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Fremes SE, Marquis-Gravel G, Gaudino MFL, Jolicoeur EM, Bédard S, Masterson Creber R, Ruel M, Vervoort D, Wijeysundera HC, Farkouh ME, Rouleau JL. STICH3C: Rationale and Study Protocol. Circ Cardiovasc Interv 2023; 16:e012527. [PMID: 37582169 DOI: 10.1161/circinterventions.122.012527] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/03/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is the recommended mode of revascularization in patients with ischemic left ventricular dysfunction (iLVSD) and multivessel disease. However, contemporary percutaneous coronary intervention (PCI) outcomes have improved with the integration of novel technologies and refinement of revascularization strategies, and PCI is often used in clinical practice in this population. There is a lack of evidence from randomized trials comparing contemporary state-of-the-art PCI versus CABG for the treatment of iLVSD and multivessel disease. This was the impetus for the STICH3C trial (Canadian CABG or PCI in Patients With Ischemic Cardiomyopathy), described here. METHODS The STICH3C trial is a prospective, unblinded, international, multicenter trial with an expected sample size of 754 participants from ≈45 centers. Patients with multivessel/left main coronary artery disease and iLVSD with left ventricular ejection fraction ≤40% considered by the local Heart Team appropriate for and amenable to revascularization by both modes of revascularization will be randomized in a 1:1 ratio to state-of-the-art PCI or CABG. RESULTS The primary end point is the composite of death from any cause, stroke, spontaneous myocardial infarction, urgent repeat revascularization, or heart failure readmission, summarized as a time-to-event outcome. The key hierarchical end point is time to death and frequency of hospitalizations for heart failure. The key safety outcome is a composite of major adverse events. Disease-specific quality-of-life and health economics measures will be compared between groups. Participants will be followed for a median of 5 years, with a minimum follow-up of 4 years. CONCLUSIONS STICH3C will directly inform patients, clinicians, and international practice guidelines about the efficacy and safety of CABG versus PCI in patients with iLVSD. The results will provide novel and broad evidence, including clinical events, health status, and economic assessments, to guide care for patients with iLVSD and severe coronary artery disease. REGISTRATION URL: https://clinicaltrials.gov/; Unique identifier: NCT05427370.
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Affiliation(s)
- Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - E Marc Jolicoeur
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - Sylvain Bédard
- Centre d'excellence sur le partenariat avec les patients et le public, Montreal, Quebec, Canada (S.B.)
| | | | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (M.R.)
| | - Dominique Vervoort
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Ontario, Canada (M.E.F.)
| | - Jean-Lucien Rouleau
- Montreal Heart Institute, University of Montreal, Quebec, Canada (G.M.-G., E.M.J., J.-L.R.)
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2
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Koshy AN, Dinh DT, Fulcher J, Brennan AL, Murphy AC, Duffy SJ, Reid CM, Ajani AE, Freeman M, Hiew C, Oqueli E, Farouque O, Yudi MB, Clark DJ. Long-term mortality in asymptomatic patients with stable ischemic heart disease undergoing percutaneous coronary intervention. Am Heart J 2022; 244:77-85. [PMID: 34780716 DOI: 10.1016/j.ahj.2021.10.190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/27/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Patients with stable ischemic heart disease (SIHD) may present with a variety of symptoms including typical angina, angina equivalents such as dyspnea or no symptoms. We sought to determine whether symptom status affects periprocedural safety and long-term mortality in patients undergoing PCI. METHODS Prospectively enrolled consecutive patients undergoing PCI for SIHD at six hospitals in Australia between 2005 to 2018 as part of the Melbourne Interventional Group registry. Symptom status was recorded at the time of PCI and patients undergoing staged PCI were excluded. RESULTS Overall, 11,730 patients with SIHD were followed up for a median period of 5 years (maximum 14.0 years, interquartile range 2.2-9.0 years) with 1,317 (11.2%) being asymptomatic. Asymptomatic patients were older, and more likely to be male, have triple-vessel disease, with multiple comorbidities including renal failure, diabetes and heart failure (all P < .01). These patients had significantly higher rates of periprocedural complications and major adverse cardiovascular events at 30-days. Long-term mortality was significantly higher in asymptomatic patients (27.2% vs 18.0%, P < .001). On cox regression for long-term mortality, after adjustment for more important clinical variables, asymptomatic status was an independent predictor (Hazard ratio (HR) 1.39 95% CI 1.16-1.66, P < .001). CONCLUSIONS In a real-world cohort of patients undergoing revascularization for SIHD, absence of symptoms was associated with higher rates of periprocedural complications and, after adjustment for more important clinical variables, was an independent predictor of long-term mortality. As the primary goal of revascularization in SIHD remains angina relief, the appropriateness of PCI in the absence of symptoms warrants justification.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Diem T Dinh
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Jordan Fulcher
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Stephen J Duffy
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- The University of Melbourne, Parkville, Victoria; Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
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3
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Figtree GA, Broadfoot K, Casadei B, Califf R, Crea F, Drummond GR, Freedman JE, Guzik TJ, Harrison D, Hausenloy DJ, Hill JA, Januzzi JL, Kingwell BA, Lam CSP, MacRae CA, Misselwitz F, Miura T, Ritchie RH, Tomaszewski M, Wu JC, Xiao J, Zannad F. A Call to Action for New Global Approaches to Cardiovascular Disease Drug Solutions. Circulation 2021; 144:159-169. [PMID: 33876947 DOI: 10.1161/cir.0000000000000981] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While we continue to wrestle with the immense challenge of implementing equitable access to established evidence-based treatments, substantial gaps remain in our pharmacotherapy armament for common forms of cardiovascular disease including coronary and peripheral arterial disease, heart failure, hypertension, and arrhythmia. We need to continue to invest in the development of new approaches for the discovery, rigorous assessment, and implementation of new therapies. Currently, the time and cost to progress from lead compound/product identification to the clinic, and the success rate in getting there reduces the incentive for industry to invest, despite the enormous burden of disease and potential size of market. There are tremendous opportunities with improved phenotyping of patients currently batched together in syndromic "buckets." Use of advanced imaging and molecular markers may allow stratification of patients in a manner more aligned to biological mechanisms that can, in turn, be targeted by specific approaches developed using high-throughput molecular technologies. Unbiased "omic" approaches enhance the possibility of discovering completely new mechanisms in such groups. Furthermore, advances in drug discovery platforms, and models to study efficacy and toxicity more relevant to the human disease, are valuable. Re-imagining the relationships among discovery, translation, evaluation, and implementation will help reverse the trend away from investment in the cardiovascular space, establishing innovative platforms and approaches across the full spectrum of therapeutic development.
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Affiliation(s)
- Gemma A Figtree
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Australia (G.A.F.)
| | - Keith Broadfoot
- Clinical Committee, National Heart Foundation of Australia (K.B.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK (B.C.)
- NIHR Oxford Biomedical Research Centre, UK (B.C.)
- British Heart Foundation Centre of Research Excellence, Oxford, UK (B.C.)
| | | | | | - Grant R Drummond
- Centre for Cardiovascular Biology and Disease Research and Department of Physiology, Anatomy and Microbiology, La Trobe University, Melbourne, Australia (G.R.D.)
| | - Jane E Freedman
- Cardiovascular Research, University of Massachusetts Medical School, Worcester (J.E.F.)
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (T.J.G.)
- Jagiellonian University Collegium Medicum, Krakow, Poland (T.J.G.)
| | - David Harrison
- Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (D.H.)
| | - Derek J Hausenloy
- Signature Research Program in Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore NUS Medical School (D.J.H.)
- National Heart Research Institute Singapore, National Heart Centre (D.J.H.)
- Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
- The Hatter Cardiovascular Institute, University College London, UK (D.J.H.)
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taiwan (D.J.H.)
| | | | - James L Januzzi
- Massachusetts General Hospital, Harvard University, Boston (J.L.J.)
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Calum A MacRae
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.A.M.)
| | | | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Japan (T.M.)
| | - Rebecca H Ritchie
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), VIC, Australia (R.H.R.)
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health and Manchester University NHS Foundation Trust, University of Manchester, UK (M.T.)
| | - Joseph C Wu
- Stanford Cardiovascular Institute, CA (J.C.W.)
| | - Junjie Xiao
- Cardiac Regeneration and Ageing Laboratory, Institute of Cardiovascular Sciences, School of Life Sciences, Shanghai University, China (J.X.)
| | - Faiez Zannad
- Universite´ de Lorraine, INSERM CIC 1493, INI CRCT, CHRU, Nancy, France (F.Z.)
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4
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Li YF, Wang YX, Wang H, Ma Y, Wang LS. Posttranslational Modifications: Emerging Prospects for Cardiac Regeneration Therapy. J Cardiovasc Transl Res 2021; 15:49-60. [PMID: 34031843 DOI: 10.1007/s12265-021-10135-7] [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] [Received: 03/14/2021] [Accepted: 05/07/2021] [Indexed: 11/30/2022]
Abstract
Heart failure (HF) following ischemic heart disease (IHD) remains a hard nut to crack and a leading cause of death worldwide. Cardiac regeneration aims to promote cardiomyocyte (CM) proliferation by transitioning the cell cycle state of CMs from arrest to re-entry. Protein posttranslational modifications (PTMs) have recently attracted extensive attention in the field of cardiac regeneration due to their reversibility and effects on the stability, activity, and subcellular localization of target proteins. The balance of PTMs is disrupted when neonatal CMs withdraw from the cell cycle, resulting in significant dysfunction of downstream substrate protein localization, expression, and activity, ultimately limiting the maintenance of cardiac regeneration ability. In this review, we summarize recent research concerning the role of PTMs in cardiac regeneration, while focusing on phosphorylation, acetylation, ubiquitination, glycosylation, methylation, and neddylation, and the effects of these modifications on CM proliferation, which may provide potential targets for future treatments for IHD.
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Affiliation(s)
- Ya-Fei Li
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ya-Xin Wang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hao Wang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Yao Ma
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Lian-Sheng Wang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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5
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Figtree GA, Broadfoot K, Casadei B, Califf R, Crea F, Drummond GR, Freedman JE, Guzik TJ, Harrison D, Hausenloy DJ, Hill JA, Januzzi JL, Kingwell BA, Lam CSP, MacRae CA, Misselwitz F, Miura T, Ritchie RH, Tomaszewski M, Wu JC, Xiao J, Zannad F. A call to action for new global approaches to cardiovascular disease drug solutions. Eur Heart J 2021; 42:1464-1475. [PMID: 33847746 DOI: 10.1093/eurheartj/ehab068] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/01/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Whilst we continue to wrestle with the immense challenge of implementing equitable access to established evidence-based treatments, substantial gaps remain in our pharmacotherapy armament for common forms of cardiovascular disease including coronary and peripheral arterial disease, heart failure, hypertension, and arrhythmia. We need to continue to invest in the development of new approaches for the discovery, rigorous assessment, and implementation of new therapies. Currently, the time and cost to progress from lead compound/product identification to the clinic, and the success rate in getting there reduces the incentive for industry to invest, despite the enormous burden of disease and potential size of market. There are tremendous opportunities with improved phenotyping of patients currently batched together in syndromic 'buckets'. Use of advanced imaging and molecular markers may allow stratification of patients in a manner more aligned to biological mechanisms that can, in turn, be targeted by specific approaches developed using high-throughput molecular technologies. Unbiased 'omic' approaches enhance the possibility of discovering completely new mechanisms in such groups. Furthermore, advances in drug discovery platforms, and models to study efficacy and toxicity more relevant to the human disease, are valuable. Re-imagining the relationships among discovery, translation, evaluation, and implementation will help reverse the trend away from investment in the cardiovascular space, establishing innovative platforms and approaches across the full spectrum of therapeutic development.
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Affiliation(s)
- Gemma A Figtree
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | | | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- British Heart Foundation Centre of Research Excellence, Oxford, UK
| | | | | | - Grant R Drummond
- Centre for Cardiovascular Biology and Disease Research; and Department of Physiology, Anatomy and Microbiology, La Trobe University, Melbourne, Australia
| | - Jane E Freedman
- Cardiovascular Research, University of Massachusetts Medical School, MA, USA
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK and Jagiellonian University Collegium Medicum, Krakow, Poland
| | - David Harrison
- Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Derek J Hausenloy
- Signature Research Program in Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore NUS Medical School, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
- The Hatter Cardiovascular Institute, University College London, London, UK
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taiwan
| | | | - James L Januzzi
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore
| | - Calum A MacRae
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Rebecca H Ritchie
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, VIC, Australia
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health and Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Junjie Xiao
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Sciences, Shanghai University, Shanghai, 200444, China
| | - Faiez Zannad
- Université de Lorraine, INSERM CIC 1493, INI CRCT, CHRU Nancy, France
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6
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Gibbons RJ. Myocardial Ischemia in the Management of Chronic Coronary Artery Disease: Past and Present. Circ Cardiovasc Imaging 2021; 14:e011615. [PMID: 33455408 DOI: 10.1161/circimaging.120.011615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
For many years, stress-induced myocardial ischemia has been considered important in the management of chronic coronary artery disease. Early evidence focused on the exercise ECG and the Duke treadmill score. In the 1970s, randomized clinical trials, which compared coronary artery bypass surgery to medical therapy, enrolled patients who were very different from contemporary practice and had inconsistent results. Surgery appeared to be of greatest benefit in high-risk patients defined by anatomy (such as left main disease) or stress-induced ischemia. However, randomized clinical trials of revascularization versus contemporary medical therapy over the past 20 years have been surprisingly negative. Nuclear cardiology substudies from these trials reported inconsistent results. Two observational studies from a single-center provided the best evidence for the use of stress-induced ischemia to identify patients who were most likely to benefit from revascularization. The recently completed ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) was designed to test the hypothesis that revascularization would improve outcomes in patients with moderate-severe ischemia on stress testing. Unfortunately, 14.2% of the randomized patients had either mild or no ischemia on core lab review. Nearly one-quarter of the patients were randomized on the basis of an exercise ECG without imaging. The negative results of the trial reflect the long-term population decline in coronary artery disease and abnormal stress tests, as well as improvements in patient outcome due to optimal medical therapy. Topics requiring further research are presented. The implications of the trial for the use of both stress imaging and coronary computed tomography angiography in clinical practice are examined.
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7
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Tsigkas G, Moulias A, Xaplanteris P, Bousoula E, Tzikas S, Toutouzas K, Davlouros P. Application and clinical implications of revascularization on chronic coronary syndromes: From COURAGE to ISCHEMIA trial. Hellenic J Cardiol 2020; 62:447-451. [PMID: 33176210 DOI: 10.1016/j.hjc.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/16/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece.
| | | | - Panagiotis Xaplanteris
- Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Eleni Bousoula
- Department of Invasive Cardiology, Onaseio Cardiothoracic Surgery Center, Athens, Greece
| | - Stergios Tzikas
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ippokrateio Hospital, Thessaloniki, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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