
- College of Medicine and Health Sciences, University of Rwanda, Kigali
- Jimma University Medical Center, Jimma, Ethiopia
| | | | | | - Fathi Maklady
- Department of Cardiology, Suez Canal University, Ismailia, Egypt
| | | | - John Musuku
- University Teaching Hospital, Lusaka, Zambia
| | - Okechukwu Samuel Ogah
- Cardiology Unit, Department of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
| | - Maria Paniagua
- College of Medicine Sciences, National University of Concepción, Concepción, Paraguay
| | | | | | - Liesl Zuhlke
- Medical Research Council of South Africa, Division of Pediatric Cardiology, Department of Pediatrics, Red Cross Children’s Hospital Faculty of Health Sciences, University of Cape Town, Cape Town
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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3
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Bai L, Li Y, Lu C, Yang Y, Zhang J, Lu Z, Huang K, Xian S, Yang X, Na N, Huang F, Zeng Z. Anti-IL-17 Inhibits PINK1/Parkin Autophagy and M1 Macrophage Polarization in Rheumatic Heart Disease. Inflammation 2024:10.1007/s10753-024-02094-3. [PMID: 38977539 DOI: 10.1007/s10753-024-02094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/14/2024] [Accepted: 06/27/2024] [Indexed: 07/10/2024]
Abstract
Rheumatic heart disease (RHD) is an important and preventable cause of cardiovascular death and disability, but the lack of clarity about its exact mechanisms makes it more difficult to find alternative methods or prevention and treatment. We previously demonstrated that increased IL-17 expression plays a crucial role in the development of RHD-related valvular inflammatory injury. Macrophage autophagy/polarization may be a pro-survival strategy in the initiation and resolution of the inflammatory process. This study investigated the mechanism by which IL-17 regulates autophagy/polarization activation in macrophages. A RHD rat model was generated, and the effects of anti-IL-17 and 3-methyladenine (3-MA) were analyzed. The molecular mechanisms underlying IL-17-induced macrophage autophagy/polarization were investigated via in vitro experiments. In our established RHD rat model, the activation of the macrophage PINK1/Parkin autophagic pathway in valve tissue was accompanied by M1 macrophage infiltration, and anti-IL-17 treatment inhibited autophagy and reversed macrophage inflammatory infiltration, thereby attenuating endothelial-mesenchymal transition (EndMT) in the valve tissue. The efficacy of 3-MA treatment was similar to that of anti-IL-17 treatment. Furthermore, in THP-1 cells, the pharmacological promotion of autophagy by IL-17 induced M1-type polarization, whereas the inhibition of autophagy by 3-MA reversed this process. Mechanistically, silencing PINK1 in THP-1 blocked autophagic flux. Moreover, IL-17-induced M1-polarized macrophages promoted EndMT in HUVECs. This study revealed that IL-17 plays an important role in EndMT in RHD via the PINK1/Parkin autophagic pathway and macrophage polarization, providing a potential therapeutic target.
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Affiliation(s)
- Ling Bai
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Yuan Li
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Chuanghong Lu
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Yiping Yang
- Department of Research, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Jie Zhang
- Emergency Office, Nanning Center for Disease Control and Prevention, Nanning , Guangxi, China
| | - Zirong Lu
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Keke Huang
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Shenglin Xian
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Xi Yang
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Na Na
- Department of Neuroscience, The Scripps Research Institute, La Jolla, USA
| | - Feng Huang
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China.
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China.
| | - Zhiyu Zeng
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Shuang Yong Road 6, Nanning, 530021, Guangxi, China.
- Guangxi Key Laboratory Base of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China.
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4
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Johansson I, Benz AP, Kovalova T, Balasubramanian K, Fukakusa B, Lynn MJ, Nair N, Sikder O, Patel K, Gayathri S, Robinson M, Hardy C, Tyrwhitt J, Schulman S, Eikelboom JW, Connolly SJ. Outcomes of Patients with a Mechanical Heart Valve and Poor Anticoagulation Control on Warfarin. Thromb Haemost 2024; 124:613-624. [PMID: 38158198 PMCID: PMC11199045 DOI: 10.1055/s-0043-1777827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with a mechanical heart valve (MHV) require oral anticoagulation. Poor anticoagulation control is thought to be associated with adverse outcomes, but data are limited. OBJECTIVE To assess the risks of clinical outcomes in patients with a MHV and poor anticoagulation control on warfarin. METHODS We conducted a retrospective study of consecutive patients undergoing MHV implantation at a tertiary care center (2010-2019). Primary outcome was a composite of ischemic stroke, systemic embolism, or prosthetic valve thrombosis. Major bleeding and death were key secondary outcomes. We constructed multivariable regression models to assess the association between time in therapeutic range (TTR) on warfarin beyond 90 days after surgery with outcomes. RESULTS We included 671 patients with a MHV (80.6% in aortic, 14.6% in mitral position; mean age 61 years, 30.3% female). Median follow-up was 4.9 years, mean TTR was 62.5% (14.5% TTR <40%, 24.6% TTR 40-60%, and 61.0% TTR >60%). Overall rates of the primary outcome, major bleeding, and death were 0.73, 1.41, and 1.44 per 100 patient-years. Corresponding rates for patients with TTR <40% were 1.31, 2.77, and 3.22 per 100 patient-years. In adjusted analyses, every 10% decrement in TTR was associated with a 31% increase in hazard for the primary outcome (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.13-1.52), 34% increase in major bleeding (HR: 1.34, 95% CI: 1.17-1.52), and 32% increase in death (HR: 1.32, 95% CI: 1.11-1.57). CONCLUSION In contemporary patients with a MHV, poor anticoagulation control on warfarin was associated with increased risks of thrombotic events, bleeding, and death.
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Affiliation(s)
- Isabelle Johansson
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
- Division of Cardiology, Department of Medicine K2, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Alexander P. Benz
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Tanya Kovalova
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Kumar Balasubramanian
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Bianca Fukakusa
- Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada
| | - Matthew J. Lynn
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Nikhil Nair
- Division of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Omaike Sikder
- Division of Medicine, School of Nursing, McMaster University, Hamilton, Canada
| | - Kashyap Patel
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sai Gayathri
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Marlene Robinson
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - Colin Hardy
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Jessica Tyrwhitt
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - John W. Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Stuart J. Connolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
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5
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA). Eur J Cardiothorac Surg 2024; 65:ezae048. [PMID: 38856237 PMCID: PMC11163458 DOI: 10.1093/ejcts/ezae048] [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: 09/05/2023] [Revised: 01/08/2024] [Accepted: 02/15/2024] [Indexed: 06/11/2024] Open
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, NY, USA
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, PA, USA
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand and, Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria
- Department of Cardiothoracic Surgery, University Hospital St. Pölten, St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women’s Hosp. and Mass General Hospital, Harvard University, Boston, MA, USA
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6
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA). Asian Cardiovasc Thorac Ann 2024; 32:271-284. [PMID: 38872357 DOI: 10.1177/02184923241259191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
SUMMARY Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, it's 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, USA
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, NY, USA
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, PA, USA
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand and, Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria
- Department of Cardiothoracic Surgery, University Clinic St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women's Hosp. and Mass General Hospital, Harvard University, Boston, MA, USA
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7
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA). J Thorac Cardiovasc Surg 2024:S0022-5223(24)00377-5. [PMID: 38864805 DOI: 10.1016/j.jtcvs.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/08/2024] [Accepted: 02/15/2024] [Indexed: 06/13/2024]
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based nongovernmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, NY
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, Pa
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand, and Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria; Department of Cardiothoracic Surgery, University Clinic St. Pölten, St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women's Hosp. and Mass General Hospital, Harvard University, Boston, Mass
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8
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Zhang N, Hou M, Mei B, Liu Y, Lai YL. Comparison of short-term efficacy of two bipolar radiofrequency ablation forceps for rheumatic heart disease concomitant with atrial fibrillation. Front Cardiovasc Med 2024; 11:1335407. [PMID: 38711794 PMCID: PMC11071666 DOI: 10.3389/fcvm.2024.1335407] [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: 11/08/2023] [Accepted: 04/01/2024] [Indexed: 05/08/2024] Open
Abstract
Background Currently, the bipolar radiofrequency ablation forceps manufactured by AtriCure are the main instrument for surgical ablation in patients with rheumatic heart disease (RHD) concomitant with atrial fibrillation (AF). The bipolar radiofrequency ablation forceps by Med-Zenith has a greater advantage in price compared with AtriCure. However, few studies have been reported on the comparison of their clinical efficacy. The aim of this study is to compare the short-term clinical efficacy of the two ablation forceps for RHD concomitant with AF. Methods Clinical data of 167 patients with RHD concomitant with AF admitted to the Department of Cardiac Major Vascular Surgery, Affiliated Hospital of North Sichuan Medical College, were retrospectively analyzed, and the restoration efficacy of sinus rhythm (SR) and cardiac function after surgery were compared with two ablation forceps. Results The end-systolic diameter of the right atrium and the end-systolic diameter of the left atrium in the patients of both groups at each postoperative time point decreased compared with that of the preoperative period (P < 0.05), and the left ventricular ejection fraction started to improve significantly at 6 months after surgery compared with that of the preoperative period (P < 0.05). There was no difference between the two groups of patients in the comparison of the aforementioned indicators at different points in time (P > 0.05). At 12 months postoperatively, the SR maintenance rate in using the ablation forceps by Med-Zenith (73.3%) was lower than that for AtriCure (86.4%) and the cumulative recurrence rate of AF in using the Med-Zenith ablation forceps was greater than that for AtriCure. Conclusions The two bipolar radiofrequency ablation forceps compared in the study are safe and effective in treating patients of RHD concomitant with AF, and the ablation forceps by AtriCure may be more effective in restoring SR in the short term.
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Affiliation(s)
- Ning Zhang
- Department of Cardiothoracic Surgery, Dazhou Dachuan District People's Hospital (Dazhou Third People's Hospital), Dazhou, Sichuan, China
- Department of Cardiac Macrovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ming Hou
- Department of Cardiac Macrovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Bo Mei
- Department of Cardiovascular Surgery, Dazhou Central Hospital, Dazhou, Sichuan, China
| | - Yong Liu
- Department of Cardiac Macrovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ying-long Lai
- Department of Cardiac Macrovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
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9
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Jin C, Cui C, Seplowe M, Lee KI, Vegunta R, Li B, Frishman WH, Iwai S. Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views. Cardiol Rev 2024; 32:131-139. [PMID: 36730534 DOI: 10.1097/crd.0000000000000489] [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] [Indexed: 02/04/2023]
Abstract
Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.
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Affiliation(s)
- Chengyue Jin
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Can Cui
- Department of Immunobiology, School of Medicine, Yale University, New Haven, CT
| | - Matthew Seplowe
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Kyu-In Lee
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | | | - Bo Li
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Sei Iwai
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
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10
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Virk GS, Javed S, Chaudhry R, Moazam MM, Mahmood A, Mahmood F, Zaheer M, Khan SM, Rajasekaran V. Assessing the Safety and Efficacy of Rivaroxaban for Stroke Prevention in Patients With Atrial Fibrillation: A Systemic Review and Meta-Analysis. Cureus 2024; 16:e54252. [PMID: 38496142 PMCID: PMC10944328 DOI: 10.7759/cureus.54252] [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] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
An effective anticoagulation therapy is required for patients with atrial fibrillation because it presents a significant risk of stroke. The current study evaluates the relative safety as well as efficacy of rivaroxaban in patients who are diagnosed with atrial fibrillation. A thorough literature review of relevant databases was conducted, focusing on academic and clinical studies that were published from 2017 onward. Inclusion criteria comprised randomized controlled trials and other observational studies comparing the incidence of stroke and the safety index of rivaroxaban in atrial fibrillation. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) for data overview reporting and overview. A total of 21 studies were selected based on the inclusion criteria. A total of 19/21 studies advocated the adoption of rivaroxaban for minimizing stroke incidence. Rivaroxaban also showed superiority in achieving the therapeutic objectives, i.e., reduction in the incidence of stroke. The results for rivaroxaban against warfarin showed an improved safety index and effectiveness of rivaroxaban. The total effect size for the analysis was calculated to be Z=2.62 (p-value=0.009). The individual effect of all studies favored the "rivaroxaban" group. The heterogeneity in the study was as follows: tau2=0.10; chi2=110.10, df=6; I2=95%. The second analysis for risk reduction and incidence of stroke after rivaroxaban therapy also showed a bias towards rivaroxaban therapy. The combined effect for the analysis was found to be as follows: HR=0.73 ((95% CI: 0.50, 1.07). The total effect was calculated to be Z=1.61 (p-value= 0.10). The heterogeneity was found to be as follows: tau2= 0.20, chi2=89.97, df=6, I2=93%. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines.
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Affiliation(s)
- Ghazala S Virk
- Internal Medicine, Avalon University School of Medicine, Ohio, USA
| | - Sana Javed
- Medicine, University of Birmingham, Royal College of General Practitioners, Birmingham, GBR
| | | | - Mustafa M Moazam
- Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Arhum Mahmood
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | - Faraz Mahmood
- Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, USA
| | - Mohammed Zaheer
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Shahroz M Khan
- Medicine, Kansas Health Science Center (KHSC) College of Osteopathic Medicine, Wichita, USA
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11
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Popat A, Patel SK, Adusumilli S, Irshad A, Nagaraj A, Patel KK, Jani SY, Nawaz G, Wahab A, Bora S, Mittal L, Yadav S. Efficacy and Safety of Different Dosing Regimens of Rivaroxaban in Patients With Atrial Fibrillation for Stroke Prevention: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e51541. [PMID: 38313978 PMCID: PMC10834223 DOI: 10.7759/cureus.51541] [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] [Accepted: 12/31/2023] [Indexed: 02/06/2024] Open
Abstract
Atrial fibrillation (AF) poses a substantial risk of stroke, necessitating effective anticoagulation therapy. This systematic review and meta-analysis (SRMA) evaluates the efficacy and safety of different dosing regimens of rivaroxaban in patients with AF. A comprehensive search of relevant databases, focusing on studies published from 2017 onward, was conducted. Inclusion criteria comprised randomized controlled trials (RCTs) and observational studies comparing standard and reduced dosing of rivaroxaban in AF. Data extraction and risk of bias (ROB) assessment were performed, and a meta-analysis was conducted for relevant outcomes. A total of 21 studies fulfilled the inclusion criteria. Standard dosing demonstrates a slightly lower risk of composite effectiveness outcomes and safety outcomes (HR: 0.79, 95% CI: 0.66-0.94, P=0.01) compared to reduced dosing (HR: 0.83, 95% CI: 0.71-0.97, P=0.02). Notable differences in major bleeding, gastrointestinal bleeding (GIB), and intracranial bleeding favored standard dosing. Hemorrhagic stroke and all-cause stroke rates differed significantly, with standard dosing showing a more favorable profile for ischemic stroke prevention. This study highlights the pivotal role of personalized anticoagulation therapy in AF. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines. The study bridges evidence from clinical trials to real-world practice, offering insights into the evolving landscape of AF management.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | | | - Ahmed Irshad
- Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
| | - Aishwarya Nagaraj
- Surgery and Pharmacology, Our Lady of Fatima University, Bangalore, IND
| | - Krisha K Patel
- College of Medicine, Dr. M. K. Shah Medical College and Research Center, Ahmedabad, IND
| | - Stavan Y Jani
- Internal Medicine, Bukovinian State Medical University, Chernivtsi, UKR
| | - Gul Nawaz
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | - Abdul Wahab
- Internal Medicine, Sargodha Medical College, Sargodha, PAK
| | - Satya Bora
- Neurology, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Ahmedabad, IND
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12
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Eikelboom JW, Weitz JI. Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials. J Thromb Haemost 2023; 21:3067-3071. [PMID: 37429508 DOI: 10.1016/j.jtha.2023.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.
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Affiliation(s)
- John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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13
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Karthikeyan G, Watkins D, Bukhman G, Cunningham MW, Haller J, Masterson M, Mensah GA, Mocumbi A, Muhamed B, Okello E, Sotoodehnia N, Machipisa T, Ralph A, Wyber R, Beaton A. Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report. BMJ Glob Health 2023; 8:e012468. [PMID: 37914183 PMCID: PMC10618973 DOI: 10.1136/bmjgh-2023-012468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. However, several important scientific issues around the secondary prevention paradigm remain unresolved. This report details research priorities for secondary prevention that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. These span basic, translational, clinical and population science research disciplines and are built on four pillars. First, we need a better understanding of RHD epidemiology to guide programmes, policies, and clinical and public health practice. Second, we need better strategies to find and diagnose people affected by ARF and RHD. Third, we urgently need better tools to manage acute RF and slow the progression of RHD. Fourth, new and existing technologies for these conditions need to be better integrated into healthcare systems. We intend for this document to be a reference point for research organisations and research sponsors interested in contributing to the growing scientific community focused on RHD prevention and control.
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Affiliation(s)
| | - David Watkins
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John Haller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - George A Mensah
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non-Communicable Diseases Division, Instituto Nacional de Saúde, Marracuene, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Babu Muhamed
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington, USA
| | - Tafadzwa Machipisa
- Cape Heart Institute (CHI), Department of Medicine, University of Cape Town, Rondebosch, South Africa
- Clinical Research Laboratory & Biobank-Genetic & Molecular Epidemiology Laboratory (CRLB-GMEL), Population Health Research Institute, Hamilton, Ontario, Canada
| | - Anna Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Rosemary Wyber
- END RHD Program, Telethon Kids Institute, Perth, Western Australia, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Canberra, Australian Capital Territory, Australia
| | - Andrea Beaton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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14
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Vervoort D, Yilgwan CS, Ansong A, Baumgartner JN, Bansal G, Bukhman G, Cannon JW, Cardarelli M, Cunningham MW, Fenton K, Green-Parker M, Karthikeyan G, Masterson M, Maswime S, Mensah GA, Mocumbi A, Kpodonu J, Okello E, Remenyi B, Williams M, Zühlke LJ, Sable C. Tertiary prevention and treatment of rheumatic heart disease: a National Heart, Lung, and Blood Institute working group summary. BMJ Glob Health 2023; 8:e012355. [PMID: 37914182 PMCID: PMC10619050 DOI: 10.1136/bmjgh-2023-012355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
Although entirely preventable, rheumatic heart disease (RHD), a disease of poverty and social disadvantage resulting in high morbidity and mortality, remains an ever-present burden in low-income and middle-income countries (LMICs) and rural, remote, marginalised and disenfranchised populations within high-income countries. In late 2021, the National Heart, Lung, and Blood Institute convened a workshop to explore the current state of science, to identify basic science and clinical research priorities to support RHD eradication efforts worldwide. This was done through the inclusion of multidisciplinary global experts, including cardiovascular and non-cardiovascular specialists as well as health policy and health economics experts, many of whom also represented or closely worked with patient-family organisations and local governments. This report summarises findings from one of the four working groups, the Tertiary Prevention Working Group, that was charged with assessing the management of late complications of RHD, including surgical interventions for patients with RHD. Due to the high prevalence of RHD in LMICs, particular emphasis was made on gaining a better understanding of needs in the field from the perspectives of the patient, community, provider, health system and policy-maker. We outline priorities to support the development, and implementation of accessible, affordable and sustainable interventions in low-resource settings to manage RHD and related complications. These priorities and other interventions need to be adapted to and driven by local contexts and integrated into health systems to best meet the needs of local communities.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Annette Ansong
- Outpatient Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | | | - Geetha Bansal
- Division of International Training and Research, John E Fogarty International Center, Bethesda, Maryland, USA
| | - Gene Bukhman
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Disease and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey W Cannon
- Department of Global Health and Population, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Marcelo Cardarelli
- Pediatric Heart Surgery, Inova Children Hospital, Falls Church, Virginia, USA
| | | | - Kathleen Fenton
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Melissa Green-Parker
- National Institutes of Health Office of Disease Prevention, Bethesda, Maryland, USA
| | | | - Mary Masterson
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Salome Maswime
- Global Surgery, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - George A Mensah
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jacques Kpodonu
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - B Remenyi
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory of Australia, Australia
| | - Makeda Williams
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Liesl J Zühlke
- South African Medical Research Council, Tygerberg, South Africa
- Department of Medicine, Red Cross War Memorial Children's Hospital, Rondebosch, Western Cape, South Africa
| | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
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15
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Eleid MF, Nkomo VT, Pislaru SV, Gersh BJ. Valvular Heart Disease: New Concepts in Pathophysiology and Therapeutic Approaches. Annu Rev Med 2023; 74:155-170. [PMID: 36400067 DOI: 10.1146/annurev-med-042921-122533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This review discusses recent advancements in the field of valvular heart disease. Topics covered include recognition of the impact of atrial fibrillation on development and assessment of valvular disease, strategies for global prevention of rheumatic heart disease, understanding and management of secondary mitral regurgitation, the updated classification of bicuspid aortic valve disease, recognition of heightened cardiovascular risk associated with moderate aortic stenosis, and a growing armamentarium of transcatheter therapies.
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Affiliation(s)
- Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA;
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA;
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA;
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA;
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16
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De Caterina R, Prisco D, Eikelboom JW. Factor XI inhibitors: cardiovascular perspectives. Eur Heart J 2023; 44:280-292. [PMID: 36263776 DOI: 10.1093/eurheartj/ehac464] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Anticoagulants are the cornerstone for prevention and treatment of thrombosis but are not completely effective, and concerns about the risk of bleeding continue to limit their uptake. Animal studies and experience from patients with genetic coagulation factor XI deficiency suggesting that this factor is more important for thrombosis than for haemostasis raises the potential for drugs that target factor XI to provide safer anticoagulation. Multiple factor XI inhibitors are currently under evaluation in clinical trials, including parenterally administered antisense oligonucleotides, monoclonal antibodies, and orally active small-molecule inhibitors. Promising results of phase 2 trials in patients undergoing major orthopaedic surgery, and in those with end-stage kidney disease, atrial fibrillation and acute coronary syndromes have led to large phase 3 trials that are currently ongoing. We here review premises for the use of these agents, results so far accrued, ongoing studies, and perspectives for future patient care.
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Affiliation(s)
- Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Division of Cardiology, Pisa University Hospital, Pisa, Italy
| | - Domenico Prisco
- Chair of Internal Medicine, Department of Experimental and Clinical Medicine, University of Florence and Careggi University Hospital, Florence, Italy
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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17
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Welker CC, Huang J, Khromava M, Boswell MR, Gil IJN, Ramakrishna H. Analysis of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines for the Management of Valvular Heart Disease. J Cardiothorac Vasc Anesth 2023; 37:803-811. [PMID: 36775745 DOI: 10.1053/j.jvca.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Affiliation(s)
- Carson C Welker
- Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Iván J Núñez Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain; Biomedical Science Faculty, Universidad Europea de Madrid, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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18
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Bioprosthetic valves and atrial fibrillation: Direct anticoagulants or warfarin. J Thorac Cardiovasc Surg 2023; 165:71-75. [PMID: 34275622 DOI: 10.1016/j.jtcvs.2021.05.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 02/08/2023]
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19
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Martino FM, Bernardi M, Pingitore A, Biondi-Zoccai G. Another meta-analysis on novel oral anticoagulants for left ventricular thrombus: when enough is enough? J Cardiovasc Med (Hagerstown) 2023; 24:20-22. [PMID: 36574298 DOI: 10.2459/jcm.0000000000001393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences
| | - Annachiara Pingitore
- Department of General Surgery, Surgical Specialties and Organ Transplantation 'Paride Stefanini', Sapienza University of Rome, Rome
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina.,Mediterranea Cardiocentro, Napoli, Italy
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20
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Abstract
Delivery of comprehensive arrhythmia care requires the simultaneous presence of many resources. These include complex hospital infrastructure, expensive implantable equipment, and expert personnel. In many low- and middle-income countries (LMICs), at least 1 of these components is often missing, resulting in a gap between the demand for arrhythmia care and the capacity to supply care. In addition to this treatment gap, there exists a training gap, as many clinicians in LMICs have limited access to formal training in cardiac electrophysiology. Given the progressive increase in the burden of cardiovascular diseases in LMICs, these patient care and clinical training gaps will widen unless further actions are taken to build capacity. Several strategies for building arrhythmia care capacity in LMICs have been described. Medical missions can provide donations of both equipment and clinical expertise but are only intermittently present and therefore are not optimized to provide the longitudinal support needed to create self-sustaining infrastructure. Use of donated or reprocessed equipment (eg, cardiac implantable electronic devices) can reduce procedural costs but does not address the need for infrastructure, including diagnostics and expert personnel. Collaborative efforts involving multiple stakeholders (eg, professional organizations, government agencies, hospitals, and educational institutions) have the potential to provide longitudinal support of both patient care and clinician education in LMICs.
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Affiliation(s)
- Zain Sharif
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts,Cardiology Service, Hermitage Clinic, Fonthill, Ireland
| | - Leon M. Ptaszek
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts,Address reprint requests and correspondence: Dr Leon M. Ptaszek, Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street (GRB 825), Boston, MA 02114.
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21
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Gómez-Outes A, Suárez-Gea ML, Pérez-Cabeza AI, García-Pinilla JM. Pharmacotherapy for stroke prevention in nonvalvular atrial fibrillation: current strategies and future directions. Expert Opin Pharmacother 2022; 23:1941-1955. [DOI: 10.1080/14656566.2022.2149323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Antonio Gómez-Outes
- Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - M Luisa Suárez-Gea
- Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Alejandro-Isidoro Pérez-Cabeza
- UGC de Cardiología y Cirugía Cardiovascular, Instituto de Biomedicina de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Jose Manuel García-Pinilla
- UGC de Cardiología y Cirugía Cardiovascular, Instituto de Biomedicina de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
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22
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Steiner DK, Søgaard P, Jensen M, Bjerregaard Larsen T, Lip GYH, Nielsen PB. Risk of stroke or systemic embolism in patients with degenerative mitral stenosis with or without atrial fibrillation: A cohort study. IJC HEART & VASCULATURE 2022; 43:101126. [PMID: 36237964 PMCID: PMC9550603 DOI: 10.1016/j.ijcha.2022.101126] [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: 09/06/2022] [Revised: 09/20/2022] [Accepted: 09/24/2022] [Indexed: 11/05/2022]
Abstract
Background Atrial fibrillation (AF) is associated with an increased risk of stroke and the combination of AF and mitral stenosis (MS) is associated with a higher risk. In developed nations, degenerative mitral stenosis (DMS) constitutes a sizeable proportion of patients with MS. Current international guidelines do not offer recommendations regarding anticoagulation in these patients. The objective of this study was to describe the incidence of stroke or systemic embolism in patients with DMS with or without prevalent AF. Methods A cohort study of DMS patients from 1997 to 2018, using data from the Danish health registries. The cohort was stratified based on AF prevalence and prior ischemic stroke. The primary outcome was a diagnosis of ischemic stroke or systemic embolism after 1 year of follow-up from time of DMS diagnosis. Results The study included 1162 patients with DMS, of which 421 had prevalent AF. The incidence rate of stroke or systemic embolism after 1 year of follow-up was highest in the DMS without AF group (7.58 vs. 6.63 per 100 person-years). In both groups, DMS without AF and DMS with AF, the incidence rate was highest in patients with prior thromboembolic events (29.61 vs. 5.15 and 19.53 vs. 5.15, respectively). Conclusions The incidence rate of stroke or systemic embolism was highest in DMS patients without AF. Current Danish guidelines recommend DMS patients should be treated with anticoagulation only with concurrent AF, yet our results call for additional research to establish if DMS patients without AF could benefit from stroke prevention therapy.
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Affiliation(s)
- Daniel Kjærgaard Steiner
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark,Corresponding author.
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Yoke Hong Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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23
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Connolly SJ, Karthikeyan G, Ntsekhe M, Haileamlak A, El Sayed A, El Ghamrawy A, Damasceno A, Avezum A, Dans AML, Gitura B, Hu D, Kamanzi ER, Maklady F, Fana G, Gonzalez-Hermosillo JA, Musuku J, Kazmi K, Zühlke L, Gondwe L, Ma C, Paniagua M, Ogah OS, Molefe-Baikai OJ, Lwabi P, Chillo P, Sharma SK, Cabral TTJ, Tarhuni WM, Benz A, van Eikels M, Krol A, Pattath D, Balasubramanian K, Rangarajan S, Ramasundarahettige C, Mayosi B, Yusuf S. Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation. N Engl J Med 2022; 387:978-988. [PMID: 36036525 DOI: 10.1056/nejmoa2209051] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Testing of factor Xa inhibitors for the prevention of cardiovascular events in patients with rheumatic heart disease-associated atrial fibrillation has been limited. METHODS We enrolled patients with atrial fibrillation and echocardiographically documented rheumatic heart disease who had any of the following: a CHA2DS2VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating a higher risk of stroke), a mitral-valve area of no more than 2 cm2, left atrial spontaneous echo contrast, or left atrial thrombus. Patients were randomly assigned to receive standard doses of rivaroxaban or dose-adjusted vitamin K antagonist. The primary efficacy outcome was a composite of stroke, systemic embolism, myocardial infarction, or death from vascular (cardiac or noncardiac) or unknown causes. We hypothesized that rivaroxaban therapy would be noninferior to vitamin K antagonist therapy. The primary safety outcome was major bleeding according to the International Society of Thrombosis and Hemostasis. RESULTS Of 4565 enrolled patients, 4531 were included in the final analysis. The mean age of the patients was 50.5 years, and 72.3% were women. Permanent discontinuation of trial medication was more common with rivaroxaban than with vitamin K antagonist therapy at all visits. In the intention-to-treat analysis, 560 patients in the rivaroxaban group and 446 in the vitamin K antagonist group had a primary-outcome event. Survival curves were nonproportional. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the vitamin K antagonist group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P<0.001). A higher incidence of death occurred in the rivaroxaban group than in the vitamin K antagonist group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted. CONCLUSIONS Among patients with rheumatic heart disease-associated atrial fibrillation, vitamin K antagonist therapy led to a lower rate of a composite of cardiovascular events or death than rivaroxaban therapy, without a higher rate of bleeding. (Funded by Bayer; INVICTUS ClinicalTrials.gov number, NCT02832544.).
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Affiliation(s)
- Stuart J Connolly
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Ganesan Karthikeyan
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Mpiko Ntsekhe
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Abraham Haileamlak
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Ahmed El Sayed
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Alaa El Ghamrawy
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Albertino Damasceno
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Alvaro Avezum
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Antonio M L Dans
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Bernard Gitura
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Dayi Hu
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Emmanuel R Kamanzi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Fathi Maklady
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Golden Fana
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - J Antonio Gonzalez-Hermosillo
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - John Musuku
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Khawar Kazmi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Liesl Zühlke
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Lillian Gondwe
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Changsheng Ma
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Maria Paniagua
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Okechukwu S Ogah
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Onkabetse J Molefe-Baikai
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Peter Lwabi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Pilly Chillo
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Sanjib K Sharma
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Tantchou T J Cabral
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Wadea M Tarhuni
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Alexander Benz
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Martin van Eikels
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Amy Krol
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Divya Pattath
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Kumar Balasubramanian
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Sumathy Rangarajan
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Chinthanie Ramasundarahettige
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Bongani Mayosi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Salim Yusuf
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
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Sadeghipour P, Farrashi M, De Caterina R. Response to "Non-vitamin K antagonist oral anticoagulants (NOACs) in preventing thromboembolism in atrial fibrillation patients with moderate to severe mitral stenosis: Results from a pilot trial". Int J Cardiol 2022; 362:137-138. [PMID: 35500822 DOI: 10.1016/j.ijcard.2022.04.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Melody Farrashi
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Raffaele De Caterina
- University Cardiology Division, Pisa University Hospital, Pisa, Italy; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy.
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Rentta NN, Bennett J, Leung W, Webb R, Jack S, Harwood M, Baker MG, Lund M, Wilson N. Medical Treatment for Rheumatic Heart Disease: A Narrative Review. Heart Lung Circ 2022; 31:1463-1470. [PMID: 35987720 DOI: 10.1016/j.hlc.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are rare in high-income countries; however, in Aotearoa New Zealand ARF and RHD disproportionately affect Indigenous Māori and Pacific Peoples. This narrative review explores the evidence regarding non-surgical management of patients with clinically significant valve disease or heart failure due to RHD. METHODS Medline, EMBASE and Scopus databases were searched, and additional publications were identified through cross-referencing. Included were 28 publications from 1980 onwards. RESULTS Of the available interventions, improved anticoagulation management and a national RHD register could improve RHD outcomes in New Zealand. Where community pharmacy anticoagulant management services (CPAMS) are available good anticoagulation control can be achieved with a time in the therapeutic range (TTR) of more than 70%, which is above the internationally recommended level of 60%. The use of pharmacists in anticoagulation control is cost-effective, acceptable to patients, pharmacists, and primary care practitioners. There is a lack of local data available to fully assess other interventions; including optimal therapy for heart failure, equitable access to specialist RHD care, prevention, and management of endocarditis. CONCLUSION As RHD continues to disproportionately affect Indigenous and minority groups, pro-equity tertiary prevention interventions should be fully evaluated to ensure they are reducing disease burden and improving outcomes in patients with RHD.
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Affiliation(s)
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand.
| | - William Leung
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Rachel Webb
- Auckland District Health Board, Auckland, New Zealand; University of Auckland, Department of Paediatrics: Child and Youth Health, Auckland, New Zealand
| | - Susan Jack
- Public Health South, Southern District Health Board, Dunedin, New Zealand
| | - Matire Harwood
- General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Mayanna Lund
- Counties Manukau District Health Board, Auckland, New Zealand
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand; Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
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Mechanism of Sevoflurane Anesthesia under Hypothermic Cardiopulmonary Bypass on Postoperative Atrial Fibrillation Rhythm in Patients Undergoing Mitral Valve Replacement. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5312897. [PMID: 35800224 PMCID: PMC9256416 DOI: 10.1155/2022/5312897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022]
Abstract
Objective It was to investigate the mechanism of atrial fibrillation after mitral valve replacement under extracorporeal circulation in patients with rheumatic heart disease under sevoflurane anesthesia maintenance and to provide scientific and effective basis for clinical treatment. Methods Forty patients with rheumatic heart disease who underwent mitral valve replacement were randomly rolled into group I (sinus rhythm of propofol anesthesia, n = 10), group II (atrial fibrillation rhythm of propofol anesthesia, n = 10), group III (sinus rhythm of sevoflurane anesthesia, n = 10), and group IV (atrial fibrillation rhythm of sevoflurane anesthesia, n = 10). Inflammatory factors, free tissue of right atrium, and incidence of postoperative atrial fibrillation were compared among all groups. Results (i) The serum levels of NT-proBNP, CRP, sST-2, IL-6, TNF-α, and TGF-β1 in group II were higher than those in group I, group III, and group IV, and the indexes in group III were higher than those in group IV (P < 0.05). (ii) The relative expression levels of PLB, CaMK II, Bax, and TP53 in the free tissue of right atrium in group II were higher than those in group I, III, and IV, and the index levels in group IV were higher than those in group III (P < 0.05). (iii) The incidence of postoperative atrial fibrillation in group III (0.00%) was significantly lower than that in group I (30%), group II (50%), and group IV (40.0%), and group II (50%) was the highest (P < 0.05). Conclusion The maintenance of sevoflurane anesthesia can improve the inflammatory response and myocardial tissue autophagy in patients with sinus rhythm and atrial fibrillation rhythm and can reduce the incidence of postoperative atrial fibrillation in patients.
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Weldegerima AH, Tesfay H, Berhane S, Leuner CJ. Tigray Siege and its impact on cardiology services in Mekelle University Hospital: a call to action. Eur Heart J 2022; 43:3095-3097. [PMID: 35713963 DOI: 10.1093/eurheartj/ehac295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Abraha Hailu Weldegerima
- Department of Internal Medicine, Cardiology Unit, Ayder Comprehensive Specialized Hospital, Mekelle University-College of Health Sciences, Mekelle, Ethiopia
| | - Hagazi Tesfay
- Department of Internal Medicine, Cardiology Unit, Ayder Comprehensive Specialized Hospital, Mekelle University-College of Health Sciences, Mekelle, Ethiopia
| | - Samuel Berhane
- Department of Internal Medicine, Cardiology Unit, Ayder Comprehensive Specialized Hospital, Mekelle University-College of Health Sciences, Mekelle, Ethiopia
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Effect of Combined Etomidate-Ketamine Anesthesia on Perioperative Electrocardiogram and Postoperative Cognitive Dysfunction of Elderly Patients with Rheumatic Heart Valve Disease Undergoing Heart Valve Replacement. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6205757. [PMID: 35035849 PMCID: PMC8759869 DOI: 10.1155/2022/6205757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022]
Abstract
Objective To explore the effect of combined etomidate-ketamine anesthesia on perioperative electrocardiogram (ECG) and postoperative cognitive dysfunction (POCD) of elderly patients with rheumatic heart valve disease (RHVD) undergoing heart valve replacement. Methods The data of 100 elderly RHVD patients treated in our hospital from May 2019 to May 2020 were selected for the retrospective analysis, and by adopting the double-blind method, the patients were divided into the ketamine group (n = 50) and the combined group (n = 50) according to the anesthesia methods. During the induction of anesthesia, the patients of the two groups were given a small dose of ketamine (0.5 mg/kg) at 5 μg/kg/min continuously via pump injection until the end of surgery, and on this basis, with the same anesthesia measures, those in the combined group were given etomidate (0.3 mg/kg) additionally. The patients' perioperative ECG indicators, POCD scores, and Numeric Rating Scale (NRS) scores were compared between the two groups. Results Compared with the ketamine group, the combined group presented significantly lower incidence of ST-T wave changes after anesthesia induction and at the time of intubation and skin incision (P < 0.05), significantly lower average magnitude of ST-segment depression after anesthesia induction (P < 0.001), significantly lower average magnitude of ST-segment elevation after anesthesia induction and extubation (P < 0.001), significantly lower POCD incidence (6.%, P < 0.05), and significantly better NRS score after surgery (P < 0.001). Conclusion Combined etomidate-ketamine anesthesia can stabilize the perioperative ECG indicators of elderly RHVD patients undergoing heart valve replacement, improve their postoperative cognitive function, and reduce their pain sensation, which should be promoted and applied in practice.
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Xu Y, Han D, Huang T, Zhang X, Lu H, Shen S, Lyu J, Wang H. Predicting ICU Mortality in Rheumatic Heart Disease: Comparison of XGBoost and Logistic Regression. Front Cardiovasc Med 2022; 9:847206. [PMID: 35295254 PMCID: PMC8918628 DOI: 10.3389/fcvm.2022.847206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRheumatic heart disease (RHD) accounts for a large proportion of Intensive Care Unit (ICU) deaths. Early prediction of RHD can help with timely and appropriate treatment to improve survival outcomes, and the XGBoost machine learning technology can be used to identify predictive factors; however, its use has been limited in the past. We compared the performance of logistic regression and XGBoost in predicting hospital mortality among patients with RHD from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database.MethodsThe patients with RHD in the MIMIC-IV database were divided into two groups retrospectively according to the availability of data and its clinical significance based on whether they survived or died. Backward stepwise regression was used to analyze the independent factors influencing patients with RHD, and to compare the differences between the two groups. The XGBoost algorithm and logistic regression were used to establish two prediction models, and the areas under the receiver operating characteristic curves (AUCs) and decision-curve analysis (DCA) were used to test and compare the models. Finally, DCA and the clinical impact curve (CIC) were used to validate the model.ResultsData on 1,634 patients with RHD were analyzed, comprising 207 who died during hospitalization and 1,427 survived. According to estimated results for the two models using AUCs [0.838 (95% confidence interval = 0.786–0.891) and 0.815 (95% confidence interval = 0.765–0.865)] and DCA, the logistic regression model performed better. DCA and CIC verified that the logistic regression model had convincing predictive value.ConclusionsWe used logistic regression analysis to establish a more meaningful prediction model for the final outcome of patients with RHD. This model might be clinically useful for patients with RHD and help clinicians to provide detailed treatments and precise management.
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Affiliation(s)
- Yixian Xu
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Didi Han
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaoshen Zhang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hua Lu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Si Shen
- Department of Radiology, Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Jun Lyu
| | - Hao Wang
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Hao Wang
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Fanaroff AC, Vora AN, Lopes RD. Non-vitamin K antagonist oral anticoagulants in patients with valvular heart disease. Eur Heart J Suppl 2022; 24:A19-A31. [PMID: 35185406 PMCID: PMC8850709 DOI: 10.1093/eurheartj/suab151] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban have transformed the management of atrial fibrillation (AF), but are only approved by regulatory authorities for stroke prophylaxis in patients with so-called "non-valvular AF." This terminology has spawned confusion about which patients with valvular heart disease benefit from NOACs and which should be treated with vitamin K antagonists (VKAs) instead. Patients with valvular heart disease other than mechanical prosthetic valves or severe mitral stenosis (including those with bioprosthetic valves) were included in pivotal trials demonstrating the benefit of NOACs over VKAs, and consensus guidelines recommend NOACs over VKAs in these patients. Subsequent devoted randomized controlled trials in patients with AF and bioprosthetic valves, including transcatheter valves, have confirmed the safety of NOACs in this population. In patients with rheumatic mitral stenosis, observational studies indicate that NOACs may be safe and effective, but randomized controlled trials are ongoing. By contrast, a randomized controlled trial showed that dabigatran is harmful in patients with mechanical prosthetic mitral valves; however, these data may not extrapolate to patients with mechanical valve prostheses in other locations or to other NOACs, and randomized controlled trials are ongoing. In this review, we discuss these data in greater depth, and make recommendations for the use of NOACs in patients with valvular heart disease.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiovascular Medicine, Department of Medicine; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center; and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Amit N Vora
- UPMC Heart and Vascular Institute, Harrisburg, PA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Duke University, 2400 Pratt St, Durham, NC 27710, USA
| | - Renato D Lopes
- Division of Cardiovascular Medicine, Department of Medicine, Duke University, 2400 Pratt St, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715, USA
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Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade's achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
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Abstract
PURPOSE OF REVIEW Rheumatic heart disease (RHD) is a neglected disease of poverty, which presents challenges for patients, communities, and health systems. These effects are magnified in low resource countries, which bear the highest disease burden. When considering the impact of RHD, it is imperative that we widen our lens in order to better understand how RHD impacts the over 40 million people currently living with this preventable condition and their communities. We aimed to perform an updated literature review on the global impact of RHD, examining a broad range of aspects from disease burden to impact on healthcare system to socioeconomic implications. RECENT FINDINGS RHD accounts for 1.6% of all cardiovascular deaths, resulting in 306,000 deaths yearly, with a much higher contribution in low- and middle-income countries, where 82% of the deaths occurred in 2015. RHD can result in severe health adverse outcomes, markedly heart failure, arrhythmias, stroke and embolisms, and ultimately premature death. Thus, preventive, diagnostic and therapeutic interventions are required, although insufficiently available in undersourced settings. As examples, anticoagulation management is poor in endemic regions - and novel oral anticoagulants cannot be recommended - and less than 15% of those in need have access to interventional procedures and valve replacement in Africa. RHD global impact remains high and unequally distributed, with a marked impact on lower resourced populations. This preventable disease negatively affects not only patients, but also the societies and health systems within which they live, presenting broad challenges and high costs along the pathway of prevention, diagnosis, and management.
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Tretter JT, Jacobs JP. Global leadership in paediatric and congenital cardiac care: "global health advocacy, lift as you rise - an interview with Liesl J. Zühlke, MBChB, MPH, PhD". Cardiol Young 2021; 31:1549-1556. [PMID: 34602114 DOI: 10.1017/s104795112100411x] [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] [Indexed: 11/07/2022]
Abstract
Professor Liesl Zühlke is the focus of our fifth in a series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Professor Zühlke (nee Hendricks) was born in Cape Town, South Africa. She would attend medical school in her hometown at University of Cape Town, graduating in 1991. Professor Zühlke then went on to complete a Diploma in Child Health at College of Medicine in Cape Town followed by completion of her Paediatric and Paediatric Cardiology training in 1999 and 2007, respectively. She would subsequently complete her Masters of Public Health (Clinical Research Methods) at the University of Cape Town, completing her dissertation in 2011 on computer-assisted auscultation as a screening tool for cardiovascular disease, under the supervision of Professors Landon Myer and Bongani Mayosi.Professor Zühlke began her clinical position as a paediatric cardiologist in the Department of Paediatrics and Child Health at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa in 2007. In this role, she has been instrumental in developing a transitional clinic at the paediatric hospital, is a team member of the combined cardio-obstetric and grown-up congenital heart disease clinics, each of which are rare in South Africa, with very few similar clinics in Africa. Professor Zühlke would continue her research training, completing her Doctorate at the University of Cape Town in 2015, with her dissertation on the outcomes of asymptomatic and symptomatic rheumatic heart disease under the supervision of Professor Bongani Mayosi and Associate Professor Mark Engel. In 2015, in affiliation with the University of Cape Town and the Department of Paediatrics and the Institute of Child Health, she established The Children's Heart Disease Research Unit, with the goals to conduct, promote and support paediatric cardiac research on the African continent, facilitate Implementation Science and provide postgraduate supervision and training in paediatric cardiac research. In 2018, she would subsequently complete her Master of Science at the London School of Economics in Health Economics, Outcomes and Management of cardiovascular sciences. Professor Zühlke currently serves as the acting Deputy-Dean of Research at the Faculty of Health Sciences, University of Cape Town.Professor Zühlke has achieved the highest leadership positions within cardiology in South Africa, including President of the Paediatric Cardiac Society of South Africa and President of the South African Heart Association. She is internationally regarded as a leader in research related to rheumatic heart disease. Professor Zühlke's work includes patient, family and health advocacy on a global scale, being involved in the development of policies that have been adopted by major global organisations such as the World Health Organization. In addition to her clinical and research efforts, she is highly regarded by students, colleagues and graduates as an effective teacher, mentor and advisor. This article presents our interview with Professor Zühlke, an interview that covers her experience as a thought leader in the field of Paediatric Cardiology, specifically in her work related to rheumatic heart disease, Global Health and paediatric and congenital cardiac care in resource-limited settings.
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Affiliation(s)
- Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Children's Hospital, Gainesville, FL, USA
- Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
- Cardiology in the Young, Cambridge University Press, Cambridge, UK
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Turek Ł, Sadowski M, Janion-Sadowska A, Kurzawski J, Andrychowski J. Giant Left Atrial Thrombus Despite Anticoagulation with Apixaban in a Patient with Mitral Stenosis and Atrial Fibrillation. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933162. [PMID: 34561412 PMCID: PMC8477984 DOI: 10.12659/ajcr.933162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 64-year-old
Final Diagnosis: Thrombus
Symptoms: Fatigue • palpitation
Medication: —
Clinical Procedure: —
Specialty: Cardiology
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Affiliation(s)
- Łukasz Turek
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Marcin Sadowski
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | | | - Jacek Kurzawski
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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Machipisa T, Chong M, Muhamed B, Chishala C, Shaboodien G, Pandie S, de Vries J, Laing N, Joachim A, Daniels R, Ntsekhe M, Hugo-Hamman CT, Gitura B, Ogendo S, Lwabi P, Okello E, Damasceno A, Novela C, Mocumbi AO, Madeira G, Musuku J, Mtaja A, ElSayed A, Elhassan HHM, Bode-Thomas F, Okeahialam BN, Zühlke LJ, Mulder N, Ramesar R, Lesosky M, Parks T, Cordell HJ, Keavney B, Engel ME, Paré G. Association of Novel Locus With Rheumatic Heart Disease in Black African Individuals: Findings From the RHDGen Study. JAMA Cardiol 2021; 6:1000-1011. [PMID: 34106200 PMCID: PMC8190704 DOI: 10.1001/jamacardio.2021.1627] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/25/2021] [Indexed: 01/02/2023]
Abstract
Importance Rheumatic heart disease (RHD), a sequela of rheumatic fever characterized by permanent heart valve damage, is the leading cause of cardiac surgery in Africa. However, its pathophysiologic characteristics and genetics are poorly understood. Understanding genetic susceptibility may aid in prevention, control, and interventions to eliminate RHD. Objective To identify common genetic loci associated with RHD susceptibility in Black African individuals. Design, Setting, and Participants This multicenter case-control genome-wide association study (GWAS), the Genetics of Rheumatic Heart Disease, examined more than 7 million genotyped and imputed single-nucleotide variations. The 4809 GWAS participants and 116 independent trio families were enrolled from 8 African countries between December 31, 2012, and March 31, 2018. All GWAS participants and trio probands were screened by use of echocardiography. Data analyses took place from May 15, 2017, until March 14, 2021. Main Outcomes and Measures Genetic associations with RHD. Results This study included 4809 African participants (2548 RHD cases and 2261 controls; 3301 women [69%]; mean [SD] age, 36.5 [16.3] years). The GWAS identified a single RHD risk locus, 11q24.1 (rs1219406 [odds ratio, 1.65; 95% CI, 1.48-1.82; P = 4.36 × 10-8]), which reached genome-wide significance in Black African individuals. Our meta-analysis of Black (n = 3179) and admixed (n = 1055) African individuals revealed several suggestive loci. The study also replicated a previously reported association in Pacific Islander individuals (rs11846409) at the immunoglobulin heavy chain locus, in the meta-analysis of Black and admixed African individuals (odds ratio, 1.16; 95% CI, 1.06-1.27; P = 1.19 × 10-3). The HLA (rs9272622) associations reported in Aboriginal Australian individuals could not be replicated. In support of the known polygenic architecture for RHD, overtransmission of a polygenic risk score from unaffected parents to affected probands was observed (polygenic transmission disequilibrium testing mean [SE], 0.27 [0.16] SDs; P = .04996), and the chip-based heritability was estimated to be high at 0.49 (SE = 0.12; P = 3.28 × 10-5) in Black African individuals. Conclusions and Relevance This study revealed a novel candidate susceptibility locus exclusive to Black African individuals and an important heritable component to RHD susceptibility in African individuals.
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Affiliation(s)
- Tafadzwa Machipisa
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
- Hatter Institute for Cardiovascular Diseases Research in Africa and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
| | - Michael Chong
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
| | - Babu Muhamed
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
- Hatter Institute for Cardiovascular Diseases Research in Africa and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
| | - Chishala Chishala
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
- Hatter Institute for Cardiovascular Diseases Research in Africa and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gasnat Shaboodien
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
- Hatter Institute for Cardiovascular Diseases Research in Africa and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shahiemah Pandie
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jantina de Vries
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Nakita Laing
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Alexia Joachim
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Rezeen Daniels
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Mpiko Ntsekhe
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Christopher T. Hugo-Hamman
- Rheumatic Heart Disease Clinic, Windhoek Central Hospital, Ministry of Health and Social Services, Windhoek, Republic of Namibia
| | - Bernard Gitura
- Cardiology Department of Medicine, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Stephen Ogendo
- Cardiology Department of Medicine, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | | | | | - Albertino Damasceno
- Faculty of Medicine, Eduardo Mondlane University/Nucleo de Investigaçao, Departamento de Medicina, Hospital Central de Maputo, Maputo, Mozambique
| | - Celia Novela
- Faculty of Medicine, Eduardo Mondlane University/Nucleo de Investigaçao, Departamento de Medicina, Hospital Central de Maputo, Maputo, Mozambique
| | - Ana O. Mocumbi
- Instituto Nacional de Saúde Ministério da Saúde, Maputo, Moçambique
| | - Goeffrey Madeira
- Emergency Department, World Health Organization Mozambique, Maputo, Mozambique
| | - John Musuku
- Department of Paediatrics and Child Health, University Teaching Hospital–Children’s Hospital, University of Zambia, Lusaka, Zambia
| | - Agnes Mtaja
- Department of Paediatrics and Child Health, University Teaching Hospital–Children’s Hospital, University of Zambia, Lusaka, Zambia
| | - Ahmed ElSayed
- Department of Cardiothoracic Surgery, Alshaab Teaching Hospital, Alazhari Health Research Center, Alzaiem Alazhari University, Khartoum, Sudan
| | - Huda H. M. Elhassan
- Department of Cardiothoracic Surgery, Alshaab Teaching Hospital, Alazhari Health Research Center, Alzaiem Alazhari University, Khartoum, Sudan
| | - Fidelia Bode-Thomas
- Department of Paediatrics, Jos University Teaching Hospital and University of Jos, Jos, Plateau State Nigeria
| | - Basil N. Okeahialam
- Department of Paediatrics, Jos University Teaching Hospital and University of Jos, Jos, Plateau State Nigeria
| | - Liesl J. Zühlke
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa
| | - Nicola Mulder
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Raj Ramesar
- Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Tom Parks
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Heather J. Cordell
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, United Kingdom
| | - Bernard Keavney
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
- Manchester University National Health Service Foundation Trust, Manchester Academic Health Science CentreManchester, United Kingdom
| | - Mark E. Engel
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Guillaume Paré
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton Ontario, Canada
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Freedman B, Hindricks G, Banerjee A, Baranchuk A, Ching CK, Du X, Fitzsimons D, Healey JS, Ikeda T, Lobban TCA, Mbakwem A, Narasimhan C, Neubeck L, Noseworthy P, Philbin DM, Pinto FJ, Rwebembera J, Schnabel RB, Svendsen JH, Aguinaga L, Arbelo E, Böhm M, Farhan HA, Hobbs FDR, Martínez-Rubio A, Militello C, Naik N, Noubiap JJ, Perel P, Piñeiro DJ, Ribeiro AL, Stepinska J. World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update. Glob Heart 2021; 16:41. [PMID: 34211827 PMCID: PMC8162289 DOI: 10.5334/gh.1023] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023] Open
Abstract
The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, University of Sydney, Sydney, AU
| | | | | | | | | | - Xin Du
- Beijing Anzhen Hospital, Capital Medical University, CN
| | | | | | | | - Trudie C. A. Lobban
- Arrhythmia Alliance & Atrial Fibrillation Association, Stratford Upon Avon, UK
| | - Amam Mbakwem
- Lagos University Teaching Hospital, Idi Araba, Lagos, NG
| | | | | | | | | | - Fausto J. Pinto
- Santa Maria University Hospital (CHULN), CAML, CCUL, Lisboa, PT
| | | | | | | | | | - Elena Arbelo
- Hospital Clinic de Barcelona, Universitat de Barcelona, ES
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Hornburg/Saar, DE
| | | | | | | | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi, IN
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Semakula JR, Kisa G, Mouton JP, Cohen K, Blockman M, Pirmohamed M, Sekaggya-Wiltshire C, Waitt C. Anticoagulation in sub-Saharan Africa: Are direct oral anticoagulants the answer? A review of lessons learnt from warfarin. Br J Clin Pharmacol 2021; 87:3699-3705. [PMID: 33624331 DOI: 10.1111/bcp.14796] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/19/2021] [Accepted: 02/17/2021] [Indexed: 12/18/2022] Open
Abstract
Warfarin has existed for >7 decades and has been the anticoagulant of choice for many thromboembolic disorders. The recent introduction of direct-acting oral anticoagulants (DOACs) has, however, caused a shift in preference by healthcare professionals all over the world. DOACs have been found to be at least as effective as warfarin in prevention of stroke in patients with atrial fibrillation and in treatment of venous thromboembolism. In sub-Saharan Africa, however, the widespread use of DOACs has been hampered mainly by their higher acquisition costs. As the drugs come off patent, their use in sub-Saharan Africa is likely to increase. However, very few trials have been conducted in African settings, and safety concerns will need to be addressed with further study before widespread adoption into clinical practice.
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Affiliation(s)
- Jerome Roy Semakula
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Geraldine Kisa
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Johannes P Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | | | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Long-term oral anticoagulation for atrial fibrillation in low and middle income countries. Indian Heart J 2021; 73:244-248. [PMID: 33865530 PMCID: PMC8065364 DOI: 10.1016/j.ihj.2021.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/12/2021] [Accepted: 02/07/2021] [Indexed: 01/01/2023] Open
Abstract
With increasing life-expectancy and changing demographics, non-valvular atrial fibrillation (AF) is currently the most common indication for long-term oral anticoagulation (OAC) in low and middle income countries (LMICs). Due to a decreasing trend in the prevalence of rheumatic heart disease (RHD), valve disease as a primary cause of AF now constitutes a small fraction of all people with AF. Moreover, emerging data also indicate that, patients with significant valve disease and AF may have a risk of stroke similar to, if not lower than, those with non-valvular AF. Previous trials of anticoagulation for AF excluded people from LMICs partly because valvular AF constituted a large proportion of those with AF, and it was thought to confer a prohibitively high risk of stroke. Trialists should therefore be less reluctant to include patients with AF from LMICs in general, and those with valve disease in particular, in future trials of anticoagulation. The quality of vitamin K antagonist based oral anticoagulation remains poor in LMICs to a large extent because of poor monitoring. The widespread use of the direct oral anticoagulants (DOAC) presents a practical approach to improve anticoagulation quality. Randomised trials of DOACs in valvular AF are particularlycriticalto bridge the knowledge gap in this area. Discussions regarding oral anticoagulation (OAC) use in low and middle income countries (LMICs) have historicallybeendominated by severallong-held beliefs. The first is that the quality of vitamin K antagonist (VKA) based anticoagulation is poor in these countries. The veracity of this assumption is supported by a large number of studies documenting both lower prescription of OACs, and a lower proportion of international normalised ratio (INR) values in the therapeutic range.1The second is that a large proportion of patients receiving OAC in LMICs have atrial fibrillation (AF) related to valvular heart disease, and rheumatic mitral stenosis in particular. This assumption, perhaps valid several decades ago, is no longer supported by the data. Finally, patients with valvular heart disease and AF (specifically those with moderate or severe valve lesions), are thought to be at prohibitively high thromboembolic risk. 2 However, recent evidence suggests that this risk may have been overestimated.34Nevertheless, the aforementioned assumptions continue to contribute to the underrepresentation of patients from LMICs in clinical trials of oral anticoagulation. Knowledge of the characteristics of contemporary patients in LMICs who are eligible for long-term OAC, estimates of their stroke risk, and a better understanding of the drivers of poor anticoagulation quality, may help guide research and clinical practice. In this review, we seek to provide an evidence-based perspective on OAC use in patients with AF living in LMICs and China.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India
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40
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Benz AP, Healey JS, Chin A, Commerford P, Marsden T, Karthikeyan G, McIntyre WF, Wong JA, Damasceno A, Hohnloser SH, Oldgren J, Wallentin L, Ezekowitz MD, Eikelboom JW, Yusuf S, Connolly SJ. Stroke risk prediction in patients with atrial fibrillation with and without rheumatic heart disease. Cardiovasc Res 2021; 118:295-304. [PMID: 33386845 DOI: 10.1093/cvr/cvaa344] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/09/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), especially mitral stenosis, are assumed to be at high risk of stroke, irrespective of other factors. We aimed to re-evaluate stroke risk factors in a contemporary cohort of AF patients. METHODS AND RESULTS We analyzed data of 15,400 AF patients presenting to an emergency department and who were enrolled in the global RE-LY AF registry, representing 47 countries from all inhabited continents. Follow-up occurred at 1 year after enrollment. A total of 1,788 (11.6%) patients had RHD. These patients were younger (51.4 ± 15.7 vs. 67.8 ± 13.6 years), more likely to be female (66.2% vs. 44.7%) and had a lower mean CHA2DS2-VASc score (2.1 ± 1.7 vs. 3.7 ± 2.2) as compared to patients without RHD (all p < 0.001). Significant mitral stenosis (average mean transmitral gradient 11.5 ± 6.5 mmHg) was the predominant valve lesion in those with RHD (59.6%). Patients with RHD had a higher baseline rate of anticoagulation use (60.4% vs. 45.2%, p < 0.001). Unadjusted stroke rates at 1 year were 2.8% and 4.1% for patients with and without RHD, respectively. The performance of the CHA2DS2-VASc score was modest in both groups (stroke at 1 year, c-statistics 0.69, 95% confidence interval [CI] 0.60-0.78 and 0.63, 95% CI 0.61-0.66, respectively). In the overall cohort, advanced age, female sex, prior stroke, tobacco use and non-use of anticoagulation were predictors for stroke (all p < 0.05). Mitral stenosis was not associated with stroke risk (adjusted odds ratio 1.07, 95% CI 0.67-1.72, p = 0.764). CONCLUSIONS The performance of the CHA2DS2-VASc score was modest in AF patients both with and without RHD. In this cohort, moderate-to-severe mitral stenosis was not an independent risk factor for stroke. TRANSLATIONAL PERSPECTIVE Based on studies conducted several decades ago, the presence of moderate-to-severe mitral stenosis has been associated with a very high risk of stroke in patients with AF. Our results, based on a large, global sample of contemporary patients with AF that contained a significant proportion of individuals with RHD, challenge the assumption that mitral stenosis is a major, independent risk factor for stroke. The performance of the widely used CHA2DS2-VASc score was modest in both patients with and without RHD. At least one ongoing randomized trial is evaluating the optimal antithrombotic strategy in patients with AF and RHD.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ashley Chin
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, and University of Cape Town, South Africa
| | - Patrick Commerford
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, and University of Cape Town, South Africa
| | - Tamara Marsden
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ganesan Karthikeyan
- Department of Cardiology, All India, Institute of Medical Sciences, New Delhi, India
| | - William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Stefan H Hohnloser
- Division Clinical Electrophysiology, Department of Cardiology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Michael D Ezekowitz
- Sidney Kimmel Medical College, at Thomas Jefferson University and Lankenau and Bryn Mawr Hospitals, Philadelphia, Pennsylvania, United States
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada
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Ansari A, Pattnaik N, Chakraborty P, Devasenapathy N. Use and assessment of knowledge of Vitamin K antagonist therapy in cardiac patients: A Tertiary Care Hospital-based survey. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.4103/jpcs.jpcs_16_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non–vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non–vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non–vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non–vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeff S. Healey
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, Canada (J.S.H.)
| | - Robert G. Hart
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
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Guimarães HP, Lopes RD, de Barros E Silva PGM, Liporace IL, Sampaio RO, Tarasoutchi F, Hoffmann-Filho CR, de Lemos Soares Patriota R, Leiria TLL, Lamprea D, Precoma DB, Atik FA, Silveira FS, Farias FR, Barreto DO, Almeida AP, Zilli AC, de Souza Neto JD, Cavalcante MA, Figueira FAMS, Kojima FCS, Damiani L, Santos RHN, Valeis N, Campos VB, Saraiva JFK, Fonseca FH, Pinto IM, Magalhães CC, Ferreira JFM, Alexander JH, Pavanello R, Cavalcanti AB, Berwanger O. Rivaroxaban in Patients with Atrial Fibrillation and a Bioprosthetic Mitral Valve. N Engl J Med 2020; 383:2117-2126. [PMID: 33196155 DOI: 10.1056/nejmoa2029603] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The effects of rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve remain uncertain. METHODS In this randomized trial, we compared rivaroxaban (20 mg once daily) with dose-adjusted warfarin (target international normalized ratio, 2.0 to 3.0) in patients with atrial fibrillation and a bioprosthetic mitral valve. The primary outcome was a composite of death, major cardiovascular events (stroke, transient ischemic attack, systemic embolism, valve thrombosis, or hospitalization for heart failure), or major bleeding at 12 months. RESULTS A total of 1005 patients were enrolled at 49 sites in Brazil. A primary-outcome event occurred at a mean of 347.5 days in the rivaroxaban group and 340.1 days in the warfarin group (difference calculated as restricted mean survival time, 7.4 days; 95% confidence interval [CI], -1.4 to 16.3; P<0.001 for noninferiority). Death from cardiovascular causes or thromboembolic events occurred in 17 patients (3.4%) in the rivaroxaban group and in 26 (5.1%) in the warfarin group (hazard ratio, 0.65; 95% CI, 0.35 to 1.20). The incidence of stroke was 0.6% in the rivaroxaban group and 2.4% in the warfarin group (hazard ratio, 0.25; 95% CI, 0.07 to 0.88). Major bleeding occurred in 7 patients (1.4%) in the rivaroxaban group and in 13 (2.6%) in the warfarin group (hazard ratio, 0.54; 95% CI, 0.21 to 1.35). The frequency of other serious adverse events was similar in the two groups. CONCLUSIONS In patients with atrial fibrillation and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin with respect to the mean time until the primary outcome of death, major cardiovascular events, or major bleeding at 12 months. (Funded by PROADI-SUS and Bayer; RIVER ClinicalTrials.gov number, NCT02303795.).
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Affiliation(s)
- Helio P Guimarães
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Renato D Lopes
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Pedro G M de Barros E Silva
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Idelzuita L Liporace
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Roney O Sampaio
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Flávio Tarasoutchi
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Conrado R Hoffmann-Filho
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Rodrigo de Lemos Soares Patriota
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Tiago L L Leiria
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Diana Lamprea
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Dalton B Precoma
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Fernando A Atik
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Fabio S Silveira
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Fabio R Farias
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Diogo O Barreto
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Adail P Almeida
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Alexandre C Zilli
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - João D de Souza Neto
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Margaret A Cavalcante
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Fernando A M S Figueira
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Flávia C S Kojima
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Lucas Damiani
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Renato H N Santos
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Nanci Valeis
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Viviane B Campos
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Jose F K Saraiva
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Francisco H Fonseca
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Ibraim M Pinto
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Carlos C Magalhães
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Joao F M Ferreira
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - John H Alexander
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Ricardo Pavanello
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Alexandre B Cavalcanti
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
| | - Otavio Berwanger
- From the HCor Research Institute (H.P.G., P.G.M.B.S., F.C.S.K., L.D., R.H.N.S., N.V., V.B.C., R.P., A.B.C., O.B.), Instituto Dante Pazzanese de Cardiologia (I.L.L.), Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (R.O.S., F.T.), Sociedade de Cardiologia do Estado de São Paulo (J.F.K.S., F.H.F., I.M.P., C.C.M., J.F.M.F., R.P., O.B.), and Hospital Israelita Albert Einstein (O.B.), São Paulo, Hospital Regional Hans Dieter Schmidt, Joinville (C.R.H.-F.), Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho (R.L.S.P.), Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre (T.L.L.L.), Pronto Socorro Cardiológico Prof. Luiz Tavares, Procape (D.L.), Instituto de Medicina Integral Prof. Fernando Figueira (F.A.M.S.F.), Recife, Sociedade Hospitalar Angelina Caron, Campina Grande do Sul (D.B.P.), Instituto de Cardiologia do Distrito Federal, Brasília (F.A.A.), Centro de Pesquisa Clínica do Coração, Aracajú (F.S.S.), Quanta Diagnóstico e Terapia, Curitiba (F.R.F.), Hospital Evangélico de Vila Velha, Vila Velha (D.O.B.), Unidade Médico Cirúrgica-Unimec, Vitória da Conquista (A.P.A.), Hospital de Caridade São Vicente de Paulo, Jundiaí (A.C.Z.), Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza (J.D.S.N.), Hospital Regional de Presidente Prudente-Universidade do Oeste Paulista, Presidente Prudente (M.A.C.), and Instituto de Pesquisa Clínica de Campinas, Campinas (J.F.K.S.) - all in Brazil; and Duke Clinical Research Institute, Duke Health, Durham, NC (R.D.L., J.H.A.)
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Karthikeyan G, Connolly SJ, Yusuf S. Overestimation of Stroke Risk in Rheumatic Mitral Stenosis and the Implications for Oral Anticoagulation. Circulation 2020; 142:1697-1699. [PMID: 33136507 DOI: 10.1161/circulationaha.120.050347] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada (S.J.C., S.Y.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Canada (S.J.C., S.Y.)
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Bansal A, Sarkar PG, Chaturvedi V. Atrial Fibrillation in Rheumatic Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00845-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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