1
|
Birdal O, İpek E, Saygı M, Doğan R, Pay L, Tanboğa IH. Cluster analysis of clinical, angiographic, and laboratory parameters in patients with ST-segment elevation myocardial infarction. Lipids Health Dis 2024; 23:166. [PMID: 38835073 DOI: 10.1186/s12944-024-02128-7] [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: 01/07/2024] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION ST-segment elevation myocardial infarction (STEMI) represents the most harmful clinical manifestation of coronary artery disease. Risk assessment plays a beneficial role in determining both the treatment approach and the appropriate time for discharge. Hierarchical agglomerative clustering (HAC), a machine learning algorithm, is an innovative approach employed for the categorization of patients with comparable clinical and laboratory features. The aim of the present study was to investigate the role of HAC in categorizing STEMI patients and to compare the results of these patients. METHODS A total of 3205 patients who were diagnosed with STEMI at the university hospital emergency clinic between 2015 and 2023 were included in the study. The patients were divided into 2 different phenotypic disease clusters using the HAC method, and their outcomes were compared. RESULTS In the present study, a total of 3205 STEMI patients were included; 2731 patients were in cluster 1, and 474 patients were in cluster 2. Mortality was observed in 147 (5.4%) patients in cluster 1 and 108 (23%) patients in cluster 2 (chi-square P value < 0.01). Survival analysis revealed that patients in cluster 2 had a significantly greater risk of death than patients in cluster 1 did (log-rank P < 0.001). After adjustment for age and sex in the Cox proportional hazards model, cluster 2 exhibited a notably greater risk of death than did cluster 1 (HR = 3.51, 95% CI = 2.71-4.54; P < 0.001). CONCLUSION Our study showed that the HAC method may be a potential tool for predicting one-month mortality in STEMI patients.
Collapse
Affiliation(s)
- Oğuzhan Birdal
- Department of Cardiology, Ataturk University, Erzurum, 25240, Turkey.
| | - Emrah İpek
- Department of First Aid and Emergency, Health Services Vocational School, Nisantasi University, Istanbul, 34360, Turkey
| | - Mehmet Saygı
- Department of Cardiology, Hisar Intercontinental Hospital, Istanbul, 34764, Turkey
| | - Remziye Doğan
- Department of Cardiology, Hisar Intercontinental Hospital, Istanbul, 34764, Turkey
| | - Levent Pay
- Department of Cardiology, Ardahan State Hospital, Ardahan, 75000, Turkey
| | - Ibrahim Halil Tanboğa
- Department of Cardiology and Biostatistics, Nisantasi University, Istanbul, 34360, Turkey
| |
Collapse
|
2
|
Al Ali L, Groot HE, Assa S, Lipsic E, Hummel YM, van Veldhuisen DJ, Voors AA, van der Horst ICC, Lam CS, van der Harst P. Predictors of adverse diastolic remodeling in non-diabetic patients presenting with ST-elevation myocardial infarction. BMC Cardiovasc Disord 2023; 23:44. [PMID: 36690932 PMCID: PMC9872414 DOI: 10.1186/s12872-023-03064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Adverse systolic remodeling after ST-elevation myocardial infarction (STEMI) is associated with poor clinical outcomes. However, little is known about diastolic remodeling. The purpose of this study was to identify the factors leading to diastolic remodeling. METHODS Echocardiography was performed during hospitalization and at 4 months follow-up in 267 non-diabetic STEMI patients from the GIPS-III trial. As parameters of diastolic remodeling we used (1.) the E/e' at 4 months adjusted for the E/e' at hospitalization and (2.) the change in E/e' between hospitalization and 4 months. Multivariable regression models correcting for age and sex were constructed to identify possible association of clinical and angiographic variables as well as biomarkers with diastolic remodeling. RESULTS Older age, female gender, hypertension, multi vessel disease, higher glucose and higher peak CK were independent predictors of higher E/e' at 4 months in a multivariable model (R2:0.20). After adjustment for E/e' during hospitalization only female gender, multivessel disease and higher glucose remained predictors of E/e' at four months (R2:0.40). Lower myocardial blush grade, AST and NT-proBNP were independent predictors of a higher increase of E/e' between hospitalization and at 4 months in a multivariable model (R2:0.08). CONCLUSIONS Our data supports the hypothesis that female gender, multivessel coronary artery disease, and microvascular damage are important predictors of adverse diastolic remodeling after STEMI. In addition, our data suggests that older age and hypertension prior to STEMI may have contributed to worse pre-existing diastolic function. TRIAL REGISTRATION NIH, NCT01217307. Prospectively registered on October 8th 2010, https://clinicaltrials.gov/ct2/show/NCT01217307 .
Collapse
Affiliation(s)
- Lawien Al Ali
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands.
| | - Hilde E Groot
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Solmaz Assa
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Yoran M Hummel
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Carolyn S Lam
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
- Department of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| |
Collapse
|
3
|
Yildirim U, Balaban F. Laboratory markers at admission to predict the presence of totally occluded culprit artery in NSTEMI. Medicine (Baltimore) 2022; 101:e31738. [PMID: 36397332 PMCID: PMC9666204 DOI: 10.1097/md.0000000000031738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A significant proportion of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) have a totally occluded culprit artery (OCA). If these patients do not meet very high-risk criteria, they may be deprived of an immediate invasive strategy. Therefore, there is a need for markers that can predict OCA in patients with NSTEMI. A total of 357 consecutive patients with NSTEMI but without very high-risk criteria were included in this retrospective study. Two groups were formed: NSTEMI with OCA (n = 106) and NSTEMI with patent culprit artery (PCA) (n = 251). Complete blood count (CBC) and serum biochemical parameters obtained immediately at admission were compared between the groups. Receiver operating characteristic (ROC) analysis to predict the presence of OCA was performed for the parameters that were significantly different between the groups, and an area under the curve (AUC) > 0.7 was considered to suggest acceptable discrimination. Neutrophil count [8.13 (2.82-27.88) × 103/µL vs 5.59 (1.85-19.71) × 103/µL, P < .001] and aspartate aminotransferase (AST) level [45 (12-405) U/L vs 25 (5-143) U/L, P < .001] were significantly higher in patients with OCA. The AUC was 0.750 for neutrophil count and 0.731 for AST level. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of elevated neutrophil and/or AST levels for the presence of OCA were 77.4%, 70.1%, 52.2%, and 88.0%, respectively. More strikingly, the specificity was 95.2% in the presence of both neutrophil and AST elevation. Elevated neutrophil and/or AST levels at admission were strongly associated with the presence of OCA in patients with NSTEMI.
Collapse
Affiliation(s)
- Ufuk Yildirim
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
- * Correspondence: Ufuk Yildirim, Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey (e-mail: )
| | - Fuatcan Balaban
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| |
Collapse
|
4
|
Badran M. Correlation between neutrophil-to-lymphocyte ratio after percutaneous coronary intervention and the size of infarction in patients with acute myocardial infarction. JOURNAL OF MEDICINE IN SCIENTIFIC RESEARCH 2022. [DOI: 10.4103/jmisr.jmisr_2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023] Open
|
5
|
Starčević J, Matić D. Impact of WBC count on admission on early and longterm mortality in patients treated with primary percutaneous coronary intervention. MEDICINSKI PODMLADAK 2022. [DOI: 10.5937/mp73-33781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction: Inflammation plays a key role in the process of atherosclerosis, its formation, progression and destabilization of plaque. One of the main mediators of inflammation is white blood cells (WBC), whose number increases significantly during inflammation. Aim: The aim of this study was to determine the effect of WBC count at admission on early and long-term mortality in patients with ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Material and methods: A total of 700 consecutive STEMI patients admitted for primary PCI were included in our study. The patients included in the study were divided into two groups: group with normal and group with elevated WBC count. A leukocyte count >11000 / mm3 was considered elevated. Patients were followed-up at 30-days and at 1-year after enrollment. Results: Out off the 700 STEMI patients treated with primary PCI, 665 had WBC count data available at admission and were included in further analysis. From this number, elevated WBC count was registered in 380 patients (57.14%). Patients with increased WBC count were younger and smokers. Observing the characteristics of patients at admission, patients with elevated WBC count had a lower ejection fraction, higher CPK values as well as a higher incidence of heart failure. Thirty-day as well as 1-year mortality were significantly higher in patients with elevated WBC count. Patients with elevated WBC count were at three-fold higher risk for 30day mortality and at two-fold higher risk for 1-year morality. Conclusion: Patients with elevated WBC counts at admission had higher 30-day and 1-year mortality compared with patients with normal WBC counts. The WBC count was an independent predictor of thirty-day and one-year mortality.
Collapse
|
6
|
Elzeneini M, Al-Ani M, Peters AE, Burdick MD, Yang N, Salerno M, Mehrad B, Keeley EC. Circulating fibrocyte levels correlate with infarct size in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention. AMERICAN HEART JOURNAL PLUS: CARDIOLOGY RESEARCH AND PRACTICE 2021; 12. [PMID: 35079723 PMCID: PMC8786221 DOI: 10.1016/j.ahjo.2021.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Study objective: Infarct size is a strong predictor of outcomes after ST elevation myocardial infarction (STEMI). Circulating fibrocytes are bone marrow-derived progenitor cells associated with fibrotic processes. We tested whether fibrocytes correlate with infarct size in STEMI patients treated with primary percutaneous coronary intervention (PCI). Design: Prospective observational study. Setting: Academic medical center. Participants: Subjects with STEMI treated with primary PCI. Interventions: Peripheral blood draw and cardiac magnetic resonance imaging (CMR). Main outcome measure: Correlation of fibrocyte levels with infarct size. Methods: Peripheral blood fibrocytes were quantified at discharge from STEMI hospitalization and at 6 months follow-up using flow cytometry. Infarct size was determined within 2 weeks of discharge and at 6 months follow-up using late gadolinium enhancement on CMR. Results: Among 14 patients (median age 54 years, 79% men) with STEMI, there was a statistically significant positive correlation between fibrocyte levels at 6 months and 6-month infarct size on CMR (r = 0.58, p = 0.031). In addition, there was positive correlation between peak troponin I level (r = 0.85, p < 0.001), and white blood cell count (r = 0.55, p = 0.042) during the hospital stay and 6-month infarct size on CMR. Conclusions: Circulating fibrocytes measured 6 months after STEMI positively correlate with 6-month infarct size assessed by CMR.
Collapse
|
7
|
White blood cell count and clinical outcomes after left main coronary artery revascularization: insights from the EXCEL trial. Coron Artery Dis 2021; 31:45-51. [PMID: 34010180 DOI: 10.1097/mca.0000000000001052] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies have reported an association between elevated white blood cell count (WBCc) and worse clinical outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). We assessed the prognostic impact of WBCc in patients undergoing revascularization for left main coronary artery disease (LMCAD). METHODS In Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL), 1905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. The 1895 patients with baseline WBCc available were grouped in tertiles of WBCc (mean 5.6 ± 0.8, 7.5 ± 0.5, and 10.1 ± 1.6 × 109/L). RESULTS Five-year rates of the primary endpoint (death, myocardial infarction or stroke) were similar across increasing WBCc tertiles (21.2, 18.9, and 21.6%; P = 0.46). Individual components of the primary endpoint, Bleeding Academic Research Consortium (BARC) 3-5 bleeding, stent thrombosis or graft occlusion and ischemia-driven revascularization were all similar across WBCc tertiles. By multivariable analysis, WBCc as a continuous variable was not an independent predictor of adverse events (hazard radio per 1 × 109/L: 1.02; 95% CI, 0.97-1.08; P = 0.43). Results were consistent in the PCI and CABG arms individually. CONCLUSION There was no association between baseline WBCc and 30-day or 5-year clinical outcomes after PCI or CABG. The absence of a clear incremental increase in events with increasing WBCc in the current analysis indicates that WBCc should not routinely be used as a prognostic marker or to guide revascularization decisions in patients with LMCAD.
Collapse
|
8
|
Using proximity extension proteomics assay to identify biomarkers associated with infarct size and ejection fraction after ST-elevation myocardial infarction. Sci Rep 2020; 10:18663. [PMID: 33122738 PMCID: PMC7596042 DOI: 10.1038/s41598-020-75399-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
Plasma concentrations of many cardiovascular and inflammatory proteins are altered after ST-elevation myocardial infarction (STEMI) and may provide prognostic information. We conducted a large-scale proteomic analysis in patients with STEMI, correlating protein levels to infarct size and left ventricular ejection fraction (LVEF) determined with cardiac magnetic resonance imaging. We analysed 131 cardiovascular and inflammatory proteins using a multiplex proximity extension assay and blood samples obtained at baseline, 6, 24, and 96 h from the randomised clinical trial CHILL-MI. Cardiac magnetic resonance imaging data at 4 ± 2 days and 6 months were available as per trial protocol. Using a linear regression model with bootstrap resampling and false discovery rate adjustment we identified five proteins (ST2, interleukin-6, pentraxin-3, interleukin-10, renin, and myoglobin) with elevated values corresponding to larger infarct size or worse LVEF and four proteins (TNF-related apoptosis-inducing ligand, TNF-related activation induced cytokine, interleukin-16, and cystatin B) with values inversely related to LVEF and infarct size, concluding that among 131 circulating inflammatory and cardiovascular proteins in the acute and sub-acute phase of STEMI, nine showed a relationship with infarct size and LVEF post-STEMI, with IL-6 and ST2 exhibiting the strongest association.
Collapse
|
9
|
Liu Y, Zhu Y, Jia W, Sun D, Zhao L, Zhang C, Wang C, Lyu Q, Chen Y, Chen G, Bo Y, Xing Y. Association of the Total White Blood Cell, Neutrophils, and Monocytes Count With the Presence, Severity, and Types of Carotid Atherosclerotic Plaque. Front Med (Lausanne) 2020; 7:313. [PMID: 32793608 PMCID: PMC7385072 DOI: 10.3389/fmed.2020.00313] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/29/2020] [Indexed: 01/07/2023] Open
Abstract
Background: Previous studies have indicated that white blood cells (WBCs) might contribute to the development of atherosclerosis. However, the associations of WBCs and WBC subgroups with carotid atherosclerotic plaque (CAP) have not been compared. Methods: A cross-sectional study including 3,569 healthy Chinese adults was conducted between January 2016 and December 2018 in Zhengzhou, China, to explore the associations of WBC and WBC subtypes with the presence, severity, and types of CAPs. Fasting peripheral venous blood was collected for measurement of the total WBC and WBC subtype counts. The size, composition, and types of CAPs in the common carotid artery, the internal carotid artery, and the external carotid artery were measured bilaterally using B-mode ultrasound. Results: The total WBC, neutrophil, and monocyte counts showed significant associations with the presence of CAPs in men, but not in women, with the adjusted odds ratios (95% CI) in the highest (compared to the lowest) quartile 1.99 (1.33-2.97), 1.65 (1.10-2.47), and 2.17 (1.41-3.18) (P trend = 0.004, P trend = 0.004, and P trend < 0.001), respectively. The three leukocyte counts were also significantly associated with the severity of CAPs, as judged by the count of CAPs, maximal internal carotid plaque thickness, and the plaque score (all P < 0.01, P trend < 0.05). Compared with individuals without CAPs, those with echolucent plaques had significantly increased total WBC and neutrophil counts, whereas those with polytype plaques had a significantly increased monocyte count. Conclusion: WBC, neutrophil, and monocyte counts were significantly associated with the presence, severity, and types of CAPs in a healthy Chinese population.
Collapse
Affiliation(s)
- Yanhua Liu
- Department of Nutrition, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongjian Zhu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenrui Jia
- Department of Physical Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dan Sun
- Department of Physical Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Zhao
- Department of Physical Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chen Zhang
- Department of Physical Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuicui Wang
- Department of Physical Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Quanjun Lyu
- Department of Nutrition, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuming Chen
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Gaiyun Chen
- Department of Nutrition, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yacong Bo
- Department of Nutrition, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yurong Xing
- Department of Physical Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
10
|
Hong D, Choi KH, Song YB, Lee JM, Park TK, Yang JH, Hahn JY, Choi JH, Choi SH, Kim SM, Choe Y, Kim EK, Chang SA, Lee SC, Oh JK, Gwon HC. Prognostic implications of post-percutaneous coronary intervention neutrophil-to-lymphocyte ratio on infarct size and clinical outcomes in patients with acute myocardial infarction. Sci Rep 2019; 9:9646. [PMID: 31273274 PMCID: PMC6609693 DOI: 10.1038/s41598-019-46117-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/24/2019] [Indexed: 11/09/2022] Open
Abstract
This study evaluated the prognostic implications of post-percutaneous coronary intervention (PCI) neutrophil-to-lymphocyte ratio (NLR) in patients with acute myocardial infarction (AMI). A total of 309 patients with AMI who underwent cardiac magnetic resonance imaging (CMR) and a complete blood cell count within 24 hours before and after PCI were enrolled. Primary outcome was infarct size. Patients were assigned to high (n = 118) or low (n = 191) NLR groups according to the best cut-off value of 3.88. Infarct size (% of total left ventricular mass) was significantly higher in the high NLR group than in the low NLR group (24.1 ± 11.0 vs. 16.7 ± 9.1, p < 0.001). Post-PCI NLR ≥ 3.88 was associated with risk of a large-sized infarction (≥20%) (OR 2.91, 95% CI 1.73-4.88, p < 0.001). The risk of MACE was also significantly higher in the high NLR group than in the low NLR group (15.8% vs. 7.4%, HR 2.60, 95% CI 1.21-5.60, p = 0.015). Among patients with AMI who underwent PCI, high post-PCI NLR value was associated with higher risk of large-sized infarction as measured by CMR, as well as adverse clinical outcomes. Our findings suggest that post-PCI NLR is a useful tool for risk assessment in patients with AMI who undergo PCI.
Collapse
Affiliation(s)
- David Hong
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Mok Kim
- Department of Radiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeonhyeon Choe
- Department of Radiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung A Chang
- Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae K Oh
- Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| |
Collapse
|
11
|
Fu R, Song C, Yang J, Wang Y, Li B, Xu H, Gao X, Li W, Liu J, Dou K, Yang Y. CAMI-NSTEMI Score - China Acute Myocardial Infarction Registry-Derived Novel Tool to Predict In-Hospital Death in Non-ST Segment Elevation Myocardial Infarction Patients. Circ J 2018; 82:1884-1891. [PMID: 29887577 DOI: 10.1253/circj.cj-17-1078] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Accurate risk stratification of non-ST segment elevation myocardial infarction (NSTEMI) patients is important due to great variability in mortality risk, but, to date, no prediction model has been available. The aim of this study was therefore to establish a risk score to predict in-hospital mortality risk in NSTEMI patients.Methods and Results:We enrolled 5,775 patients diagnosed with NSTEMI from the China Acute Myocardial Infarction (CAMI) registry and extracted relevant data. Patients were divided into a derivation cohort (n=4,332) to develop a multivariable logistic regression risk prediction model, and a validation cohort (n=1,443) to test the model. Eleven variables independently predicted in-hospital mortality and were included in the model: age, body mass index, systolic blood pressure, Killip classification, cardiac arrest, electrocardiogram ST-segment depression, serum creatinine, white blood cells, smoking status, previous angina, and previous percutaneous coronary intervention. In the derivation cohort, the area under curve (AUC) for the CAMI-NSTEMI risk model and score was 0.81 and 0.79, respectively. In the validation cohort, the score also showed good discrimination (AUC, 0.86). Diagnostic performance of CAMI-NSTEMI risk score was superior to that of the GRACE risk score (AUC, 0.81 vs. 0.72; P<0.01). CONCLUSIONS The CAMI-NSTEMI score is able to accurately predict the risk of in-hospital mortality in NSTEMI patients.
Collapse
Affiliation(s)
- Rui Fu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Chenxi Song
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Jingang Yang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Yan Wang
- Xiamen Cardiovascular Hospital, Xiamen University
| | - Bao Li
- Shanxi Province Cardiovascular Hospital
| | - Haiyan Xu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Xiaojin Gao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Jia Liu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Kefei Dou
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital.,National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College
| | | |
Collapse
|
12
|
Prevalence and Predictive Value of Microvascular Flow Abnormalities after Successful Contemporary Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction. J Am Soc Echocardiogr 2018. [DOI: 10.1016/j.echo.2018.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
13
|
Zhang Y, Yang Y. Arctigenin exerts protective effects against myocardial infarction via regulation of iNOS, COX‑2, ERK1/2 and HO‑1 in rats. Mol Med Rep 2018; 17:4839-4845. [PMID: 29328478 DOI: 10.3892/mmr.2018.8420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 09/05/2017] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to determine the protective effects of arctigenin against myocardial infarction (MI), and its effects on oxidative stress and inflammation in rats. Left anterior coronary arteries of Sprague‑Dawley rats were ligated, in order to generate an acute MI (AMI) model. Arctigenin was administered to AMI rats at 0, 50, 100 or 200 µmol/kg. Western blotting and ELISAs were performed to analyze protein expression and enzyme activity. Arctigenin was demonstrated to effectively inhibit the levels of alanine transaminase, creatine kinase‑MB and lactate dehydrogenase, and to reduce infarct size in AMI rats. In addition, the activity levels of malondialdehyde, interleukin (IL)‑1β and IL‑6 were significantly suppressed, and the levels of glutathione peroxidase, catalase and superoxide dismutase were significantly increased by arctigenin treatment. Arctigenin treatment also suppressed the protein expression levels of inducible nitric oxide synthase (iNOS), cyclooxygenase 2 (COX‑2) and heme oxygenase 1 (HO‑1), and increased the protein expression levels of phosphorylated‑extracellular signal‑regulated kinase 1/2 (p‑ERK1/2) in AMI rats. Overall, the results of the present study suggest that arctigenin may inhibit MI, and exhibits antioxidative and anti‑inflammatory effects through regulation of the iNOS, COX‑2, ERK1/2 and HO‑1 pathways in a rat model of AMI.
Collapse
Affiliation(s)
- Yanmin Zhang
- Department of Emergency, Liaocheng People's Hospital of Shandong, Liaocheng, Shandong 252000, P.R. China
| | - Yong Yang
- Department of Cardiology, Liaocheng People's Hospital of Shandong, Liaocheng, Shandong 252000, P.R. China
| |
Collapse
|
14
|
Yang TC, Chang PY, Kuo TL, Lu SC. Electronegative L5-LDL induces the production of G-CSF and GM-CSF in human macrophages through LOX-1 involving NF-κB and ERK2 activation. Atherosclerosis 2017; 267:1-9. [PMID: 29078142 DOI: 10.1016/j.atherosclerosis.2017.10.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/30/2017] [Accepted: 10/12/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Circulating levels of granulocyte colony-stimulating factor (G-CSF) and granulocyte macrophage colony-stimulating factor (GM-CSF) are associated with the severity of acute myocardial infarction (AMI). However, what causes increases in G-CSF and GM-CSF is unclear. In this study, we investigated whether L5-low-density lipoprotein (LDL), a mildly oxidized LDL from AMI, can induce G-CSF and GM-CSF production in human macrophages. METHODS L1-LDL and L5-LDL were isolated through anion-exchange chromatography from AMI plasma. Human macrophages derived from THP-1 and peripheral blood mononuclear cells were treated with L1-LDL, L5-LDL, or copper-oxidized LDL (Cu-oxLDL) and G-CSF and GM-CSF protein levels in the medium were determined. In addition, the effects of L5-LDL on G-CSF and GM-CSF production were tested in lectin-type oxidized LDL receptor-1 (LOX-1), CD36, extracellular signal-regulated kinase (ERK) 1, and ERK2 knockdown THP-1 macrophages. RESULTS L5-LDL but not L1-LDL or Cu-oxLDL significantly induced production of G-CSF and GM-CSF in macrophages. In vitro oxidation of L1-LDL and L5-LDL altered their ability to induce G-CSF and GM-CSF, suggesting that the degree of oxidation is critical for the effects. Knockdown and antibody neutralization experiments suggested that the effects were caused by LOX-1. In addition, nuclear factor (NF)-κB and ERK1/2 inhibition resulted in marked reductions of L5-LDL-induced G-CSF and GM-CSF production. Moreover, knockdown of ERK2, but not ERK1, hindered L5-LDL-induced G-CSF and GM-CSF production. CONCLUSIONS The results indicate that L5-LDL, a naturally occurring mild oxidized LDL, induced G-CSF and GM-CSF production in human macrophages through LOX-1, ERK2, and NF-κB dependent pathways.
Collapse
Affiliation(s)
- Tzu-Ching Yang
- Department of Biochemistry and Molecular Biology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Yuan Chang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Tzu-Ling Kuo
- Department of Biochemistry and Molecular Biology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shao-Chun Lu
- Department of Biochemistry and Molecular Biology, National Taiwan University College of Medicine, Taipei, Taiwan.
| |
Collapse
|
15
|
Devaux Y. Transcriptome of blood cells as a reservoir of cardiovascular biomarkers. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2017; 1864:209-216. [DOI: 10.1016/j.bbamcr.2016.11.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/04/2016] [Accepted: 11/05/2016] [Indexed: 02/07/2023]
|
16
|
Hartman MHT, Eppinga RN, Vlaar PJJ, Lexis CPH, Lipsic E, Haeck JDE, van Veldhuisen DJ, van der Horst ICC, van der Harst P. The contemporary value of peak creatine kinase-MB after ST-segment elevation myocardial infarction above other clinical and angiographic characteristics in predicting infarct size, left ventricular ejection fraction, and mortality. Clin Cardiol 2016; 40:322-328. [PMID: 28026027 DOI: 10.1002/clc.22663] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/23/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Complex multimarker approaches to predict outcome after ST-elevation myocardial infarction (STEMI) have only considered a single baseline sample, while neglecting easily obtainable peak creatine kinase and creatine kinase-MB (CK-MB) values during hospitalization. METHODS We studied 476 patients undergoing primary percutaneous coronary intervention for STEMI and cardiac magnetic resonance imaging (CMRI) at 4-6 months after STEMI. We determined the association with cardiac biomarkers (peak CK-MB, peak troponin T, N-terminal pro-brain natriuretic peptide), clinical and angiographic characteristics with infarct size, and LVEF, followed by association with mortality in 1120 STEMI patients. RESULTS Peak CK-MB was the strongest predictor for infarct size (P<0.001, R 2 =0.60) and LVEF (P<0.001, R 2 =0.40). The additional value of clinical and angiographic characteristics was limited. The optimal peak CK-MB cutpoints, for differentiation among small (<10% of the left ventricle), moderate (≥10%-<30%), and large infarct size (≥30%), were 210 U/L and 380 U/L, respectively. These cutpoints were associated with 90-day mortality; the hazard ratio for moderate infarct was 2.99 (95% confidence interval [CI]: 1.51-5.93, P=0.002) and for large infarct 6.53 (95% CI: 3.63-11.76, P<0.001). CONCLUSIONS Classical peak CK-MB measured during hospitalization for STEMI was superior to other clinical and angiographic characteristics in predicting CMRI-defined infarct size and LVEF, and should be included and validated in future multimarker studies. Peak CK-MB cutpoints differentiated among infarct size categories and were associated with increased 90-day mortality risk.
Collapse
Affiliation(s)
- Minke H T Hartman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ruben N Eppinga
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Pieter J J Vlaar
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Chris P H Lexis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joost D E Haeck
- Department of Cardiology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
17
|
Biomarker ratios and acute myocardial infarction: when one goes up and the other goes down. Coron Artery Dis 2016; 27:167-8. [PMID: 27049958 DOI: 10.1097/mca.0000000000000354] [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: 11/26/2022]
|
18
|
Yeh YT, Liu CW, Li AH, Ke SR, Liu YH, Chen KC, Liao PC, Wu YW. Rapid Early Triage by Leukocytosis and the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: An Observational Study. Medicine (Baltimore) 2016; 95:e2857. [PMID: 26886652 PMCID: PMC4998652 DOI: 10.1097/md.0000000000002857] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The clinical utility of leukocytosis in risk assessment for ST-elevation myocardial infarction (STEMI) is still unclear. We aim to demonstrate the prognostic value of leukocyte counts independent from traditional risk factors and the TIMI risk score (TRS) for STEMI and to propose a practical model comprising leukocyte count for early triage in STEMI undergoing primary angioplasty. A prospective database (n = 796) of consecutive STEMI cases receiving primary angioplasty at a tertiary medical center was retrospectively analyzed in the period from February 1, 2007 through December 31, 2012. Primary endpoints were 30-day and 1-year mortality. Propensity score-adjusted Cox regression models and subdivision analysis were performed. Leukocytosis group (n = 306) had higher 30-day mortality (5.9% vs 3.1%, P = 0.048) and 1-year mortality (9.2% vs 5.1%, P = 0.022). After adjustment by propensity score and TRS, leukocyte count (per 10/μL) was an independent predictor of 1-year mortality (HR: 1.086, 95% CI: 1.034-1.140, P = 0.001). Subdivision analysis demonstrated the correlation between leukocytosis and higher 1-year mortality within both high and low TRS strata (divided by 4, the median of TRS). Additionally, 24% (191 out of 796) of patients were characterized by nonleukocytosis and TRS < 4, having 0% of mortality rate at 1-year follow-up. In conclusion, leukocyte count is an independent prognostic factor adding incremental value to TRS for STEMI. Nonleukocytosis in conjunction with TRS < 4 identifies a large patient group at extremely low risk and thus provides rapid early triage for STEMI patients undergoing primary PCI. This finding is worth validation in the future.
Collapse
Affiliation(s)
- Yen-Ting Yeh
- From the Cardiology Division of Cardiovascular Medical Center (Y-TY, C-WL, A-HL, S-RK, Y-WL, K-CC, P-CL, Y-WW), Department of Nuclear Medicine (Y-WW), Far Eastern Memorial Hospital, New Taipei City, National Yang-Ming University School of Medicine, Taipei, Taiwan (Y-WW), National Defense Medical Center (C-WL), Department of Nuclear Medicine and Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine (Y-WW), Taipei, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Seropian IM, Sonnino C, Van Tassell BW, Biasucci LM, Abbate A. Inflammatory markers in ST-elevation acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:382-95. [PMID: 25681486 DOI: 10.1177/2048872615568965] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 01/02/2015] [Indexed: 01/05/2023]
Abstract
After acute myocardial infarction, ventricular remodeling is characterized by changes at the molecular, structural, geometrical and functional level that determine progression to heart failure. Inflammation plays a key role in wound healing and scar formation, affecting ventricular remodeling. Several, rather different, components of the inflammatory response were studied as biomarkers in ST-elevation acute myocardial infarction. Widely available and inexpensive tests, such as leukocyte count at admission, as well as more sophisticated immunoassays provide powerful predictors of adverse outcome in patients with ST-elevation acute myocardial infarction. We review the value of inflammatory markers in ST-elevation acute myocardial infarction and their association with ventricular remodeling, heart failure and sudden death. In conclusion, the use of these biomarkers may identify subjects at greater risk of adverse events and perhaps provide an insight into the mechanisms of disease progression.
Collapse
Affiliation(s)
- Ignacio M Seropian
- Interventional Cardiology Department, Hospital Italiano de Buenos Aires, Argentina
| | - Chiara Sonnino
- VCU Pauley Heart Center, Virginia Commonwealth University, USA Victoria Johnson Research Laboratory, Virginia Commonwealth University, USA Department of Cardiovascular Medicine, Catholic University, Italy
| | - Benjamin W Van Tassell
- VCU Pauley Heart Center, Virginia Commonwealth University, USA Victoria Johnson Research Laboratory, Virginia Commonwealth University, USA School of Pharmacy, Virginia Commonwealth University, USA
| | - Luigi M Biasucci
- Department of Cardiovascular Medicine, Catholic University, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, USA Victoria Johnson Research Laboratory, Virginia Commonwealth University, USA
| |
Collapse
|
21
|
Soufras GD, Hahali G, Kounis NG, Kounis NG. Relation between white blood cell count and infarct size: what about differential? Am J Cardiol 2014; 113:412. [PMID: 24387903 DOI: 10.1016/j.amjcard.2013.10.006] [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: 10/20/2013] [Accepted: 10/24/2013] [Indexed: 12/01/2022]
|
22
|
Kounis NG, Soufras GD, Tsigkas G, Hahalis G. White blood count and infarct size, myocardial salvage and clinical outcomes: the role of differentials. Int J Cardiovasc Imaging 2014; 30:677-9. [PMID: 24384860 DOI: 10.1007/s10554-013-0359-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 12/30/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Nicholas G Kounis
- Medical Sciences, Patras Highest Institute of Education and Technology, Patras, Achaia, Greece,
| | | | | | | |
Collapse
|