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Razavi AC, Raggi P, Whelton SP. Coronary artery calcium: The canary in the coal mine. Atherosclerosis 2024; 392:117499. [PMID: 38508916 DOI: 10.1016/j.atherosclerosis.2024.117499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Alexander C Razavi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Paolo Raggi
- Department of Medicine and Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Razavi AC, Dzaye O, Michos ED, Budoff MJ, Allen NB, Lima JA, Polak JF, Post WS, Nasir K, Blumenthal RS, Sperling LS, Blaha MJ, Whelton SP. Nontraditional Risk Markers for Incident Coronary Artery Calcium Among Persons ≥65 Years of Age. JACC. ADVANCES 2024; 3:100755. [PMID: 38939371 PMCID: PMC11198298 DOI: 10.1016/j.jacadv.2023.100755] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 08/07/2023] [Accepted: 09/25/2023] [Indexed: 06/29/2024]
Abstract
Background The initiation of coronary artery calcium (CAC) is an important physiologic milestone associated with increased cardiovascular disease risk. However, traditional risk factors (RF) do not perform well for predicting incident CAC among the 54 million older U.S. adults. Objectives The authors sought to assess the association between nontraditional cardiovascular disease RF and incident CAC in older persons. Methods There were 815 MESA (Multi-Ethnic Study of Atherosclerosis) participants ≥65 years of age who had CAC = 0 at Visit 1 and a follow-up CAC scan. Multivariable adjusted Cox hazards ratios (aHR) and C-statistics were calculated to examine the association of nontraditional RF with incident CAC. Results The mean age was 70.2 years and 67% were women. The median follow-up time to repeat CAC scan was 3.6 years (IQR: 2.6-9.2 years) and 45% of participants developed incident CAC. Albuminuria (aHR: 1.50, 95% CI: 1.07-2.09), carotid plaque (aHR: 1.32, 95% CI: 1.04-1.66), and thoracic aortic calcification (TAC) (aHR: 1.38, 95% CI: 1.10-1.75) were significantly associated with incident CAC, while higher levels of nontraditional RF including apolipoprotein-B, lipoprotein(a), high-sensitivity troponin T, and N-terminal pro-brain natriuretic peptide were not. When added to demographics, albuminuria, carotid plaque, and TAC provided a greater C-statistic improvement (+0.047, P = 0.004) vs all traditional RF combined (+0.033, P = 0.05). Conclusions Among nontraditional RF and measures of subclinical atherosclerosis, only albuminuria, carotid plaque, and TAC were significantly associated with incident CAC in persons ≥65 years of age. Identification of albuminuria or extracoronary atherosclerosis may help guide the timing of repeat CAC scoring in older persons with baseline CAC = 0.
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Affiliation(s)
- Alexander C. Razavi
- Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew J. Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Norrina B. Allen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joao A.C. Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph F. Polak
- Department of Radiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Wendy S. Post
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Roger S. Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurence S. Sperling
- Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Seamus P. Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sperling LS, Jain V, Razavi AC. Primary Atherosclerotic Cardiovascular Disease Prevention: Optimally Active, Agile, and Accountable. JACC. ADVANCES 2023; 2:100677. [PMID: 38938487 PMCID: PMC11198444 DOI: 10.1016/j.jacadv.2023.100677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Laurence S. Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vardhmaan Jain
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexander C. Razavi
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
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Whelton SP, Blaha MJ. Coronary artery calcium: from risk prediction to treatment allocation and clinical trials. Heart 2023; 109:1714-1721. [PMID: 37130748 DOI: 10.1136/heartjnl-2022-321711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Coronary artery calcium (CAC) is a direct measure of an individual's coronary atherosclerotic burden. Higher levels of CAC are strongly associated with an increased risk of cardiovascular disease (CVD) events and individuals with very high CAC levels have a CVD risk similar to stable persons with a prior CVD event. Conversely, the absence of CAC (CAC=0) is associated with a low long-term risk of CVD, even among groups classified as high risk based on traditional risk factors. Accordingly, the guideline-based role of CAC in allocation of CVD prevention therapies has expanded to include both statin and non-statin medications. Beyond prevention therapies, it is now widely recognised that the total burden of atherosclerosis is a stronger risk factor for CVD than a sole focus on coronary stenosis. Furthermore, evidence is accruing to support expanding the value of CAC=0 among low-risk symptomatic patients given its very high negative predictive value for ruling out obstructive coronary artery disease. There is now an appreciation of the value of routine assessment of CAC on all non-gated chest CTs and with the advent of artificial intelligence, automated interpretation is now possible. Additionally, CAC is now firmly established in randomised trials as a tool to identify high-risk patients most likely to benefit from pharmacotherapies. Future studies incorporating measures of atherosclerosis beyond the Agatston score will lead to continued refinement of CAC scoring, further improvements in personalisation of CVD risk prediction and more individualised allocation of prevention therapies to the patients at highest CVD risk.
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Affiliation(s)
- Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Razavi AC, Mortensen MB, Blaha MJ, Dzaye O. Coronary artery calcium testing in young adults. Curr Opin Cardiol 2023; 38:32-38. [PMID: 36598447 PMCID: PMC9830553 DOI: 10.1097/hco.0000000000001006] [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] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW To provide a summary of recent literature on coronary artery calcium testing (CAC) for risk stratification in young adults <45 years old. RECENT FINDINGS One of every ten young adults in the general population, and one out of every three young adults with traditional atherosclerotic cardiovascular disease (ASCVD) risk factors, have CAC. While the definition of premature CAC has yet to be formally defined in guidelines, it has become increasingly clear that any prevalent CAC among adults <45 years old should be considered premature. Traditional risk factors are strong predictors of CAC in young adults; however, this association has been found to wane over the life course which suggests that the onset and severity of risk factors for calcific atherosclerosis varies as individuals age. Though CAC is a robust predictor of both ASCVD and cancer-related mortality in old age, CAC in young adults confers a stepwise higher risk uniquely for incident ASCVD mortality, and not for non-ASCVD causes. New tools are available to assist in interpretation of CAC in the young, and for estimating the ideal age to initiate CAC scoring. SUMMARY The identification of premature CAC is important because it suggests that calcific plaque can be detected with modern imaging earlier in the natural history than previously thought. Taken together, these findings underline a utility of selective use of CAC scoring on non-contrast computed tomography among at-risk young adults to facilitate timely lifestyle modification and pharmacotherapies for the prevention of later life ASCVD.
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Affiliation(s)
- Alexander C. Razavi
- Center for Heart Disease Prevention, Emory University Hospital, Atlanta, Georgia, United States of America
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | | | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Omar Dzaye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
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Razavi AC, Prabakaran S, Sawan M, Tummala L, Onuorah I, Amin SB, van Assen M, De Cecco CN, Quyyumi AA, Whelton SP, Sperling LS, Rollin FG. Transient left bundle branch block associated with very high coronary artery calcium: a case report. Ther Adv Cardiovasc Dis 2023; 17:17539447231196758. [PMID: 37724558 PMCID: PMC10510344 DOI: 10.1177/17539447231196758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 08/07/2023] [Indexed: 09/21/2023] Open
Abstract
Coronary artery calcium (CAC) is the measure of subclinical coronary artery atherosclerosis most strongly associated with atherosclerotic cardiovascular disease (ASCVD) risk. However, CAC is rarely reported in the inpatient setting to guide chest pain management. We present a case of very high CAC in a 64-year-old woman with hypertension, type 2 diabetes, and hyperlipidemia presenting with dyspnea. Initial electrocardiogram (ECG) demonstrated normal conduction with a heart rate of 76 beats/min, but new T-wave inversions in V1-V4 and a high-sensitivity troponin-I (hsTnI) value of 6 ng/L (normal < 6 ng/L). Repeat ECG in the emergency department showed normal sinus rhythm (heart rate of 80 beats/min); however, it subsequently demonstrated a left bundle branch block (LBBB) with a repeat hsTnI of 7 ng/L. Stress testing with pharmacologic single-photon emission computerized tomography did not show scintigraphic evidence of ischemia but noted extensive CAC and a concern for balanced ischemia. Subsequent coronary computed tomography angiography (CCTA) showed nonobstructive disease and a total Agatston CAC score of 1262. Invasive evaluation with left heart catheterization was deferred given the patient's unchanged symptoms and CCTA findings. Statin therapy was intensified and aspirin, metoprolol succinate, and antihypertension therapies were continued. Initiation of glucose-lowering therapy and lipoprotein(a) testing was strongly recommended on follow-up. Our case suggests that CAC ⩾ 1000 may be incidentally associated with transient LBBB during the workup of coronary artery disease. Here, we specifically show that functional testing that incorporates measurement of CAC burden can help to improve ASCVD-preventive pharmacotherapy initiation and intensification beyond the identification of obstructive disease alone.
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Affiliation(s)
- Alexander C Razavi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sindhu Prabakaran
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Mariem Sawan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Lakshmi Tummala
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ifeoma Onuorah
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sagar B Amin
- Division of Cardiothoracic Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Marly van Assen
- Division of Cardiothoracic Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Carlo N De Cecco
- Division of Cardiothoracic Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laurence S Sperling
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Francois G Rollin
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Razavi AC, Agatston AS, Shaw LJ, De Cecco CN, van Assen M, Sperling LS, Bittencourt MS, Daubert MA, Nasir K, Blumenthal RS, Mortensen MB, Whelton SP, Blaha MJ, Dzaye O. Evolving Role of Calcium Density in Coronary Artery Calcium Scoring and Atherosclerotic Cardiovascular Disease Risk. JACC Cardiovasc Imaging 2022; 15:1648-1662. [PMID: 35861969 PMCID: PMC9908416 DOI: 10.1016/j.jcmg.2022.02.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
Coronary artery calcium (CAC) is a specific marker of coronary atherosclerosis that can be used to measure calcified subclinical atherosclerotic burden. The Agatston method is the most widely used scoring algorithm for quantifying CAC and is expressed as the product of total calcium area and a quantized peak calcium density weighting factor defined by the calcification attenuation in HU on noncontrast computed tomography. Calcium density has emerged as an important area of inquiry because the Agatston score is upweighted based on the assumption that peak calcium density and atherosclerotic cardiovascular disease (ASCVD) risk are positively correlated. However, recent evidence demonstrates that calcium density is inversely associated with lesion vulnerability and ASCVD risk in population-based cohorts when accounting for age and plaque area. Here, we review calcium density by focusing on 3 main areas: 1) CAC scan acquisition parameters; 2) pathophysiology of calcified plaques; and 3) epidemiologic evidence relating calcium density to ASCVD outcomes. Through this process, we hope to provide further insight into the evolution of CAC scoring on noncontrast computed tomography.
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Affiliation(s)
- Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arthur S Agatston
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Leslee J Shaw
- Blavatnik Family Women's Health Research Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurence S Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcio S Bittencourt
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Razavi AC, Mehta A, Sperling LS. Statin therapy for the primary prevention of cardiovascular disease: Pros. Atherosclerosis 2022; 356:41-45. [PMID: 35945050 DOI: 10.1016/j.atherosclerosis.2022.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Abstract
The initiation of statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) remains a debated subject, despite decades worth of clinical trial data demonstrating efficacy, effectiveness, and safety. Statin therapy, in addition to blood pressure-lowering drugs and efforts to reduce cigarette smoking, was a key component of the preventive cardiology renaissance that achieved a dramatic reduction in ASCVD-related mortality from the 1950s to 2010. However, deaths attributable to ASCVD have increased by approximately 13% in recent years, which are in part driven by incomplete treatment of risk factor burden starting in youth. Statins are a cornerstone of preventive cardiology practice, not only due to their lipid-lowering properties, but also in part due to their ability to exert pleiotropic effects that promote atherosclerotic plaque stability which reduces the likelihood of atherothrombotic clinical events. While the benefit of statin therapy undoubtedly depends on the presence and degree of atherosclerotic plaque burden, a broader statin allocation strategy on a population-based level should be considered especially in younger communities that are disproportionately affected by ASCVD risk factors. Thus, the era of precision medicine must be balanced with a pragmatic, cost-effective approach that maximizes ASCVD prevention across the life course. Herein, we examine the pros of statin pharmacotherapy in primary prevention while examining over three decades worth of basic science, translational, and clinical research in the setting of clinical practice guidelines.
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Affiliation(s)
- Alexander C Razavi
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States; Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Anurag Mehta
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States; Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Laurence S Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States; Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States.
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Lian Y, Wang Y, Zhang D, Xu L. Peroxidase-like and oxidase-like nanozyme activities of reusable Mn–Co–S–Se/Ni foam for antibacterial application. Colloids Surf A Physicochem Eng Asp 2021. [DOI: 10.1016/j.colsurfa.2021.127010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Raggi P. Healthy ageing to guide targeted versus universal treatment: A different approach to prevention. Atherosclerosis 2021; 326:45-46. [PMID: 33906730 DOI: 10.1016/j.atherosclerosis.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Paolo Raggi
- Department of Medicine, University of Alberta, 5A9-014, 11220 83rd Avenue NW, Edmonton, AB, T6G 2B7, Canada.
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