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Inoue K, Guo R, Lee ML, Ebrahimi R, Neverova NV, Currier JW, Bashir MT, Leung AM. Iodine-Induced Hyperthyroidism and Long-term Risks of Incident Atrial Fibrillation and Flutter. J Clin Endocrinol Metab 2023; 108:e956-e962. [PMID: 37146179 PMCID: PMC10584637 DOI: 10.1210/clinem/dgad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 05/07/2023]
Abstract
CONTEXT Although iodine-induced hyperthyroidism is a potential consequence of iodinated radiologic contrast administration, its association with long-term cardiovascular outcomes has not been previously studied. OBJECTIVE To investigate the relationships between hyperthyroidism observed after iodine contrast administration and incident atrial fibrillation/flutter. METHODS Retrospective cohort study of the U.S. Veterans Health Administration (1998-2021) of patients age ≥18 years with a normal baseline serum thyrotropin (TSH) concentration, subsequent TSH <1 year, and receipt of iodine contrast <60 days before the subsequent TSH. Cox proportional hazards regression was employed to ascertain the adjusted hazard ratio (HR) with 95% CI of incident atrial fibrillation/flutter following iodine-induced hyperthyroidism, compared with iodine-induced euthyroidism. RESULTS Iodine-induced hyperthyroidism was observed in 2500 (5.6%) of 44 607 Veterans (mean ± SD age, 60.9 ± 14.1 years; 88% men) and atrial fibrillation/flutter in 10.4% over a median follow-up of 3.7 years (interquartile range 1.9-7.4). Adjusted for sociodemographic and cardiovascular risk factors, iodine-induced hyperthyroidism was associated with an increased risk of atrial fibrillation/flutter compared with those who remained euthyroid after iodine exposure (adjusted HR 1.19, 95% CI 1.06-1.33). Females were at greater risk for incident atrial fibrillation/flutter than males (females, HR 1.81, 95% CI 1.12-2.92; males, HR 1.15, 95% CI 1.03-1.30; P for interaction = .04). CONCLUSION Hyperthyroidism following a high iodine load was associated with an increased risk of incident atrial fibrillation/flutter, particularly among females. The observed sex-based differences should be confirmed in a more sex-diverse study sample, and the cost-benefit analysis of long-term monitoring for cardiac arrhythmias following iodine-induced hyperthyroidism should be evaluated.
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Affiliation(s)
- Kosuke Inoue
- Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Rong Guo
- Research Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Martin L. Lee
- Veterans Affairs Health Services Research & Development Center for the Study of Health Care Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Department of Biostatistics, University of California Los Angeles Fielding School of Public Health, Los Angeles, CA 90095, USA
| | - Ramin Ebrahimi
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Division of Cardiology, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Natalia V. Neverova
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Division of Cardiology, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Jesse W. Currier
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Division of Cardiology, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Muhammad T. Bashir
- Research Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Division of Endocrinology, Diabetes, and Metabolism, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA 90095, USA
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Trohman RG, Huang HD, Sharma PS. Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1. Front Cardiovasc Med 2023; 10:1060030. [PMID: 37396596 PMCID: PMC10311453 DOI: 10.3389/fcvm.2023.1060030] [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: 10/02/2022] [Accepted: 03/14/2023] [Indexed: 07/04/2023] Open
Abstract
Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia. It was once thought to be benign as long as the ventricular rate was controlled, however, AF is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a MEDLINE search to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched via the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare noninvasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.
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Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
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Naser JA, Pislaru SV, Stan MN, Lin G. Incidence, Risk Factors, and Outcomes of Incident Atrial Fibrillation in Patients With Graves Disease. Mayo Clin Proc 2023:S0025-6196(22)00709-1. [PMID: 36922268 DOI: 10.1016/j.mayocp.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To describe the incidence, risk factors, and outcomes of incident atrial fibrillation (AF) in Graves disease (GD). PATIENTS AND METHODS Patients with GD between January 1, 2009, and December 31, 2019, were included retrospectively. We defined GD-related AF as AF diagnosed less than or equal to 30 days before or any time after GD. Late-onset AF was defined as incident AF diagnosed more than 90 days after GD. RESULTS Of 1371 patients with GD, AF occurred in 139 patients. Late-onset AF occurred in 32 (23.0%) of AF cases, of which 16 (50.0%) had attained euthyroidism. Independent risk factors were age (HR, 1.05; 95% CI, 1.03-1.06 per year), overt hyperthyroidism (free T4 >1.7 ng/dL; HR, 2.75; 95% CI, 1.38 to 5.46), and male sex (HR, 2.30; 95% CI, 1.54 to 3.43) for early AF. These were age (HR, 1.08; 95% CI, 1.05 to 1.119 per year), chronic obstructive pulmonary disease (HR, 3.47; 95% CI, 1.36 to 5.54), and heart failure (HR, 5.86; 95% CI, 2.39 to 14.38) for late AF. Atrial fibrillation in GD was associated with higher mortality (HR, 16.32; 95% CI, 4.66 to 56.58), acute coronary syndrome/stable angina events (HR, 3.89; 95% CI, 1.23 to 12.31), and cardiac hospitalizations (HR, 15.39; 95% CI, 8.17 to 29.00) when adjusted to age, sex, and pre-existing AF. CONCLUSION Late-onset AF comprised one-quarter of GD-related AF cases requiring surveillance even after restoring euthyroidism. Risk factors for AF in GD are similar to those in the general population although overt hyperthyroidism conferred the highest risk, especially for early AF. Treatment with thionamide was associated with late AF.
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Affiliation(s)
- Jwan A Naser
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marius N Stan
- Department of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Liu SD, Lin SJ, Ray CY, Lin FT, Lin WC, Wang LH. Associations of Warfarin Use with Risks of Ischemic Cerebrovascular Events and Major Bleeding in Patients with Hyperthyroidism-Related Atrial Fibrillation. Biomedicines 2022; 10:2670. [PMID: 36359190 PMCID: PMC9687236 DOI: 10.3390/biomedicines10112670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/07/2022] [Accepted: 10/20/2022] [Indexed: 08/30/2023] Open
Abstract
The use of oral anticoagulants for patients with new-onset hyperthyroidism-related atrial fibrillation (AF) is controversial. We aimed to evaluate the clinical benefits of warfarin therapy in this population. This retrospective cohort study used a data-cut of Taiwan Health and Welfare Database between 2000 and 2016. We compared warfarin users and nonusers among AF patients with hyperthyroidism. We used 1:2 propensity score matching to balance covariates and Cox regression model to calculate hazard ratios (HRs). The primary outcome was risk of ischemic stroke/transient ischemic attack (TIA), and the secondary outcome was major bleeding. After propensity score matching, we defined 90 and 168 hyperthyroidism-related AF patients with mean (SD) age of 59.9 ± 13.5 and 59.2 ± 14.6 in the warfarin-treated group and untreated group separately. The mean (SD) CHA2DS2-VASc scores for the two groups were 2.1 ± 1.6 and 1.8 ± 1.5, respectively. Patients with hyperthyroidism-related AF receiving warfarin had no significant risk of ischemic stroke/TIA (adjusted HR: 1.16, 95% confidence interval [CI]: 0.52-2.56, p = 0.717) compared to nonusers. There was a comparable risk of major bleeding between those receiving warfarin or not (adjusted HR: 0.91, 95% CI: 0.56-1.47, p = 0.702). The active-comparator design also demonstrated that warfarin use had no significant association with the risk of stroke/TIA versus aspirin use (adjusted HR: 2.43; 95% CI: 0.68-8.70). In conclusion, anticoagulation therapy did not have a statistically significant benefit on ischemic stroke/TIA nor risk of bleeding, among patients with new-onset hyperthyroidism-related AF under a low CHA2DS2-VASc score, by comparing those without use.
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Affiliation(s)
- Sian-De Liu
- School of Pharmacy, Taipei Medical University, Taipei 110, Taiwan
- Department of Pharmacy, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City 236, Taiwan
| | - Shwu-Jiuan Lin
- School of Pharmacy, Taipei Medical University, Taipei 110, Taiwan
- PhD Program in Clinical Drug Development of Herbal Medicine, College of Pharmacy, Taipei Medical University, Taipei 110, Taiwan
| | - Chin-Ying Ray
- Department of Clinical Pharmacy, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan
- Heart Failure Center, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan
| | - Fang-Tsyr Lin
- Section of Hematology/Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Weei-Chin Lin
- Section of Hematology/Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Li-Hsuan Wang
- School of Pharmacy, Taipei Medical University, Taipei 110, Taiwan
- Department of Pharmacy, Taipei Medical University Hospital, Taipei 110, Taiwan
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Paschou SA, Bletsa E, Stampouloglou PK, Tsigkou V, Valatsou A, Stefanaki K, Kazakou P, Spartalis M, Spartalis E, Oikonomou E, Siasos G. Thyroid disorders and cardiovascular manifestations: an update. Endocrine 2022; 75:672-683. [PMID: 35032315 DOI: 10.1007/s12020-022-02982-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/09/2022] [Indexed: 12/25/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of death worldwide, representing a major health, social, and economic issue. Thyroid disorders are very common and affect >10% of the adult population in total. The aim of this review is to describe the physiologic role of thyroid hormones on cardiovascular system, to present cardiovascular manifestations in patients with thyroid disorders, emphasizing in molecular mechanisms and biochemical pathways, and to summarize current knowledge of treatment options. Thyroid hormone receptors are located both in myocardium and vessels, and changes in their concentrations affect cardiovascular function. Hyperthyroidism or hypothyroidism, both clinical and subclinical, without the indicated therapeutical management, may contribute to the progression of CVD. According to recent studies, even middle changes in thyroid hormones levels increase cardiovascular mortality from 20% to 80%. In more details, thyroid disorders seem to have serious effects on the cardiovascular system via plenty mechanisms, including dyslipidemia, hypertension, systolic and diastolic myocardial dysfunction, as well endothelial dysfunction. On top of clinical thyroid disorders management, current therapeutics focus on younger patients with subclinical hypothyroidism and elderly patients with subclinical hyperthyroidism.
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Affiliation(s)
- Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Evanthia Bletsa
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiota K Stampouloglou
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Tsigkou
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Angeliki Valatsou
- 1st Department of Cardiology, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Stefanaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Kazakou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Spartalis
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Zhang J, Bisson A, Fauchier G, Bodin A, Herbert J, Ducluzeau PH, Lip GYH, Fauchier L. Yearly Incidence of Stroke and Bleeding in Atrial Fibrillation with Concomitant Hyperthyroidism: A National Discharge Database Study. J Clin Med 2022; 11:jcm11051342. [PMID: 35268432 PMCID: PMC8911027 DOI: 10.3390/jcm11051342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Hyperthyroidism is associated with atrial fibrillation (AF), and the latter is a major risk factor for stroke. Aim: We aimed to investigate the yearly incidence of stroke and bleeding in AF patients with and without concomitant hyperthyroidism from the French National Hospital Discharge Database. Methods: Admissions with AF between January 2010 and December 2019 were retrospectively identified and retrieved from the French national database. Incidence rates of ischaemic stroke and bleeding were compared in AF patients with and without concomitant hyperthyroidism. The associations of risk factors with ischaemic stroke were assessed by Cox regression. Results: Overall 2,421,087 AF patients, among whom 32,400 had concomitant hyperthyroidism were included in the study. During the follow-up (mean: 2.0 years, standard deviation SD: 2.2 years), the yearly incidence of ischaemic stroke was noted to be 2.6 (95% confidence interval CI: 2.5−2.8) in AF patients with concomitant hyperthyroidism, and 2.3 (95%CI: 2.3−2.4) in non-thyroid AF patients. Hyperthyroidism was noted as an independent risk factor for ischaemic stroke (adjusted hazard ratio aHR: 1.133, 95%CI: 1.080−1.189) overall, particularly within the first year of hyperthyroidism diagnosis (aHR 1.203, 95%CI 1.120−1.291), however, the association became non-significant in subsequent years (aHR 1.047, 95%CI 0.980−1.118). Major bleeding incidence was lower in the hyperthyroid AF group in comparison to the non-thyroid AF group (incidence ratio: 5.1 vs. 5.4%/year, p < 0.001). The predictive value of CHA2DS2VASc and HAS-BLED scores for ischaemic stroke and bleeding events, respectively, did not differ significantly between AF patients with or without concomitant hyperthyroidism. Conclusions: Hyperthyroidism seems to be an independent risk factor of ischaemic stroke in AF patients, particularly within the first year of hyperthyroidism diagnosis.
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Affiliation(s)
- Juqian Zhang
- Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool L7 8TX, UK;
| | - Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.); (L.F.)
| | - Grégoire Fauchier
- Service de Médecine Interne, Unité d’Endocrinologie Diabétologie et Nutrition, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (G.F.); (P.H.D.)
| | - Alexandre Bodin
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.); (L.F.)
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.); (L.F.)
| | - Pierre Henri Ducluzeau
- Service de Médecine Interne, Unité d’Endocrinologie Diabétologie et Nutrition, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (G.F.); (P.H.D.)
- Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement, Unité Mixte de Recherche Physiologie de la Reproduction et des Comportements, 37380 Nouzilly, France
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool L7 8TX, UK;
- Correspondence: ; Tel.: +44-0151-794-9020
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.); (L.F.)
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