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Gaba P, Gersh BJ, Muller J, Narula J, Stone GW. Evolving concepts of the vulnerable atherosclerotic plaque and the vulnerable patient: implications for patient care and future research. Nat Rev Cardiol 2023; 20:181-196. [PMID: 36151312 DOI: 10.1038/s41569-022-00769-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenarios, revascularization of these atherosclerotic plaques has not substantially improved freedom from death or myocardial infarction, questioning the utility of contemporary revascularization strategies to improve prognosis. Advances in non-invasive and invasive imaging techniques have helped to identify the characteristics of obstructive and non-obstructive plaques that are precursors for plaque progression and future acute coronary syndromes as well as cardiac death. These 'vulnerable plaques' develop as a consequence of systemic inflammation and are prone to inducing thrombosis. Vulnerable plaques most commonly have a large plaque burden with a well-formed necrotic core and thin fibrous cap and are metabolically active. Perivascular adipose tissue might, in some patients, be used as a surrogate for coronary inflammation and predict future risk of adverse cardiac events. Vulnerable plaques can be identified in their quiescent state, offering the potential for therapeutic passivation. In this Review, we describe the biological and compositional features of vulnerable plaques, the non-invasive and invasive diagnostic modalities to characterize vulnerable plaques, the prognostic utility of identifying vulnerable plaques, and the future studies needed to explore the value of intensified pharmacological and focal treatments of vulnerable plaques.
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Affiliation(s)
- Prakriti Gaba
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - James Muller
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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2
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Theofilis P, Sagris M, Antonopoulos AS, Oikonomou E, Tsioufis K, Tousoulis D. Non-Invasive Modalities in the Assessment of Vulnerable Coronary Atherosclerotic Plaques. Tomography 2022; 8:1742-1758. [PMID: 35894012 PMCID: PMC9326642 DOI: 10.3390/tomography8040147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 12/26/2022] Open
Abstract
Coronary atherosclerosis is a complex, multistep process that may lead to critical complications upon progression, revolving around plaque disruption through either rupture or erosion. Several high-risk features are associated with plaque vulnerability and may add incremental prognostic information. Although invasive imaging modalities such as optical coherence tomography or intravascular ultrasound are considered to be the gold standard in the assessment of vulnerable coronary atherosclerotic plaques (VCAPs), contemporary evidence suggests a potential role for non-invasive methods in this context. Biomarkers associated with deleterious pathophysiologic pathways, including inflammation and extracellular matrix degradation, have been correlated with VCAP characteristics and adverse prognosis. However, coronary computed tomography (CT) angiography has been the most extensively investigated technique, significantly correlating with invasive method-derived VCAP features. The estimation of perivascular fat attenuation as well as radiomic-based approaches represent additional concepts that may add incremental information. Cardiac magnetic resonance imaging (MRI) has also been evaluated in clinical studies, with promising results through the various image sequences that have been tested. As far as nuclear cardiology is concerned, the implementation of positron emission tomography in the VCAP assessment currently faces several limitations with the myocardial uptake of the radiotracer in cases of fluorodeoxyglucose use, as well as with motion correction. Moreover, the search for the ideal radiotracer and the most adequate combination (CT or MRI) is still ongoing. With a look to the future, the possible combination of imaging and circulating inflammatory and extracellular matrix degradation biomarkers in diagnostic and prognostic algorithms may represent the essential next step for the assessment of high-risk individuals.
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Affiliation(s)
- Panagiotis Theofilis
- 1st Cardiology Department, “Hippokration” General Hospital, Medical School, University of Athens, 11527 Athens, Greece; (M.S.); (A.S.A.); (E.O.); (K.T.); (D.T.)
- Correspondence:
| | - Marios Sagris
- 1st Cardiology Department, “Hippokration” General Hospital, Medical School, University of Athens, 11527 Athens, Greece; (M.S.); (A.S.A.); (E.O.); (K.T.); (D.T.)
| | - Alexios S. Antonopoulos
- 1st Cardiology Department, “Hippokration” General Hospital, Medical School, University of Athens, 11527 Athens, Greece; (M.S.); (A.S.A.); (E.O.); (K.T.); (D.T.)
| | - Evangelos Oikonomou
- 1st Cardiology Department, “Hippokration” General Hospital, Medical School, University of Athens, 11527 Athens, Greece; (M.S.); (A.S.A.); (E.O.); (K.T.); (D.T.)
- 3rd Cardiology Department, Thoracic Diseases Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, “Hippokration” General Hospital, Medical School, University of Athens, 11527 Athens, Greece; (M.S.); (A.S.A.); (E.O.); (K.T.); (D.T.)
| | - Dimitris Tousoulis
- 1st Cardiology Department, “Hippokration” General Hospital, Medical School, University of Athens, 11527 Athens, Greece; (M.S.); (A.S.A.); (E.O.); (K.T.); (D.T.)
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3
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Liu W, Wu S, Wang Z, Du Y, Fan Z, Dong L, Guo Y, Liu Y, Bi X, An J, Zhou Y, Liu W, Li D, Yu W, Xie Y. Relationship between coronary hyper-intensive plaques identified by cardiovascular magnetic resonance and clinical severity of acute coronary syndrome. J Cardiovasc Magn Reson 2021; 23:12. [PMID: 33627144 PMCID: PMC7905639 DOI: 10.1186/s12968-021-00706-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Coronary hyper-intense plaque (CHIP) detected on T1-weighted cardiovascular magnetic resonance (CMR) has been shown to associate with vulnerable plaque features and worse outcomes in low- and intermediate-risk populations. However, the prevalence of CHIP and its clinical significance in the higher-risk acute coronary syndrome (ACS) population have not been systematically studied. This study aims to assess the relationship between CHIP and ACS clinical severity using intracoronary optical coherence tomography (OCT) as the reference. METHODS A total of 62 patients with known or suspected coronary artery disease were prospectively enrolled including a clinically diagnosed ACS group (n = 50) and a control group with stable angina pectoris (n = 12). The ACS group consisted of consecutive patients including unstable angina pectoris (n = 27), non-ST-segment-elevation myocardial infarction (non-STEMI) (n = 8), and ST-segment-elevation myocardial infarction (STEMI) (n = 15), respectively. All patients underwent non-contrast coronary CMR to determine the plaque-to-myocardium signal intensity ratio (PMR). RESULTS Among the four groups of patients, a progressive increase in the prevalence of CHIPs (stable angina, 8%; unstable angina, 26%; non-STEMI, 38%; STEMI, 67%; p = 0.009), and PMR values (stable angina, 1.1; unstable angina, 1.2; non-STEMI, 1.3; STEMI, 1.6; median values, P = 0.004) were observed. Thrombus (7/8, 88% vs. 4/22, 18%, p = 0.001) and plaque rupture (5/8, 63% vs. 2/22, 9%, p = 0.007) were significantly more prevalent in CHIPs than in plaques without hyper-intensity. Elevated PMR was associated with high-risk plaque features including plaque rupture, thrombus, and intimal vasculature. A positive correlation was observed between PMR and the number of high-risk plaque features identified by OCT (r = 0.44, p = 0.015). CONCLUSIONS The prevalence of CHIPs and PMR are positively associated with the disease severity and high-risk plaque morphology in ACS.
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Affiliation(s)
- Wen Liu
- Department of Radiology, Anzhen Hospital, Affiliated to Capital Medical University, 2 Anzhen Road, ChaoYang District, Beijing, 100029 China
- Department of Radiology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Hai Dian District, Beijing, 100142 China
| | - Sijing Wu
- Department of Cardiology, Beijing AnZhen Hospital, Affiliated to Capital Medical University, Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Zhenjia Wang
- Department of Radiology, Anzhen Hospital, Affiliated to Capital Medical University, 2 Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Yanni Du
- Department of Radiology, Anzhen Hospital, Affiliated to Capital Medical University, 2 Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Zhaoyang Fan
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA USA
| | - Li Dong
- Department of Radiology, Anzhen Hospital, Affiliated to Capital Medical University, 2 Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Yonghe Guo
- Department of Cardiology, Beijing AnZhen Hospital, Affiliated to Capital Medical University, Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Yi Liu
- Department of Radiology, Anzhen Hospital, Affiliated to Capital Medical University, 2 Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Xiaoming Bi
- MR R&D, Siemens Healthineers, Los Angeles, CA USA
| | - Jing An
- MR Collaborations NE Asia, Siemens Healthineers, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing AnZhen Hospital, Affiliated to Capital Medical University, Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Wei Liu
- Department of Cardiology, Beijing AnZhen Hospital, Affiliated to Capital Medical University, Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Debiao Li
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA USA
| | - Wei Yu
- Department of Radiology, Anzhen Hospital, Affiliated to Capital Medical University, 2 Anzhen Road, ChaoYang District, Beijing, 100029 China
| | - Yibin Xie
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA USA
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Aizaz M, Moonen RPM, van der Pol JAJ, Prieto C, Botnar RM, Kooi ME. PET/MRI of atherosclerosis. Cardiovasc Diagn Ther 2020; 10:1120-1139. [PMID: 32968664 DOI: 10.21037/cdt.2020.02.09] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Myocardial infarction and stroke are the most prevalent global causes of death. Each year 15 million people worldwide die due to myocardial infarction or stroke. Rupture of a vulnerable atherosclerotic plaque is the main underlying cause of stroke and myocardial infarction. Key features of a vulnerable plaque are inflammation, a large lipid-rich necrotic core (LRNC) with a thin or ruptured overlying fibrous cap, and intraplaque hemorrhage (IPH). Noninvasive imaging of these features could have a role in risk stratification of myocardial infarction and stroke and can potentially be utilized for treatment guidance and monitoring. The recent development of hybrid PET/MRI combining the superior soft tissue contrast of MRI with the opportunity to visualize specific plaque features using various radioactive tracers, paves the way for comprehensive plaque imaging. In this review, the use of hybrid PET/MRI for atherosclerotic plaque imaging in carotid and coronary arteries is discussed. The pros and cons of different hybrid PET/MRI systems are reviewed. The challenges in the development of PET/MRI and potential solutions are described. An overview of PET and MRI acquisition techniques for imaging of atherosclerosis including motion correction is provided, followed by a summary of vessel wall imaging PET/MRI studies in patients with carotid and coronary artery disease. Finally, the future of imaging of atherosclerosis with PET/MRI is discussed.
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Affiliation(s)
- Mueez Aizaz
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Rik P M Moonen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Jochem A J van der Pol
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Claudia Prieto
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Escuela de Ingenieria, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - René M Botnar
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Escuela de Ingenieria, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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5
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Hajhosseiny R, Bahaei TS, Prieto C, Botnar RM. Molecular and Nonmolecular Magnetic Resonance Coronary and Carotid Imaging. Arterioscler Thromb Vasc Biol 2020; 39:569-582. [PMID: 30760017 DOI: 10.1161/atvbaha.118.311754] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atherosclerosis is the leading cause of cardiovascular morbidity and mortality. Over the past 2 decades, increasing research attention is converging on the early detection and monitoring of atherosclerotic plaque. Among several invasive and noninvasive imaging modalities, magnetic resonance imaging (MRI) is emerging as a promising option. Advantages include its versatility, excellent soft tissue contrast for plaque characterization and lack of ionizing radiation. In this review, we will explore the recent advances in multicontrast and multiparametric imaging sequences that are bringing the aspiration of simultaneous arterial lumen, vessel wall, and plaque characterization closer to clinical feasibility. We also discuss the latest advances in molecular magnetic resonance and multimodal atherosclerosis imaging.
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Affiliation(s)
- Reza Hajhosseiny
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,National Heart and Lung Institute, Imperial College London, United Kingdom (R.H.)
| | - Tamanna S Bahaei
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.)
| | - Claudia Prieto
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,Escuela de Ingeniería, Pontificia Universidad Catolica de Chile, Santiago, Chile (C.P., R.M.B.)
| | - René M Botnar
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,Escuela de Ingeniería, Pontificia Universidad Catolica de Chile, Santiago, Chile (C.P., R.M.B.)
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6
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Bing R, Driessen RS, Knaapen P, Dweck MR. The clinical utility of hybrid imaging for the identification of vulnerable plaque and vulnerable patients. J Cardiovasc Comput Tomogr 2019; 13:242-247. [PMID: 31345766 DOI: 10.1016/j.jcct.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/03/2019] [Accepted: 07/07/2019] [Indexed: 12/24/2022]
Abstract
Despite decades of research and major innovations in technology, cardiovascular disease remains the leading cause of death globally. Our understanding of major cardiovascular events and their prevention is centred around the atherosclerotic plaque and the processes that ultimately lead to acute plaque rupture. Recent advances in hybrid imaging technology allow the combination of high spatial resolution and anatomical detail with molecular assessments of disease activity. This provides the ability to identify vulnerable plaque characteristics and differentiate active and quiescent disease, with the potential to improve patient risk stratification. Combined positron emission tomography and computed tomography is the prototypical non-invasive hybrid imaging technique for coronary artery plaque assessment. In this review we discuss the current state of play in the field of hybrid coronary atherosclerosis imaging.
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Affiliation(s)
- Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh, United Kingdom
| | - Roel S Driessen
- Department of Cardiology, VU University Medical Centre, de Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, VU University Medical Centre, de Boelelaan 1117, 1081, HV, Amsterdam, the Netherlands
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh, United Kingdom.
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7
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Bom MJ, van der Heijden DJ, Kedhi E, van der Heyden J, Meuwissen M, Knaapen P, Timmer SA, van Royen N. Early Detection and Treatment of the Vulnerable Coronary Plaque. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005973. [DOI: 10.1161/circimaging.116.005973] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Early identification and treatment of the vulnerable plaque, that is, a coronary artery lesion with a high likelihood of rupture leading to an acute coronary syndrome, have gained great interest in the cardiovascular research field. Postmortem studies have identified clear morphological characteristics associated with plaque rupture. Recent advances in invasive and noninvasive coronary imaging techniques have empowered the clinician to identify suspected vulnerable plaques in vivo and paved the way for the evaluation of therapeutic agents targeted at reducing plaque vulnerability. Local treatment of vulnerable plaques by percutaneous coronary intervention and systemic treatment with anti-inflammatory and low-density lipoprotein–lowering drugs are currently being investigated in large randomized clinical trials to assess their therapeutic potential for reducing adverse coronary events. Results from these studies may enable a more patient-tailored strategy for the treatment of coronary artery disease.
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Affiliation(s)
- Michiel J. Bom
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Dirk J. van der Heijden
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Elvin Kedhi
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Jan van der Heyden
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Martijn Meuwissen
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Paul Knaapen
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Stefan A.J. Timmer
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
| | - Niels van Royen
- From the Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.J.B., D.J.v.d.H., P.K., S.A.J.T., N.v.R.); Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands (E.K.); Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands (J.v.d.H.); and Department of Cardiology, Amphia Hospital, Breda, The Netherlands (M.M.)
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