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Solitano V, Facheris P, Petersen M, D'Amico F, Ortoncelli M, Aletaha D, Olivera PA, Bieber T, Ramiro S, Ghosh S, D'Agostino MA, Siegmund B, Chary-Valckenaere I, Hart A, Dagna L, Magro F, Felten R, Kotze PG, Jairath V, Costanzo A, Kristensen LE, Biroulet LP, Danese S. Implementation of regulatory guidance for JAK inhibitors use in patients with immune-mediated inflammatory diseases: An international appropriateness study. Autoimmun Rev 2024; 23:103504. [PMID: 38128748 DOI: 10.1016/j.autrev.2023.103504] [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: 11/24/2023] [Accepted: 12/17/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIMS The Pharmacovigilance Risk Assessment Committee (PRAC) proposed measures to address severe side effects linked to Janus kinase inhibitors (JAKi) in immune-mediated inflammatory diseases (IMID). Use of these medications in individuals aged 65 and older, those at high cardiovascular risk, active or former long-term smokers, and those with increased cancer risk should be considered only if no alternatives exist. Caution is advised when administering JAKi to patients at risk of venous thromboembolism. We aim to implement recommendations from regulatory guidelines based on areas of uncertainty identified. METHODS A two-round modified Research and Development/University of California Los Angeles appropriateness methodology study was conducted. A panel of 21 gastroenterologists, dermatologists and rheumatologists used a 9-point Likert scale to rate the appropriateness of administering a JAKi for each proposed clinical scenario. Scores for appropriateness were categorized as appropriate, uncertain, or inappropriate. Two rounds were performed, each with online surveys and a virtual meeting to enable discussion and rating of each best practice. RESULTS Round 1 involved participants rating JAKi appropriateness and suggesting descriptors to reduce uncertainty. Survey results were discussed in a virtual meeting, identifying areas of disagreement. In round 2, participants rated their agreement with descriptors from round 1, and the level of uncertainty and disagreement reduced. Age flexibility is recommended in the absence of other risk factors. Active counseling on modifiable risks (e.g., overweight, mild hyperlipidemia and hypertension) and smoking cessation is advised. Uncertainty persists regarding cancer risk due to various factors. CONCLUSIONS We outlined regulatory guidance without a personalized evaluation of the patient's risk profile might lead to uncertainty and become an arid technicality. Therefore, we identified gaps and implemented PRAC recommendations to help health professionals in clinical practice.
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Affiliation(s)
- Virginia Solitano
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Paola Facheris
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Magnus Petersen
- The Parker Institute, University of Copenhagen & Bispebjerg University Hospital, Copenhagen, Denmark
| | - Ferdinando D'Amico
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Michela Ortoncelli
- Medical Sciences Department, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Pablo A Olivera
- Gastroenterology Department, CEMIC, Buenos Aires C1425ASS, Argentina; Zane Cohen Centre for Digestive Diseases-Lunenfeld-Tanenbaum Research Institute-Sinai Health System-Gastroenterology, Toronto, ON M5T 3L9, Canada
| | - Thomas Bieber
- Department of Dermatology and Allergy, University Hospital of Bonn, Bonn, Germany
| | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, the Netherlands; Zuyderland Medical Center, Heerlen, the Netherlands
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, T12 E138 Cork, Ireland
| | - Maria Antonietta D'Agostino
- Rheumatology Fondazione Policlinico Universitario A. Gemelli,IRCSS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Britta Siegmund
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | | | | | - Lorenzo Dagna
- IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Fernando Magro
- CINTESIS@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Renaud Felten
- Centre d'Investigation Clinique, INSERM CIC-1434, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Service de Rhumatologie, Centre National de Référence des Maladies Autoimmunes (RESO), Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Département Universitaire de Pharmacologie-Addictologie, Toxicologie et Thérapeutique, Université de Strasbourg, Strasbourg, France
| | - Paulo Gustavo Kotze
- Health Sciences Postgraduate Program, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba 80215-901, Brazil
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Antonio Costanzo
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences Humanitas University, Pieve Emanuele, Italy
| | - Lars Erik Kristensen
- The Parker Institute, University of Copenhagen & Bispebjerg University Hospital, Copenhagen, Denmark
| | - Laurent Peyrin Biroulet
- Department of Gastroenterology, Nancy University Hospital, F-54500 Vandœuvre-lès-Nancy, France; Inserm, NGERE, University of Lorraine, F-54000 Vandœuvre-lès-Nancy, France; INFINY Institute, Nancy University Hospital, F-54500 Vandœuvre-lès-Nancy, France; FHU-CURE, Nancy University Hospital, F-54500 Vandœuvre-lès-Nancy, France; Groupe Hospitalier Privé Ambroise Paré-Hartmann, Paris IBD Center, F-92200 Neuilly sur Seine, France; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Silvio Danese
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy.
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Bagrova A, Alsamarah AY, Winchester DE. Comparing two methods for determining appropriateness of myocardial perfusion imaging: Criteria from the American College of Cardiology Foundation and the American College of Radiology. J Nucl Cardiol 2019; 26:826-830. [PMID: 28660600 DOI: 10.1007/s12350-017-0965-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 06/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) developed by the American College of Cardiology Foundation and the appropriateness criteria (AC) developed by the American College of Radiology (ACR) are two existing methods of rating appropriateness of myocardial perfusion imaging (MPI). One study found poor agreement of ratings between the two methods. However, using the most contemporary AUC from 2013, it is unknown if poor agreement still exists. METHODS Retrospective cohort investigation comparing patients undergoing nuclear MPI between June 2011 and September 2014. The appropriateness category was determined based on the 2013 AUC (Appropriate, may be appropriate, rarely appropriate) and the 2010 ACR AC (usually appropriate, maybe appropriate, usually not appropriate). The primary outcome was the degree of the agreement between the two methods. RESULTS The kappa coefficient between ACR AC and AUC was 0.32, P < 0.0001, indicating poor agreement; 40 (8%) patients were classified by the AUC but could not be classified by the ACR AC. CONCLUSION The two methods for rating the appropriateness of MPI have poor agreement; a potential for disagreement between providers and payers if only one method is used.
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Affiliation(s)
| | - Ali Y Alsamarah
- College of Medicine, University of Florida, Gainesville, FL, USA.
- Cardiovascular Medicine Department, Boston Medical Center, 88 East Newton Pavilion, Boston, MA, 02218, USA.
| | - David E Winchester
- College of Medicine, University of Florida, Gainesville, FL, USA
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
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Bagrova A, Alsamarah AY, Winchester DE. Comparing two methods for determining appropriateness of myocardial perfusion imaging: Criteria from the American College of Cardiology Foundation and the American College of Radiology. JOURNAL OF NUCLEAR CARDIOLOGY : OFFICIAL PUBLICATION OF THE AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY 2017. [PMID: 28660600 DOI: 10.1007/s12350-017-0965–1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) developed by the American College of Cardiology Foundation and the appropriateness criteria (AC) developed by the American College of Radiology (ACR) are two existing methods of rating appropriateness of myocardial perfusion imaging (MPI). One study found poor agreement of ratings between the two methods. However, using the most contemporary AUC from 2013, it is unknown if poor agreement still exists. METHODS Retrospective cohort investigation comparing patients undergoing nuclear MPI between June 2011 and September 2014. The appropriateness category was determined based on the 2013 AUC (Appropriate, may be appropriate, rarely appropriate) and the 2010 ACR AC (usually appropriate, maybe appropriate, usually not appropriate). The primary outcome was the degree of the agreement between the two methods. RESULTS The kappa coefficient between ACR AC and AUC was 0.32, P < 0.0001, indicating poor agreement; 40 (8%) patients were classified by the AUC but could not be classified by the ACR AC. CONCLUSION The two methods for rating the appropriateness of MPI have poor agreement; a potential for disagreement between providers and payers if only one method is used.
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Affiliation(s)
| | - Ali Y Alsamarah
- College of Medicine, University of Florida, Gainesville, FL, USA. .,Cardiovascular Medicine Department, Boston Medical Center, 88 East Newton Pavilion, Boston, MA, 02218, USA.
| | - David E Winchester
- College of Medicine, University of Florida, Gainesville, FL, USA.,Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
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Elgendy IY, Mahmoud A, Shuster JJ, Doukky R, Winchester DE. Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis. J Nucl Cardiol 2016; 23:680-9. [PMID: 26253327 PMCID: PMC5442883 DOI: 10.1007/s12350-015-0240-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 06/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes. METHODS We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method. RESULTS A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10). CONCLUSION Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100277, Gainesville, FL, 32610, USA
| | - Ahmed Mahmoud
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jonathan J Shuster
- Department of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - David E Winchester
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100277, Gainesville, FL, 32610, USA.
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Clough JD, Rajkumar R, Crim MT, Ott LS, Desai NR, Conway PH, Maresh S, Kahvecioglu DC, Krumholz HM. Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes. J Am Heart Assoc 2016; 5:e002594. [PMID: 26908402 PMCID: PMC4802452 DOI: 10.1161/jaha.115.002594] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/22/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care. METHODS AND RESULTS We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]). CONCLUSION Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.
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Affiliation(s)
- Jeffrey D Clough
- Centers for Medicare and Medicaid Services, Baltimore, MD Duke Clinical Research Institute, Department of Medicine, Duke University, Durham, NC
| | - Rahul Rajkumar
- Centers for Medicare and Medicaid Services, Baltimore, MD
| | | | - Lesli S Ott
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | | | - Sha Maresh
- Centers for Medicare and Medicaid Services, Baltimore, MD
| | | | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
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Ye S, Rabbani LE, Kelly CR, Kelly MR, Lewis M, Paz Y, Peck CL, Rao S, Bokhari S, Weiner SD, Einstein AJ. Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging. Circ Cardiovasc Qual Outcomes 2015; 8:23-9. [PMID: 25563660 PMCID: PMC4303551 DOI: 10.1161/circoutcomes.114.001067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 11/13/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND We sought to determine inter-rater reliability of the 2009 Appropriate Use Criteria for radionuclide imaging and whether physicians at various levels of training can effectively identify nuclear stress tests with inappropriate indications. METHODS AND RESULTS Four hundred patients were randomly selected from a consecutive cohort of patients undergoing nuclear stress testing at an academic medical center. Raters with different levels of training (including cardiology attending physicians, cardiology fellows, internal medicine hospitalists, and internal medicine interns) classified individual nuclear stress tests using the 2009 Appropriate Use Criteria. Consensus classification by 2 cardiologists was considered the operational gold standard, and sensitivity and specificity of individual raters for identifying inappropriate tests were calculated. Inter-rater reliability of the Appropriate Use Criteria was assessed using Cohen κ statistics for pairs of different raters. The mean age of patients was 61.5 years; 214 (54%) were female. The cardiologists rated 256 (64%) of 400 nuclear stress tests as appropriate, 68 (18%) as uncertain, 55 (14%) as inappropriate; 21 (5%) tests were unable to be classified. Inter-rater reliability for noncardiologist raters was modest (unweighted Cohen κ, 0.51, 95% confidence interval, 0.45-0.55). Sensitivity of individual raters for identifying inappropriate tests ranged from 47% to 82%, while specificity ranged from 85% to 97%. CONCLUSIONS Inter-rater reliability for the 2009 Appropriate Use Criteria for radionuclide imaging is modest, and there is considerable variation in the ability of raters at different levels of training to identify inappropriate tests.
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Affiliation(s)
- Siqin Ye
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital.
| | - LeRoy E Rabbani
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Christopher R Kelly
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Maureen R Kelly
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Matthew Lewis
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Yehuda Paz
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Clara L Peck
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Shaline Rao
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Sabahat Bokhari
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Shepard D Weiner
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
| | - Andrew J Einstein
- From the Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital
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Oliveira AD, Rezende MF, Corrêa R, Mousinho R, Azevedo JC, Miranda SM, Oliveira AR, Gutterres RF, Mesquita ET, Mesquita CT. Applicability of the Appropriate use Criteria for Myocardial Perfusion Scintigraphy. Arq Bras Cardiol 2014; 103:375-381. [PMID: 25252163 PMCID: PMC4262097 DOI: 10.5935/abc.20140140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/26/2014] [Indexed: 11/29/2022] Open
Abstract
Background Appropriateness Criteria for nuclear imaging exams were created by American
College of Cardiology (ACC) e American Society of Nuclear Cardiology (ASNC) to
allow the rational use of tests. Little is known whether these criteria have been
followed in clinical practice. Objective To evaluate whether the medical applications of myocardial perfusion scintigraphy
(MPS) in a private nuclear medicine service of a tertiary cardiology hospital were
suitable to the criteria of indications proposed by the American medical societies
in 2005 and 2009 and compare the level of indication of both. Methods We included records of 383 patients that underwent MPS, November 2008 up to
February 2009. Demographic characteristics, patient's origin, coronary risk
factors, time of medical graduation and appropriateness criteria of medical
applications were studied. The criteria were evaluated by two independent
physicians and, in doubtful cases, defined by a medical expert in MPS. Results Mean age was 65 ± 12 years. Of the 367 records reviewed, 236 (64.3%) studies were
performed in men and 75 (20.4%) were internee. To ACC 2005, 255 (69.5%) were
considered appropriate indication and 13 (3.5%) inappropriate. With ACC 2009, 249
(67.8%) were considered appropriate indications and 13 (5.2%) inappropriate. Conclusions We observed a high rate of adequacy of medical indications for MPS. Compared to
the 2005 version, 2009 did not change the results.
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Affiliation(s)
- M-J de Boer
- Department of Cardiology, Heart Lung Center, 670 Cardiology, UMC St Radboud Nijmegen, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands,
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Using the world financial crisis as an opportunity to denuclearize cardiac stress-testing. Am J Cardiol 2012; 110:467. [PMID: 22792999 DOI: 10.1016/j.amjcard.2012.05.001] [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: 05/02/2012] [Accepted: 05/09/2012] [Indexed: 11/22/2022]
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