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Ezhumalai B, Modi R, Panchanatham M, Kaliyamoorthy D. The contemporary role of sodium-glucose co-transporter 2 inhibitor (SGLT2i) and angiotensin receptor-neprilysin inhibitor (ARNI) in the management of heart failure: State-of-the-art review. Indian Heart J 2024:S0019-4832(24)00158-5. [PMID: 39009078 DOI: 10.1016/j.ihj.2024.07.005] [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: 10/30/2023] [Revised: 05/11/2024] [Accepted: 07/12/2024] [Indexed: 07/17/2024] Open
Abstract
Novel therapies for heart failure with reduced ejection fraction (HFrEF) are angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose co-transporter 2 inhibitor (SGLT2i), etc. The purpose of this review is to determine the effects of ARNI and SGLT2i in heart failure (HF), compare the impact of SGLT2i with ARNI, and finally evaluate the current data regarding the combination of these two drugs in HF. Various trials on the respective medications have shown some significant reduction in all-cause mortality and cardiovascular (CV) death. The combination of these drugs has shown more CV benefits than monotherapy. There is emerging data about these two drugs in patients with heart failure with preserved ejection fraction (HFpEF). At present, there are less head-to-head comparison trials of these two drugs. This review provides insights on the current evidence, comparative efficacy, and combination therapy of ARNI and SGLT2i in managing HF, focussing on HFrEF and HFpEF.
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Affiliation(s)
- Babu Ezhumalai
- Department of Cardiology, Apollo Speciality Hospitals Vanagaram, Chennai, India.
| | - Ranjan Modi
- Department of Cardiology, Indraprastha Apollo Hospitals, New Delhi, India
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Lin YW, Lin CH, Lin CL, Lin CH, Lin MH. Association Between Use of Sodium-Glucose Cotransporter-2 Inhibitors or Angiotensin Receptor-Neprilysin Inhibitor and the Risk of Atherosclerotic Cardiovascular Disease With Coexisting Diabetes and Heart Failure. J Cardiovasc Pharmacol Ther 2024; 29:10742484241233872. [PMID: 38438119 DOI: 10.1177/10742484241233872] [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: 03/06/2024]
Abstract
PURPOSE This study was to investigate the association between the use of Sodium-glucose Cotransporter-2 inhibitors (SGLT2i) or angiotensin receptor-neprilysin inhibitor (ARNI; ie, Sacubitril + valsartan, Product name ENTRESTO) and the risk of atherosclerotic cardiovascular disease (ASCVD) in patients with coexisting diabetes and heart failure. Specifically, the study compared outcomes between patients using SGLT2i or valsartan + sacubitril and those not using these medications. METHODS This study utilized data from the National Health Insurance Research Database (NHIRD) from 2017 to 2018. The case group consisted of 8691 patients with coexisting diabetes and heart failure who did not use SGLT2i or Entresto, while the control group consisted of 8691 patients with coexisting diabetes and heart failure who used SGLT2i or Entresto. The primary outcome was ASCVD, including a composite of cardiovascular death and hospitalization for worsening heart failure. Secondary outcomes included all-cause death, cause of cardiovascular death, and recurrence of heart failure, non-fatal myocardial infarction, non-fatal stroke (including ischemic stroke and hemorrhagic stroke) and new renal replacement therapy. RESULTS The study found that the use of SGLT2 inhibitors or ARNI was associated with a lower risk of ASCVD in patients with coexisting diabetes and heart failure. CONCLUSION The study suggests that the use of SGLT2 inhibitors, alone or in combination with Entresto, may be effective in reducing the risk of ASCVD and its associated adverse outcomes in patients with diabetes and heart failure. This finding has important implications for the management of these conditions.
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Affiliation(s)
- Ya-Wen Lin
- School of Nursing, China Medical University, Taichung, Taiwan
- Department of Nursing, HungKuang University, Taichung, Taiwan
| | - Chun-Hsiang Lin
- Department of Neurology, Yuanlin Christian Hospital, Yuanlin, Changhua County, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Che-Huei Lin
- Department of Pharmacy and Master Program, Tajen University, Pingtung, Taiwan
| | - Ming-Hung Lin
- Department of Pharmacy and Master Program, Tajen University, Pingtung, Taiwan
- Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan
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Dalal J, Chandra P, Ray S, Hazra PK, Hiremath J, Kumar V, Shah MK, Abdullakutty J, Ghosh D, Vasudevan K, Sahoo P. Practical Recommendations for the Use of Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in Heart Failure: Insights from Indian Cardiologists. Cardiol Ther 2023; 12:445-471. [PMID: 37382802 PMCID: PMC10423183 DOI: 10.1007/s40119-023-00323-8] [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: 04/19/2023] [Accepted: 06/01/2023] [Indexed: 06/30/2023] Open
Abstract
Heart failure is a significant public health concern characterized by notable rates of morbidity and mortality. Despite the presence of guideline-directed medical therapy (GDMT), its utilization remains inadequate. This practical recommendation paper focuses on the utilization of angiotensin receptor-neprilysin inhibitor (ARNI) as a pivotal treatment for heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and heart failure with improved ejection fraction (HFimpEF). The recommendations presented in this paper have been developed by a group of cardiologists in India who convened six advisory board meetings to discuss the utilization of ARNI in the management of heart failure. The paper emphasizes the importance of accurate biomarkers for diagnosing heart failure, particularly N-terminal pro-B-type natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP), which are commonly used. Additionally, the paper advocates the use of imaging, specifically echocardiography, in diagnosing and monitoring heart failure patients. Moreover, the paper highlights the role of ARNI in heart failure management, with numerous clinical trials that have demonstrated its effectiveness in reducing cardiovascular death or heart failure hospitalization, enhancing quality of life, and diminishing the risk of ventricular arrhythmias. This practical recommendation paper offers valuable insights into the utilization of ARNI in the management of heart failure, aiming to enhance the implementation of GDMT and ultimately alleviate the burden of heart failure on society.
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Affiliation(s)
| | | | | | | | | | | | - Mahesh K Shah
- PD Hinduja Hospital and Medical Research Center, Mumbai, India
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Girerd N, Zannad F. SGLT2 inhibition in heart failure with reduced or preserved ejection fraction: Finding the right patients to treat. J Intern Med 2023; 293:550-558. [PMID: 36871279 DOI: 10.1111/joim.13620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Sodium-glucose transport inhibitors (SGLT2i) are effective in heart failure (HF) with ejection fraction (EF) <40% (referred to as HF with reduced EF - HFrEF) and left ventricular EF (LVEF) >40%. Current evidence suggests that SGLT2i should be initiated across a large spectrum of EFs and renal function in patients with HF and with and without diabetes. We reviewed the benefits of SGLT2i in the entire spectrum of HF and provided some clues that may guide physicians in their strategy of initiating and maintaining SGLT2i (with or without SGLT1i effect) therapy. Taken together, the evidence thus far arises from an array of trials performed in different settings (acute/chronic), risk categories, and phenotypes of HF (HFrEF/HFpEF), and in addition to the most common HF therapies, supports the homogenous effect of SGLT2i across a large spectrum of patients with HF. SGLT2i appear to be effective and well-tolerated drugs in the majority of clinical HF scenarios, regardless of LVEF, estimated glomerular filtration rate, diabetic status or the level of the acuteness of the clinical setting. Therefore, most patients with HF should be treated with SGLT2i. However, in the face of the therapeutic inertia that has been observed in HF over the past decades, the actual implementation of SGLT2i in routine practice remains the most significant challenge.
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Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 14-33, CHRU Nancy, Vandoeuvre les Nancy, France
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 14-33, CHRU Nancy, Vandoeuvre les Nancy, France
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Huang Y, Fang C, Zhang Y, Ma L, Zhou H, Ye H. Effectiveness and safety of angiotensin receptor-neprilysin inhibitor and sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction: a meta-analysis. J Cardiovasc Med (Hagerstown) 2023; 24:123-131. [PMID: 36583980 DOI: 10.2459/jcm.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The current review aimed to study the effectiveness and safety of angiotensin receptor-neprilysin inhibitor (ARNI) combined with sodium-glucose cotransporter-2 (SGLT2) inhibitors versus ARNI or SGLT2 inhibitors monotherapy in patients with heart failure with reduced ejection fraction (HFrEF). Studies containing patients with HFrEF who used ARNI combined with SGLT2 inhibitors versus ARNI or SGLT2 inhibitors alone were retrieved from the Medline, Embase, and Cochrane Library databases. From the selected studies, the pooled risk ratios with 95% confidence intervals of dichotomous outcomes were assessed by a random or fixed effects model in our meta-analysis. Compared with ARNI monotherapy, the reduction in ARNI combined with SGLT2 inhibitors in a composite of the first hospitalization for heart failure or cardiovascular death was 32%, hospitalization for heart failure was 35% and cardiovascular death was 35%; also all-cause death was 30%, worsening renal function was 35%, respectively, for patients with HFrEF. In addition, compared with SGLT2 inhibitors monotherapy, the reduction in ARNI combined with SGLT2 inhibitors in cardiovascular death was 36% and all-cause death was 28%, respectively, for patients with HFrEF. Although the estimated treatment effect is a 55% increase in volume depletion, overall, ARNI combined with SGLT2 inhibitors might be effective and safe for patients with HFrEF, and volume depletion should be given more attention.
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Affiliation(s)
| | | | | | | | | | - Honghua Ye
- Cardiology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
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Rastogi T, Girerd N. SGLT2 Inhibitors in Heart Failure with Reduced Ejection Fraction. Heart Fail Clin 2022; 18:561-577. [DOI: 10.1016/j.hfc.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abdin A, Schulz M, Riemer U, Hadëri B, Wachter R, Laufs U, Bauersachs J, Kindermann I, Vukadinović D, Böhm M. Sacubitril/valsartan in heart failure: efficacy and safety in and outside clinical trials. ESC Heart Fail 2022; 9:3737-3750. [PMID: 35921043 PMCID: PMC9773772 DOI: 10.1002/ehf2.14097] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/13/2022] [Accepted: 07/19/2022] [Indexed: 01/19/2023] Open
Abstract
Heart failure (HF) treatment has changed substantially over the last 30 years, leading to significant reductions in mortality and hospital admissions in patients with HF with reduced ejection fraction (HFrEF). Currently, the optimization of guideline-directed chronic HF therapy remains the mainstay to further improve quality of life, mortality, and HF hospitalizations for patients with HFrEF. The angiotensin receptor-neprilysin inhibitor sacubitril/valsartan (S/V) has an important role in the treatment of patients with HFrEF. The PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) randomized controlled trial has established solid evidence for the treatment of HFrEF in various subgroups. Apart from HFrEF, several studies have been conducted using S/V in various indications: patients hospitalized with acute decompensated HF, HF with preserved ejection fraction, acute myocardial infarction with reduced ejection fraction, uncontrolled and resistant hypertension, and chronic kidney disease. Data from the German Institute for Drug Use Evaluation reveal that implementation of S/V has increased steadily over time and, by the end of 2021, an estimated 266 000 patients were treated with S/V in Germany. The estimated cumulative real-world patient exposure is >5.5 million patient-treatment years worldwide. The number of patients treated with S/V largely exceeds the number of patients treated in clinical trials, and the current indication for S/V is larger than the strict inclusion/exclusion criteria of the randomized trials. Especially elderly patients, women, and patients with more and more severe comorbidities are underrepresented in the clinical trials. We therefore aimed to summarize the importance of S/V in HF in terms of efficacy and safety in clinical trials and daily clinical practice.
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Affiliation(s)
- Amr Abdin
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| | - Martin Schulz
- Institute of PharmacyFreie Universität BerlinBerlinGermany,German Institute for Drug Use Evaluation (DAPI)BerlinGermany
| | - Uwe Riemer
- Medical DepartmentNovartis Pharma GmbHNurembergGermany
| | - Bledar Hadëri
- Medical DepartmentNovartis Pharma AGBaselSwitzerland
| | - Rolf Wachter
- Klinik und Poliklinik für KardiologieUniversitätsklinikum LeipzigLeipzigGermany
| | - Ulrich Laufs
- Klinik und Poliklinik für KardiologieUniversitätsklinikum LeipzigLeipzigGermany
| | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Ingrid Kindermann
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| | - Davor Vukadinović
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| | - Michael Böhm
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
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Gan L, Lyu X, Yang X, Zhao Z, Tang Y, Chen Y, Yao Y, Hong F, Xu Z, Chen J, Gu L, Mao H, Liu Y, Sun J, Zhou Z, Du X, Jiang H, Li Y, Sun N, Liang X, Zuo L. Application of Angiotensin Receptor–Neprilysin Inhibitor in Chronic Kidney Disease Patients: Chinese Expert Consensus. Front Med (Lausanne) 2022; 9:877237. [PMID: 35928297 PMCID: PMC9343998 DOI: 10.3389/fmed.2022.877237] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem, and cardiovascular disease is the most common cause of death in patients with CKD. The incidence and prevalence of cardiovascular events during the early stages of CKD increases significantly with a decline in renal function. More than 50% of dialysis patients die from cardiovascular disease, including coronary heart disease, heart failure, arrhythmia, and sudden cardiac death. Therefore, developing effective methods to control risk factors and improve prognosis is the primary focus during the diagnosis and treatment of CKD. For example, the SPRINT study demonstrated that CKD drugs are effective in reducing cardiovascular and cerebrovascular events by controlling blood pressure. Uncontrolled blood pressure not only increases the risk of these events but also accelerates the progression of CKD. A co-crystal complex of sacubitril, which is a neprilysin inhibitor, and valsartan, which is an angiotensin receptor blockade, has the potential to be widely used against CKD. Sacubitril inhibits neprilysin, which further reduces the degradation of natriuretic peptides and enhances the beneficial effects of the natriuretic peptide system. In contrast, valsartan alone can block the angiotensin II-1 (AT1) receptor and therefore inhibit the renin–angiotensin–aldosterone system. These two components can act synergistically to relax blood vessels, prevent and reverse cardiovascular remodeling, and promote natriuresis. Recent studies have repeatedly confirmed that the first and so far the only angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril/valsartan can reduce blood pressure more effectively than renin–angiotensin system inhibitors and improve the prognosis of heart failure in patients with CKD. Here, we propose clinical recommendations based on an expert consensus to guide ARNI-based therapeutics and reduce the occurrence of cardiovascular events in patients with CKD.
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Affiliation(s)
- Liangying Gan
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Xiaoxi Lyu
- Institute of Materia Medica, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | | | - Zhanzheng Zhao
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Tang
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Yuanhan Chen
- Guangdong Provincial People's Hospital, Guangzhou, China
| | - Ying Yao
- Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | | | - Zhonghao Xu
- Bethune First Hospital of Jilin University, Changchun, China
| | - Jihong Chen
- Shenzhen Bao'an People's Hospital, Shenzhen, China
| | - Leyi Gu
- Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Ying Liu
- First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Sun
- Shandong Provincial Hospital, Jinan, China
| | - Zhu Zhou
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xuanyi Du
- The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong Jiang
- People's Hospital of Xinjiang, Urumqi, China
| | - Yong Li
- Huashan Hospital, Fudan University, Shanghai, China
| | - Ningling Sun
- Peking University People's Hospital, Beijing, China
| | - Xinling Liang
- Guangdong Provincial People's Hospital, Guangzhou, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
- *Correspondence: Li Zuo
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Affiliation(s)
- Eugene Braunwald
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and the Department of Medicine, Harvard Medical School, Boston
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Raschi E, Diemberger I, Sabatino M, Poluzzi E, De Ponti F, Potena L. Evaluating sacubitril/valsartan as a treatment option for heart failure with reduced ejection fraction and preserved ejection fraction. Expert Opin Pharmacother 2022; 23:303-320. [PMID: 35050813 DOI: 10.1080/14656566.2022.2027909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Sacubitril/valsartan is the first-in-class angiotensin-receptor neprilysin inhibitor approved in 2015 for the treatment of heart failure with reduced ejection fraction (HFrEF). On 16 February 2021, the Food and Drug Administration acknowledged that "Benefits are most clearly evident in patients with left ventricular ejection fraction below normal," thus potentially extending the use in subjects with heart failure and preserved ejection fraction (HFpEF). AREAS COVERED The authors outline the regulatory history, pharmacokinetics, pharmacodynamics, and risk-benefit profile of sacubitril/valsartan in HFrEF and HFpEF. A critical cross-trial comparison is presented, including sodium-glucose cotransporter 2 inhibitors (SGLT2i), together with an insight into the latest European Society of Cardiology guidelines, where the new category of heart failure with mildly reduced ejection fraction is introduced. EXPERT OPINION Sacubitril/valsartan is a foundation of the pharmacological armamentarium in HFrEF to counteract the neuro-hormonal changes and reverse cardiac remodeling, together with beta-blockers, SGLT2i and mineralocorticoid receptor antagonists. The optimal sequence algorithm is an evolving issue, and the authors provide the reader with their personal perspective. A multidisciplinary management is encouraged to minimize the therapeutic inertia and manage tolerability issues, thus supporting adherence. Pragmatic trials, pharmacovigilance, and high-quality real-world evidence are crucial toward personalized safe prescribing of sacubitril/valsartan.
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Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Mario Sabatino
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Luciano Potena
- Cardiology Unit, IRCCS Azienda Ospedaliero-universitaria Di Bologna, Bologna, Italy
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Volpe M, Gallo G, Zieroth S. Are Post Hoc Analyses on Subgroups Sufficient to Support New Treatment Algorithms of Heart Failure? The Case of SGLT2 Inhibitors Associated with Sacubitril/Valsartan. Cardiology 2021; 147:23-25. [PMID: 34587618 DOI: 10.1159/000519905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
Abstract
The use of sodium glucose cotransporter 2 inhibitors (SGLT2i) in heart failure (HF) with reduced ejection fraction (HFrEF) has been strongly supported by the results of recent randomized clinical trials. Upon this evidence, international recommendations and consensus documents propose the inclusion of SGLT2i among the first-line classes for HFrEF management. Subsequent analyses of treatment subgroups have been performed to investigate the effects of SGLT2i in patients treated with first-line classes including sacubitril/valsartan (Sac/Val), showing a consistent reduction of cardiovascular outcomes with a good safety profile of SGLT2i in combination with the other classes. Accordingly, SGLT2i are recommended also in combination with Sac/Val. This association, however, may require caution before being translated into guideline-directed medical therapy in clinical practice, since the proportion of patients receiving Sac/Val and SGLT2i in the available studies was poorly represented. In order to support an effective and safe sequencing or a simultaneous initiation of these 2 drug classes, pragmatic and real-world clinical studies would be helpful.
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Affiliation(s)
- Massimo Volpe
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Giovanna Gallo
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy,
| | - Shelley Zieroth
- Department of Medicine, Department of Physiology and Pathophysiology, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
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