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Ueno K, Kamiya K, Hamazaki N, Nozaki K, Ichikawa T, Yamashita M, Uchida S, Noda T, Miki T, Hotta K, Maekawa E, Yamaoka-Tojo M, Matsunaga A, Ako J. Leg strength and incidence of heart failure in patients with acute coronary syndrome. Eur J Prev Cardiol 2024; 31:834-842. [PMID: 38150177 DOI: 10.1093/eurjpc/zwad406] [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: 10/10/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
AIMS The risk of developing heart failure (HF) after acute coronary syndrome (ACS) remains high. It is unclear whether skeletal muscle strength, in addition to existing risk factors, is a predictor for developing HF after ACS. We aimed to clarify the relationship between quadriceps isometric strength (QIS), a skeletal muscle strength indicator, and the risk of developing HF in patients with ACS. METHODS AND RESULTS We included 1053 patients with ACS without a prior HF or complications of HF during hospitalization. The median (interquartile range) age was 67 (57-74) years. The patients were classified into two groups-high and low QIS-using the sex-specific median QIS. The endpoint was HF admissions. During a mean follow-up period of 4.4 ± 3.7 years, 75 (7.1%) HF admissions were observed. After multivariate adjustment, a high QIS was associated with a lower risk of HF [hazard ratio: 0.52, 95% confidence interval (CI): 0.32-0.87]. Hazard ratio (95% CI) per 5% body weight increment increase of QIS for HF incidents was 0.87 (0.80-0.95). Even when competing risks of death were taken into account, the results did not change. The inclusion of QIS was associated with increases in net reclassification improvement (0.26; 95% CI: 0.002-0.52) and an integrated discrimination index (0.01; 95% CI: 0.004-0.02) for HF. CONCLUSION The present study showed that a higher level of QIS was strongly associated with a lower risk of developing HF after ACS. These findings suggest that skeletal muscle strength could be one of the factors contributing to the risk of developing HF after ACS.
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Affiliation(s)
- Kensuke Ueno
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Nobuaki Hamazaki
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Kohei Nozaki
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Takafumi Ichikawa
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Masashi Yamashita
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
- Division of Research, ARCE Inc., Sagamihara, Japan
| | - Shota Uchida
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
- Research Fellow of Japan Society for the Promotion of Science, Tokyo, Japan
| | - Takumi Noda
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Takashi Miki
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Kazuki Hotta
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Emi Maekawa
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Sagamihara, Japan
| | - Minako Yamaoka-Tojo
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Sagamihara, Japan
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Ashikawa H, Adachi T, Iwatsu K, Kamisaka K, Kamiya K, Uchiyama Y, Yamada S. Physical Frailty May Predict 2-Year Prognosis in Elderly Patients With Acute Myocardial Infarction - A Report From the FLAGSHIP Study. Circ J 2023; 87:490-497. [PMID: 36567107 DOI: 10.1253/circj.cj-22-0515] [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: 12/24/2022]
Abstract
BACKGROUND Elderly patients with acute myocardial infarction (AMI) are a high-risk population for heart failure (HF), but the association between physical frailty and worsening prognosis, including HF development, has not been documented extensively. METHODS AND RESULTS As part of the FLAGSHIP study, we enrolled 524 patients aged ≥70 years hospitalized for AMI and capable of walking at discharge. Physical frailty was assessed using the FLAGSHIP frailty score. The primary outcome was a composite outcome of all-cause death and HF rehospitalization within 2 years after discharge. The secondary outcome was all-cause death and HF rehospitalization. After adjusting for confounders, physical frailty showed a significant association with an increased risk of the composite outcome (hazard ratio [HR]=2.09, 95% confidence interval [CI]: 1.03-4.22, P=0.040). The risk of HF rehospitalization increased with physical frailty, but the association was not statistically significant (HR=2.14, 95% CI: 0.84-5.44, P=0.110). Physical frailty was not associated with an increased risk of all-cause death (HR=1.45, 95% CI: 0.49-4.26, P=0.501). CONCLUSIONS The findings suggest that physical frailty assessment serves as a stratifying tool to identify high-risk populations for post-discharge clinical events among ambulant elderly patients with AMI.
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Affiliation(s)
- Hironobu Ashikawa
- Program in Physical and Occupational Therapy, Nagoya University Graduate School of Medicine
| | - Takuji Adachi
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine
| | - Kotaro Iwatsu
- Department of Rehabilitation, Hirakata Kohsai Hospital
| | - Kenta Kamisaka
- Department of Rehabilitation, Tazuke Kofukai Medical Institute Kitano Hospital
| | - Kuniyasu Kamiya
- Department of Hygiene & Public Health, Osaka Medical and Pharmaceutical University
| | - Yasushi Uchiyama
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine
| | - Sumio Yamada
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine
- Department of Cardiology, Aichi Medical University
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Harrington J, Jones WS, Udell JA, Hannan K, Bhatt DL, Anker SD, Petrie MC, Vedin O, Butler J, Hernandez AF. Acute Decompensated Heart Failure in the Setting of Acute Coronary Syndrome. JACC. HEART FAILURE 2022; 10:404-414. [PMID: 35654525 DOI: 10.1016/j.jchf.2022.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 06/15/2023]
Abstract
Acute coronary syndrome (ACS) is frequently complicated by evidence of heart failure (HF). Those at highest risk for acute decompensated HF in the setting of ACS (ACS-HF) are older, female, and have preexisting heart disease, type 2 diabetes mellitus, hypertension, and/or kidney disease. The presence of ACS-HF is strongly associated with higher mortality and more frequent readmissions, especially for HF. Low implementation of guideline-directed medical therapy has further complicated the clinical care of this high-risk population. Improved utilization of current therapies, coupled with further investigation of strategies to manage ACS-HF, is desperately needed to improve outcomes in this vulnerable population, and the results of currently ongoing or recently concluded ACS-HF studies in this population are of great interest. In this review, we explore the pathophysiology, epidemiology, risk factors, and outcomes for patients with ACS-HF, and describe both existing evidence for management of this challenging condition and areas requiring further research.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - W Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jacob A Udell
- Cardiovascular Division, Department of Medicine, Women's College Hospital; and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Karen Hannan
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Ola Vedin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Boehringer Ingelheim AB, Stockholm, Sweden
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
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Cordero A, Martínez Rey-Rañal E, Moreno MJ, Escribano D, Moreno-Arribas J, Quintanilla MA, Zuazola P, Núñez J, Bertomeu-González V. Predictive Value of Pro-BNP for Heart Failure Readmission after an Acute Coronary Syndrome. J Clin Med 2021; 10:1653. [PMID: 33924437 PMCID: PMC8069470 DOI: 10.3390/jcm10081653] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND N-terminal pro-brain natural peptide (NT-pro-BNP) is a well-established biomarker of tissue congestion and has prognostic value in patients with heart failure (HF). Nonetheless, there is scarce evidence on its predictive capacity for HF re-admission after an acute coronary syndrome (ACS). We performed a prospective, single-center study in all patients discharged after an ACS. HF re-admission was analyzed by competing risk regression, taking all-cause mortality as a competing event. Results are presented as sub-hazard ratios (sHR). Recurrent hospitalizations were tested by negative binomial regression, and results are presented as incidence risk ratio (IRR). RESULTS Of the 2133 included patients, 528 (24.8%) had HF during the ACS hospitalization, and their pro-BNP levels were higher (3220 pg/mL vs. 684.2 pg/mL; p < 0.001). In-hospital mortality was 2.9%, and pro-BNP was similarly higher in these patients. Increased pro-BNP levels were correlated to increased risk of HF or death during the hospitalization. Over follow-up (median 38 months) 243 (11.7%) patients had at least one hospital readmission for HF and 151 (7.1%) had more than one. Complete revascularization had a preventive effect on HF readmission, whereas several other variables were associated with higher risk. Pro-BNP was independently associated with HF admission (sHR: 1.47) and readmission (IRR: 1.45) at any age. Significant interactions were found for the predictive value of pro-BNP in women, diabetes, renal dysfunction, STEMI and patients without troponin elevation. CONCLUSIONS In-hospital determination of pro-BNP is an independent predictor of HF readmission after an ACS.
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Affiliation(s)
- Alberto Cordero
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
- Unidad de Investigación en Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), 46020 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226-CB16/11/00420), 28028 Madrid, Spain;
| | - Elías Martínez Rey-Rañal
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
| | - María J. Moreno
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
| | - David Escribano
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
- Unidad de Investigación en Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), 46020 Valencia, Spain
| | - José Moreno-Arribas
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
- Unidad de Investigación en Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), 46020 Valencia, Spain
| | - Maria A. Quintanilla
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
| | - Pilar Zuazola
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
| | - Julio Núñez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226-CB16/11/00420), 28028 Madrid, Spain;
- Cardiology Department, Hospital Clínico Universitario, 46010 Valencia, Spain
- Instituto de Investigación Sanitaria (INCLIVA), Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | - Vicente Bertomeu-González
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain; (E.M.R.-R.); (M.J.M.); (D.E.); (J.M.-A.); (M.A.Q.); (P.Z.); (V.B.-G.)
- Unidad de Investigación en Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), 46020 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226-CB16/11/00420), 28028 Madrid, Spain;
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Abdissa SG. Predictors of incident heart failure in a cohort of patients with ischemic heart disease. Pan Afr Med J 2020; 35:45. [PMID: 32537050 PMCID: PMC7250204 DOI: 10.11604/pamj.2020.35.45.18257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 08/18/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION heart failure (HF) is a major complication following ischemic heart disease (IHD) and it adversely affects the outcome. The objective of this study was to identify predictors of HF in patients with IHD. METHODS this is a 24-month longitudinal retrospective study of all consecutive patients diagnosed with IHD. Endpoints were incident HF and time to incident HF. Patients with a previous history of HF were excluded. RESULTS a total of 306 patients with IHD were included in the analysis. The 6-month, 12-month and 18-month cumulative risk of developing incident HF were 18.8%, 28.4%, and 53.5% respectively. Increasing age, female gender, diabetes mellitus (DM), lower hemoglobin, and dilated left atrium were strong predictors of incident HF. Predictors of shorter time to incident HF were coexisting DM and hypertension, and the presence of dilated left atrium in patients with left ventricular ejection fraction < 40%. The strongest predictor of incident HF in patients with DM was a higher level of LDL cholesterol. CONCLUSION patients with IHD have a higher risk of incident HF. Strong predictors of incident HF in these patients were increasing age, female gender, DM, lower hemoglobin and dilated left atrium. Such patients need close follow-up and more intensive treatment.
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Affiliation(s)
- Senbeta Guteta Abdissa
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
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Cordero A, Rodríguez-Mañero M, Fácila L, Fernández-Olmo MR, Gómez-Martínez MJ, Valle A, Castellano JM, Toro MM, Seijas-Amigo J, Vicedo A, González-Juanatey JR. Prevention of myocardial infarction and stroke with PCSK9 inhibitors treatment: a metanalysis of recent randomized clinical trials. J Diabetes Metab Disord 2020; 19:759-765. [PMID: 33520801 DOI: 10.1007/s40200-020-00557-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Abstract
Purpose Proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors treatment induce large reductions in low-density lipoprotein cholesterol (LDLc) and major cardiovascular events. Clinical trials might have been underpowered to test the effect of PSCK9 inhibitors treatment on myocardial infarction and stroke, two of the most relevant cardiovascular events, since all analyzed a combined endpoint. Methods we performed a meta-analysis, with currently available studies involving PCSK9 inhibitors and event rate adjudication, with the aim of assessing treatment effects on myocardial infarction and stroke. Results We included 81,700 patients, 41,979 treated with a PSCK9 inhibitors: 17,244 with evolocumab; 13,720 with bococizumab and 11,015 with alirocumab. A total of 1,319 cases of myocardial infarctions were registered in the treatment group vs. 1,608 in controls, resulting in 19.0% reduction associated with PCSK9 treatment (RR: 0.81, 95% CI 0.76-0.87). Similarly, PCSK9 inhibitors treatment resulted in a 25% reduction of stroke (RR: 0.75, 95% CI 0.65-0.85) when all studies were analyzed together and the statistically significant heterogeneity was not observed in the analysis restricted to end-point based clinical trials. PCSK9 inhibitors treatment had no effect on mortality (RR: 0.95, 95% CI 0.86-1.04). Conclusions PCSK9 inhibitors reduce the incidence of myocardial infarction by 19% and stroke by 25%.
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Affiliation(s)
- Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital Universitario de San Juan, Carretera Valencia-Alicante sn, San Juan de Alicante, 03550 Spain
| | - Moisés Rodríguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Lorenzo Fácila
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | | | | | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - Jose Mª Castellano
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Cardiology Department, Hospitales de Madrid, Madrid, Spain
| | | | - José Seijas-Amigo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Alvaro Vicedo
- Cardiology Department, Hospital de Denia, Denia, Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
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Guedeney P, Sorrentino S, Claessen B, Mehran R. The link between anemia and adverse outcomes in patients with acute coronary syndrome. Expert Rev Cardiovasc Ther 2019; 17:151-159. [DOI: 10.1080/14779072.2019.1575729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul Guedeney
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
- Institut de Cardiologie, Sorbonne Université, ACTION Study group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Sabato Sorrentino
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
- Division of cardiology, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Bimmer Claessen
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
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