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Fernández-Jiménez R, Barreiro-Pérez M, Martin-García A, Sánchez-González J, Agüero J, Galán-Arriola C, García-Prieto J, Díaz-Pelaez E, Vara P, Martinez I, Zamarro I, Garde B, Sanz J, Fuster V, Sánchez PL, Ibanez B. Dynamic Edematous Response of the Human Heart to Myocardial Infarction: Implications for Assessing Myocardial Area at Risk and Salvage. Circulation 2017; 136:1288-1300. [PMID: 28687712 PMCID: PMC5625960 DOI: 10.1161/circulationaha.116.025582] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 06/26/2017] [Indexed: 01/28/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Clinical protocols aimed to characterize the post–myocardial infarction (MI) heart by cardiac magnetic resonance (CMR) need to be standardized to take account of dynamic biological phenomena evolving early after the index ischemic event. Here, we evaluated the time course of edema reaction in patients with ST-segment–elevation MI by CMR and assessed its implications for myocardium-at-risk (MaR) quantification both in patients and in a large-animal model. Methods: A total of 16 patients with anterior ST-segment–elevation MI successfully treated by primary angioplasty and 16 matched controls were prospectively recruited. In total, 94 clinical CMR examinations were performed: patients with ST-segment–elevation MI were serially scanned (within the first 3 hours after reperfusion and at 1, 4, 7, and 40 days), and controls were scanned only once. T2 relaxation time in the myocardium (T2 mapping) and the extent of edema on T2-weighted short-tau triple inversion-recovery (ie, CMR-MaR) were evaluated at all time points. In the experimental study, 20 pigs underwent 40-minute ischemia/reperfusion followed by serial CMR examinations at 120 minutes and 1, 4, and 7 days after reperfusion. Reference MaR was assessed by contrast-multidetector computed tomography during the index coronary occlusion. Generalized linear mixed models were used to take account of repeated measurements. Results: In humans, T2 relaxation time in the ischemic myocardium declines significantly from early after reperfusion to 24 hours, and then increases up to day 4, reaching a plateau from which it decreases from day 7. Consequently, edema extent measured by T2-weighted short-tau triple inversion-recovery (CMR-MaR) varied with the timing of the CMR examination. These findings were confirmed in the experimental model by showing that only CMR-MaR values for day 4 and day 7 postreperfusion, coinciding with the deferred edema wave, were similar to values measured by reference contrast-multidetector computed tomography. Conclusions: Post-MI edema in patients follows a bimodal pattern that affects CMR estimates of MaR. Dynamic changes in post–ST-segment–elevation MI edema highlight the need for standardization of CMR timing to retrospectively delineate MaR and quantify myocardial salvage. According to the present clinical and experimental data, a time window between days 4 and 7 post-MI seems a good compromise solution for standardization. Further studies are needed to study the effect of other factors on these variables.
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Affiliation(s)
- Rodrigo Fernández-Jiménez
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Manuel Barreiro-Pérez
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Ana Martin-García
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Javier Sánchez-González
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Jaume Agüero
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Carlos Galán-Arriola
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Jaime García-Prieto
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Elena Díaz-Pelaez
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Pedro Vara
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Irene Martinez
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Ivan Zamarro
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Beatriz Garde
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Javier Sanz
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Valentin Fuster
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.)
| | - Pedro L Sánchez
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.).
| | - Borja Ibanez
- From Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., J.A., C.G.-A., J.G.-P., J.S., V.F., B.I.); CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (R.F.-J., M.B.-P., A.M.-G., J.A., C.G.-A., J.G.-P., B.G., P.L.S., B.I.); The Zena and Michael A. Wiener CVI, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.F.); Hospital Universitario de Salamanca, Spain (M.B.-P., A.M.-G., E.D.-P., P.V., I.M., I.Z., B.G., P.L.S.); Philips Healthcare, Madrid, Spain (J.S.-G.); Cardiology Department, Hospital Universtitari i Politecnic La Fe, Valencia, Spain (J.A.); and IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (B.I.).
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Fernández-Jiménez R, Galán-Arriola C, Sánchez-González J, Agüero J, López-Martín GJ, Gomez-Talavera S, Garcia-Prieto J, Benn A, Molina-Iracheta A, Barreiro-Pérez M, Martin-García A, García-Lunar I, Pizarro G, Sanz J, Sánchez PL, Fuster V, Ibanez B. Effect of Ischemia Duration and Protective Interventions on the Temporal Dynamics of Tissue Composition After Myocardial Infarction. Circ Res 2017; 121:439-450. [PMID: 28596216 PMCID: PMC5542781 DOI: 10.1161/circresaha.117.310901] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/02/2017] [Accepted: 06/08/2017] [Indexed: 01/18/2023]
Abstract
Supplemental Digital Content is available in the text. Rationale: The impact of cardioprotective strategies and ischemia duration on postischemia/reperfusion (I/R) myocardial tissue composition (edema, myocardium at risk, infarct size, salvage, intramyocardial hemorrhage, and microvascular obstruction) is not well understood. Objective: To study the effect of ischemia duration and protective interventions on the temporal dynamics of myocardial tissue composition in a translational animal model of I/R by the use of state-of-the-art imaging technology. Methods and Results: Four 5-pig groups underwent different I/R protocols: 40-minute I/R (prolonged ischemia, controls), 20-minute I/R (short-duration ischemia), prolonged ischemia preceded by preconditioning, or prolonged ischemia followed by postconditioning. Serial cardiac magnetic resonance (CMR)-based tissue characterization was done in all pigs at baseline and at 120 minutes, day 1, day 4, and day 7 after I/R. Reference myocardium at risk was assessed by multidetector computed tomography during the index coronary occlusion. After the final CMR, hearts were excised and processed for water content quantification and histology. Five additional healthy pigs were euthanized after baseline CMR as reference. Edema formation followed a bimodal pattern in all 40-minute I/R pigs, regardless of cardioprotective strategy and the degree of intramyocardial hemorrhage or microvascular obstruction. The hyperacute edematous wave was ameliorated only in pigs showing cardioprotection (ie, those undergoing short-duration ischemia or preconditioning). In all groups, CMR-measured edema was barely detectable at 24 hours postreperfusion. The deferred healing-related edematous wave was blunted or absent in pigs undergoing preconditioning or short-duration ischemia, respectively. CMR-measured infarct size declined progressively after reperfusion in all groups. CMR-measured myocardial salvage, and the extent of intramyocardial hemorrhage and microvascular obstruction varied dramatically according to CMR timing, ischemia duration, and cardioprotective strategy. Conclusions: Cardioprotective therapies, duration of index ischemia, and the interplay between these greatly influence temporal dynamics and extent of tissue composition changes after I/R. Consequently, imaging techniques and protocols for assessing edema, myocardium at risk, infarct size, salvage, intramyocardial hemorrhage, and microvascular obstruction should be standardized accordingly.
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Affiliation(s)
- Rodrigo Fernández-Jiménez
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Carlos Galán-Arriola
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Javier Sánchez-González
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Jaume Agüero
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Gonzalo J López-Martín
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Sandra Gomez-Talavera
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Jaime Garcia-Prieto
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Austin Benn
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Antonio Molina-Iracheta
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Manuel Barreiro-Pérez
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Ana Martin-García
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Inés García-Lunar
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Gonzalo Pizarro
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Javier Sanz
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Pedro L Sánchez
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Valentin Fuster
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.)
| | - Borja Ibanez
- From the Department of Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (R.F.-J., C.G.-A., J.A., G.J.L.-M., S.G.-T., J.G.-P., A.B., A.M.-I., I.G.-L., G.P., J.S., V.L., B.I.); Centro de Investigación Biomédica en Red de enfermedades CardioVasculares (CIBERCV) (R.F.-J., C.G.-A., J.A., S.G.-T., J.G.-P., M.B.-P., A.M.-G., I.G.-L., G.P., P.L.S., B.I.); Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.F.-J., J.S., V.L.); Department of Clinical Research, Philips Healthcare, Madrid, Spain (J.S.-G.); Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Spain (M.B.-P., A.M.-G., P.L.S.); Department of Cardiology, Hospital Universitario Quiron (I.G.-L.) and Complejo Hospitalario Ruber Juan Bravo (G.P.), European University of Madrid, Spain; and Department of Cardiology, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain (S.G.-T., B.I.).
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