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Bergamini C, Niro L, Springhetti P, Ferri L, Trento L, Minnucci I, Maffeis C, Tafciu E, Rossi A, Fiorio E, Benfari G, Ribichini F. Role of Early Left Atrial Functional Decline in Predicting Cardiotoxicity in HER2 Positive Breast Cancer Patients Treated With Trastuzumab. Cardiovasc Toxicol 2024; 24:550-562. [PMID: 38696070 PMCID: PMC11102377 DOI: 10.1007/s12012-024-09861-6] [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: 12/28/2023] [Accepted: 04/13/2024] [Indexed: 05/19/2024]
Abstract
Trastuzumab is widely used in HER2 breast cancer. However, it may cause left ventricular (LV) dysfunction. A decrease in LV global longitudinal strain (GLS) has been previously demonstrated to be a good predictor of subsequent cancer therapy related dysfunction (CTRCD). Left atrial morphological remodeling during Trastuzumab therapy has also been shown. The aim of this study is exploring the relationship between early changes in left atrial function and the development of Trastuzumab-induced cardiotoxicity. Consecutive patients with diagnosis of HER2+non-metastatic breast cancer treated with Trastuzumab were prospectively enrolled. A clinical, conventional, and advanced echocardiographic assessment was performed at baseline and every three months, until a one-year follow-up was reached. One-hundred-sixteen patients completed the 12 months follow-up, 10 (9%) cases of CTRCD were observed, all after the sixth month. GLS and LVEF significantly decreased in the CTRCD group at 6 months of follow-up, with an earlier (3 months) significant worsening in left atrial morpho-functional parameters. Systolic blood pressure, early peak atrial longitudinal strain (PALS), peak atrial contraction (PACS) and left atrial volume (LAVI) changes resulted independent predictors of CTRCD at multivariable logistic regression analysis. Moreover, early changes in PALS and PACS resulted good predictors of CTRCD development (AUC 0.85; p = 0.008, p < 0.001 and 0.77; p = 0.008, respectively). This prospective study emphasizes that the decline in PALS and PACS among trastuzumab-treated patients could possibly increase the accuracy in identifying future CTRCD in non-metastatic HER2 breast cancer cases, adding predictive value to conventional echocardiographic assessment.
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Affiliation(s)
- Corinna Bergamini
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy.
| | - Lorenzo Niro
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Paolo Springhetti
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Luisa Ferri
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Laura Trento
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Ilaria Minnucci
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Caterina Maffeis
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Elvin Tafciu
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Andrea Rossi
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Elena Fiorio
- Department of Medicine, Section of Oncology, University of Verona, 37100, Verona, VR, Italy
| | - Giovanni Benfari
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
| | - Flavio Ribichini
- Department of Medicine, Section of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100, Verona, VR, Italy
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Gąsior T, Zaborska B, Stachowiak P, Sikora-Frąc M, Mizia-Stec K, Kasprzak J, Bodys A, Bijoch J, Szmagała A, Kosior DA, Płońska-Gościniak E. Echocardiographic Assessment of Left Ventricular Function in Three Oncologic Therapeutic Modalities in Women with Breast Cancer: The ONCO-ECHO Multicenter Study. J Clin Med 2024; 13:2543. [PMID: 38731072 PMCID: PMC11084324 DOI: 10.3390/jcm13092543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/17/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Oncological treatment of breast cancer may be associated with adverse effects on myocardial function. Objectives: The objective of this study was to compare the influence of three oncological treatment methods of intervention on the echocardiographic (ECHO) parameters of left ventricular function. Materials and Methods: One hundred and fifty-five women with breast cancer were divided into three groups depending on the type of therapy used: group I (AC)-anthracyclines; group II (AC + TZ)-anthracyclines + trastuzumab; and group III (RTls+)-anthracyclines with or without trastuzumab + left-sided radiotherapy. Prospective ECHO examinations were performed at baseline and every 3 months, up to 12 months from the start of the therapy. Patients with a history of chemotherapy or who were diagnosed with heart disease were not included in the study. Results: Out of 155 patients, 3 died due to cancer as the primary cause, and 12 withdrew their consent for further observation. Baseline systolic and diastolic ECHO parameters did not differ between the analyzed groups. Cardiotoxicity, according to the LVEF criteria, occurred during follow-up in 20 patients (14.3%), irrespective of the treatment method used. Diastolic echocardiographic parameters did not change significantly after 12 months in each group, except for the left atrial volume index (LAVi), which was significantly higher in the AC + TZ compared to the values in the RTls+ group. Conclusions: All three oncologic therapeutic modalities in women with breast cancer showed no significant differences in relation to the incidence of echocardiographic cardiotoxicity criterion; however, transient systolic decrease in LVEF was most frequently observed in the AC + TZ therapeutic regimen. Left-sided radiotherapy was not associated with excess left ventricular systolic and diastolic dysfunction during a 12-month follow-up period. The predictors of negative changes in diastolic parameters included age and combined anthracycline and trastuzumab therapy.
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Affiliation(s)
- Tomasz Gąsior
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland
- Boehringer Ingelheim International GmbH, 55218 Ingelheim, Germany
| | - Beata Zaborska
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Paweł Stachowiak
- Department of Cardiology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Małgorzata Sikora-Frąc
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Katarzyna Mizia-Stec
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Jarosław Kasprzak
- Department of Cardiology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Artur Bodys
- Stefan Cardinal Wyszynski Regional Hospital, 20-468 Lublin, Poland
| | - Julia Bijoch
- Collegium Medicum—Faculty of Medicine, WSB University, 41-300 Dabrowa Gornicza, Poland
| | - Adrianna Szmagała
- Xth Department of Invasive Cardiology, Electrophysiology and Electrostimulation, American Heart of Poland, 43-100 Tychy, Poland
| | - Dariusz A. Kosior
- Mossakowski Medical Research Centre Polish Academy of Sciences, 02-106 Warsaw, Poland
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Pinho J, Carvalho M, Paiva M, Teixeira-Tavares N, Costa-Santos C, Sousa C. Is dyslipidemia a risk factor for trastuzumab-induced cardiotoxicity in breast cancer patients? A systematic review and meta-analysis. Rev Port Cardiol 2023; 42:961-984. [PMID: 37399885 DOI: 10.1016/j.repc.2022.10.016] [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: 05/26/2021] [Accepted: 10/11/2022] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION Breast cancer patients undergoing trastuzumab therapy have greater risk of cardiovascular disease. Risk factors for this effect have been proposed. However, the role of dyslipidemia is not completely understood. This systematic review aimed to explore the role of dyslipidemia in trastuzumab-induced cardiotoxicity. METHODS The investigators searched MEDLINE, Scopus, and Web of Science up to October 25, 2020. A random-effects model was used to determine pooled estimates of the results. The primary endpoint was trastuzumab-induced cardiotoxicity in patients with and without dyslipidemia. RESULTS A total of 39 studies were selected for inclusion in our systematic review assessing 21079 patients. One study demonstrated a statistically significant association between dyslipidemia and cardiotoxicity (OR=2.28, 95% CI 1.22-4.26, p=0.01). In all other studies, no such association was observed. Twenty-one studies including 6135 patients were eligible for meta-analysis. In this meta-analysis of unadjusted data, dyslipidemia was significantly associated with cardiotoxicity (OR=1.25, 95% CI 1.01-1.53, p=0.04, I2=0%), however, a subgroup analysis of studies reporting adjusted measures did not demonstrate a significant association (OR=0.89, 95% CI 0.73-1.10, p=0.28, I2=0%). CONCLUSION This systematic review and meta-analysis did not demonstrate a significant association between dyslipidemia alone and the development of cardiotoxicity. In the absence of other relevant cardiovascular risk factors, review of lipid profile may not be obligatory, and management of patients could be performed without referral for cardio-oncology assessment. Further investigation of risk factors for trastuzumab-induced cardiotoxicity is required to confirm these results.
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Affiliation(s)
- Jaime Pinho
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Miguel Carvalho
- Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Mariana Paiva
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Centro Hospitalar e Universitário de São João, Porto, Portugal
| | | | | | - Carla Sousa
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Centro Hospitalar e Universitário de São João, Porto, Portugal
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Evaluation of left atrial remodeling using cardiovascular magnetic resonance imaging in breast cancer patients treated with adjuvant trastuzumab. Eur Radiol 2022; 32:4234-4242. [PMID: 34993574 DOI: 10.1007/s00330-021-08466-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/14/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated left atrial (LA) remodeling using cardiac MRI (CMR) in patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer during and after trastuzumab therapy. METHODS In this prospective 2-center longitudinal study, 41 women with HER2-positive breast cancer received adjuvant trastuzumab for 12 months, in addition to standard chemotherapy. Serial CMRs were performed at baseline, 6, 12, and 18 months after initiation of trastuzumab. LA volumes were measured by a blinded reader. Linear mixed model was used to evaluate longitudinal changes. RESULTS Of 41 women (mean age 52 ± 11 [SD] years; 56% received anthracycline), one patient experienced trastuzumab-induced cardiotoxicity (TIC) for which trastuzumab was interrupted for one cycle. Mean baseline left ventricular ejection fraction (LVEF) was 68.0 ± 5.9% and LA ejection fraction (LAEF) was 66.0 ± 6.6%. Compared to baseline, LAEF decreased significantly at 6 months (62.7 ± 5.7%, p = 0.027) and 12 months (62.2 ± 6.1%, p = 0.003), while indexed LA minimum volume (LAmin) significantly increased at 12 months (11.6 ± 4.9 ml/m2 vs 13.8 ± 4.5 ml/m2, p = 0.002). At 18 months, all changes from baseline were no longer significant. From baseline to 6 months, change in LAEF correlated with change in LVEF (Spearman's r = 0.41, p = 0.014). No significant interactions (all p > 0.10) were detected between time and anthracycline use for LA parameters. CONCLUSIONS Among trastuzumab-treated patients with low incidence of TIC, we observed a small but significant decline in LAEF and increase in LAmin that persisted for the duration of therapy and recovered 6 months after therapy cessation. These findings suggest that trastuzumab has concurrent detrimental effects on atrial and ventricular remodeling. KEY POINTS • In trastuzumab-treated breast cancer patients evaluated by cardiac MRI, left atrial ejection fraction declined and minimum volume increased during treatment and recovered to baseline after trastuzumab cessation. • Changes in left atrial ejection fraction correlated with changes in left ventricular ejection fraction in the first 6 months of trastuzumab treatment. • Trastuzumab therapy is associated with concurrent detrimental effects on left atrial and ventricular remodeling.
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Laufer-Perl M, Arias O, Dorfman SS, Baruch G, Rothschild E, Beer G, Hasson SP, Arbel Y, Rozenbaum Z, Topilsky Y, Kapusta L. Left Atrial Strain changes in patients with breast cancer during anthracycline therapy. Int J Cardiol 2021; 330:238-244. [PMID: 33581179 DOI: 10.1016/j.ijcard.2021.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/25/2021] [Accepted: 02/04/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cardiotoxicity has become a significant adverse effect of cancer therapy, with Anthracyclines (ANT) in particular. There is a crucial need for new imaging techniques for the early subclinical detection of cardiotoxic effect. We aimed to evaluate left atrial strain (LAS) changes during ANT therapy and to assess the correlation between LAS and the routine echocardiographic diastolic parameters. METHODS AND RESULTS Data were prospectively collected as part of the Israel Cardio-Oncology Registry (ICOR). All female patients with breast cancer, planned for ANT therapy were included. All patients underwent serial echocardiography exams including baseline LAS (before chemotherapy, T1) and shortly after the completion of ANT therapy (T3). LAS was assessed in 3 phases: Reservoir (LASr), Conduit (LASc) and Pump (LASp). Significant reduction in LASr was determined by either a relative reduction of >10% or an absolute value of <35%. From September 2016 to June 2019, 40 patients were evaluated with a mean Doxorubicin (type of ANT) dose of 237±13.24mg/m2. At T3, significant reduction in LASr was observed among 50% of the patients with a mean LASr reduction from 40.15 ± 6.83% to 36.04 ± 7.73% (p < 0.001). LASc showed significant reduction as well (p < 0.004) as opposed to LASp (p=0.076). Both LASr and LASc showed significant correlation to the routine diastolic parameters. CONCLUSIONS LASr and LASc reduction are frequent and occur early in the course of ANT therapy, showing significant correlation to the routine echocardiographic diastolic parameters, which may imply a role in the detection of early cardiotoxicity.
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Affiliation(s)
- Michal Laufer-Perl
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Orly Arias
- Department of Internal medicine B, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Svetlana Sirota Dorfman
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Guy Baruch
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ehud Rothschild
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Gil Beer
- Pediatric Cardiology Unit, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shira Peleg Hasson
- Department of Oncology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Arbel
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zach Rozenbaum
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Livia Kapusta
- Pediatric Cardiology Unit, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Pediatrics Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
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Bhat S, Gahungu N, Thavendiranathan P, Dwivedi G. The Role of Echocardiography in Cardio-oncology Patients: Contemporary Indications and Future Directions. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9519-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Ballo P, Nistri S, Cameli M, Zuppiroli A, Mondillo S. Reply to "Comparison of Accuracy of Left Atrial Area and Volume by Two-Dimensional Transthoracic Echocardiography Versus Computed Tomography". Am J Cardiol 2019; 124:461-463. [PMID: 31182212 DOI: 10.1016/j.amjcard.2019.05.003] [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: 04/14/2019] [Accepted: 05/06/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Piercarlo Ballo
- Cardiology Unit, S. Maria Annunziata Hospital, Florence, Italy.
| | - Stefano Nistri
- Cardiology Unit, S. Maria Annunziata Hospital, Florence, Italy
| | - Matteo Cameli
- Cardiology Unit, S. Maria Annunziata Hospital, Florence, Italy
| | | | - Sergio Mondillo
- Cardiology Unit, S. Maria Annunziata Hospital, Florence, Italy
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Cerrito LF, Bergamini C, Dolci G, Fiorio E, Ribichini FL. Early functional and structural changes of the left atrium in a patient with trastuzumab: related cardiotoxicity. Minerva Cardioangiol 2019; 67:359-360. [PMID: 31347821 DOI: 10.23736/s0026-4725.19.04919-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luca F Cerrito
- Division of Cardiology, Department of Medicine, A.O.U.I. Verona, Verona, Italy -
| | - Corinna Bergamini
- Division of Cardiology, Department of Medicine, A.O.U.I. Verona, Verona, Italy
| | - Giulia Dolci
- Division of Cardiology, Department of Medicine, A.O.U.I. Verona, Verona, Italy
| | - Elena Fiorio
- Division of Oncology, Department of Medicine, A.O.U.I Verona, Verona, Italy
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, A.O.U.I. Verona, Verona, Italy
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Tadic M, Genger M, Cuspidi C, Belyavskiy E, Frydas A, Dordevic A, Morris DA, Völkl J, Parwani AS, Pieske B, Haßfeld S. Phasic Left Atrial Function in Cancer Patients Before Initiation of Anti-Cancer Therapy. J Clin Med 2019; 8:jcm8040421. [PMID: 30934794 PMCID: PMC6518037 DOI: 10.3390/jcm8040421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/21/2019] [Accepted: 03/23/2019] [Indexed: 12/24/2022] Open
Abstract
We aimed to explore left atrial (LA) remodeling in the patients with solid cancer before initiation of chemo- or radiotherapy. This retrospective investigation included 92 chemo- and radiotherapy-naive cancer patients and 40 age- and gender-matched controls with a similar cardiovascular risk profile as the cancer group. All participants underwent comprehensive echocardiographic examination before the start of chemo- or radiotherapy. LA phasic function was evaluated in volumetric and strain method. Indexed minimal and pre-A LA volumes were significantly higher in the cancer patients. Total and passive LA emptying fraction (EF) were significantly lower, whereas active LAEF was significantly higher in the cancer patients. LA total longitudinal strain was significantly lower in the cancer patients. Strain rate analysis of LA phasic function showed that LA function during systole and early diastole was reduced in the cancer group, while it was increased during late diastole. These findings indicated that LA reservoir and conduit functions, assessed with LA volumetric and strain analysis, were deteriorated in the cancer group. On the other hand, LA booster pump function was elevated in the cancer group in comparison with the controls. In the whole population, cancer was associated with reduced LA total longitudinal strain independently of age, gender, BMI, LV hypertrophy, E/e’ ratio, diabetes, and hypertension. LA phasic function was impaired in the chemo- and radiotherapy-naive cancer patients in comparison with the control group. Cancer, LV hypertrophy, and hypertension were associated with reduced LA longitudinal strain independently of other important clinical parameters.
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Affiliation(s)
- Marijana Tadic
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Martin Genger
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Cesare Cuspidi
- Clinical Research Unit, University of Milan-Bicocca and Istituto Auxologico Italiano, 13353 Meda 20821, Italy.
| | - Evgeny Belyavskiy
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Athanasios Frydas
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Aleksandar Dordevic
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Daniel A Morris
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Jakob Völkl
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Abdul Shokor Parwani
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Berlin/Charité, 13353 Berlin, Germany.
- Department of Cardiology, Deutsches Herzzentrum Berlin, 13353 Berlin, Germany.
| | - Sabine Haßfeld
- Department of Internal Medicine and Cardiology, Charité-University-Medicine Berlin, Campus Virchow Klinikum (CVK), 13353 Berlin, Germany.
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