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Bate GL, Kirk C, Rehman RZU, Guan Y, Yarnall AJ, Del Din S, Lawson RA. The Role of Wearable Sensors to Monitor Physical Activity and Sleep Patterns in Older Adult Inpatients: A Structured Review. SENSORS (BASEL, SWITZERLAND) 2023; 23:4881. [PMID: 37430796 PMCID: PMC10222486 DOI: 10.3390/s23104881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 07/12/2023]
Abstract
Low levels of physical activity (PA) and sleep disruption are commonly seen in older adult inpatients and are associated with poor health outcomes. Wearable sensors allow for objective continuous monitoring; however, there is no consensus as to how wearable sensors should be implemented. This review aimed to provide an overview of the use of wearable sensors in older adult inpatient populations, including models used, body placement and outcome measures. Five databases were searched; 89 articles met inclusion criteria. We found that studies used heterogenous methods, including a variety of sensor models, placement and outcome measures. Most studies reported the use of only one sensor, with either the wrist or thigh being the preferred location in PA studies and the wrist for sleep outcomes. The reported PA measures can be mostly characterised as the frequency and duration of PA (Volume) with fewer measures relating to intensity (rate of magnitude) and pattern of activity (distribution per day/week). Sleep and circadian rhythm measures were reported less frequently with a limited number of studies providing both physical activity and sleep/circadian rhythm outcomes concurrently. This review provides recommendations for future research in older adult inpatient populations. With protocols of best practice, wearable sensors could facilitate the monitoring of inpatient recovery and provide measures to inform participant stratification and establish common objective endpoints across clinical trials.
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Affiliation(s)
- Gemma L. Bate
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK; (G.L.B.); (C.K.); (R.Z.U.R.); (A.J.Y.); (S.D.D.)
| | - Cameron Kirk
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK; (G.L.B.); (C.K.); (R.Z.U.R.); (A.J.Y.); (S.D.D.)
| | - Rana Z. U. Rehman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK; (G.L.B.); (C.K.); (R.Z.U.R.); (A.J.Y.); (S.D.D.)
| | - Yu Guan
- Department of Computer Science, University of Warwick, Coventry CV4 7EZ, UK;
| | - Alison J. Yarnall
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK; (G.L.B.); (C.K.); (R.Z.U.R.); (A.J.Y.); (S.D.D.)
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- National Institute for Health and Care Research (NIHR), Newcastle Biomedical Research Centre (BRC), Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Silvia Del Din
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK; (G.L.B.); (C.K.); (R.Z.U.R.); (A.J.Y.); (S.D.D.)
- National Institute for Health and Care Research (NIHR), Newcastle Biomedical Research Centre (BRC), Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Rachael A. Lawson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK; (G.L.B.); (C.K.); (R.Z.U.R.); (A.J.Y.); (S.D.D.)
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Burger P, Van den Ende ES, Lukman W, Burchell GL, Steur LM, Merten H, Nanayakkara PW, Gemke RJ. Sleep in hospitalized pediatric and adult patients - A systematic review and meta-analysis. Sleep Med X 2022; 4:100059. [PMID: 36406659 PMCID: PMC9672415 DOI: 10.1016/j.sleepx.2022.100059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 11/07/2022] Open
Abstract
Background Sleep is essential for recovery from illness. As a result, researchers have shown a growing interest in the sleep of hospitalized patients. Although many studies have been conducted over the past years, an up to date systematic review of the results is missing. Objective The objective of this systematic review was to assess sleep quality and quantity of hospitalized patients and sleep disturbing factors. Methods A systematic literature search was conducted within four scientific databases. The search focused on synonyms of 'sleep' and 'hospitalization'. Papers written in English or Dutch from inception to April 25th,2022 were included for hospitalized patients >1 year of age. Papers exclusively reporting about patients receiving palliative, obstetric or psychiatric care were excluded, as well as patients in rehabilitation and intensive care settings, and long-term hospitalized geriatric patients. This review was performed in accordance with the PRISMA guidelines. Results Out of 542 full text studies assessed for eligibility, 203 were included, describing sleep quality and/or quantity of 17,964 patients. The median sample size of the studies was 51 patients (IQR 67, range 6-1472). An exploratory meta-analysis of the Total Sleep Time showed an average of 7.2 h (95%-CI 4.3, 10.2) in hospitalized children, 5.7 h (95%-CI 4.8, 6.7) in adults and 5.8 h (95%-CI 5.3, 6.4) in older patients (>60y). In addition, a meta-analysis of the Wake After Sleep Onset (WASO) showed a combined high average of 1.8 h (95%-CI 0.7, 2.9). Overall sleep quality was poor, also due to nocturnal awakenings. The most frequently cited external factors for poor sleep were noise and number of patients in the room. Among the variety of internal/disease-related factors, pain and anxiety were most frequently mentioned to be associated with poor sleep. Conclusion Of all studies, 76% reported poor sleep quality and insufficient sleep duration in hospitalized patients. Children sleep on average 0.7-3.8 h less in the hospital than recommended. Hospitalized adults sleep 1.3-3.2 h less than recommended for healthy people. This underscores the need for interventions to improve sleep during hospitalization to support recovery.
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Affiliation(s)
- Pia Burger
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Eva S. Van den Ende
- Section General Internal Medicine Unit Acute Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wen Lukman
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - George L. Burchell
- Medical Library, Vrije Universiteit, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Lindsay M.H. Steur
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Prabath W.B. Nanayakkara
- Section General Internal Medicine Unit Acute Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Reinoud J.B.J. Gemke
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
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Abstract
INTRODUCTION Sleep deprivation is a relevant problem among patients hospitalized in ICUs. Further, noise is the most critical disruptive factor according to patients. OBJECTIVE To implement scientific evidence-based best practices for noise control in an adult ICU. METHODS This was an evidence-based implementation project of best practices in noise control, conducted in a high-complexity hospital's adult ICU. The intervention consisted of three steps: baseline audit and identification of barriers, implementation of best practices, and a follow-up audit. RESULTS No compliance with best practices was detected in the baseline audit. After the implementation phase, the unit reached compliance levels of 78-88% for most of these criteria only one criterion related to noise level did not match the expected compliance. CONCLUSION Adherence to best practices regarding noise control was satisfactory, achieving more than 70% compliance in the six audit criteria. Only the noise level did not reach the threshold recommended by the WHO - a difficulty reported in other studies. RELEVANCE TO CLINICAL PRACTICE Best practices related to noise control are essential for managing sleep deprivation in ICUs and include changes in the behaviour of involved professionals.
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Sakr N, Hallit S, Mattar H. Incidence of and Factors Associated with New-Onset Insomnia Among Lebanese Hospitalised Patients: A single-centre study. Sultan Qaboos Univ Med J 2021; 21:e210-e220. [PMID: 34221468 PMCID: PMC8219334 DOI: 10.18295/squmj.2021.21.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/19/2020] [Accepted: 08/18/2020] [Indexed: 12/29/2022] Open
Abstract
Objectives This study aimed to determine the incidence and post-discharge resolution of new-onset insomnia in hospitalised patients with no previous history of insomnia, as well as to define major correlates of in-hospital insomnia. Methods This prospective observational study was conducted between November 2019 and January 2020 at a tertiary care centre in Lebanon. All hospitalised patients >18 years of age with no history of insomnia were screened for new-onset insomnia using the Insomnia Severity Index (ISI) scale. Subsequently, patients were re-assessed two weeks after discharge to determine insomnia resolution. Results A total of 75 patients were included in the study. Of these, nine (12%) had no insomnia, 34 (45.3%) had subthreshold insomnia, 22 (29.3%) had moderate insomnia and 10 (13.3%) had severe insomnia. The mean ISI score was 14.95 ± 6.05, with 88% of patients having ISI scores of >7 (95% confidence interval: 0.822–0.965). The frequency of new-onset insomnia was significantly higher among patients who shared a room compared to those in single-bed rooms (95.7% versus 75%; P = 0.011). Other factors were not found to be associated with new-onset insomnia, including the administration of medications known to cause insomnia, in-hospital sedative use, overnight oxygen, cardiac monitoring and self-reported nocturnal toilet use. Overall, insomnia resolution occurred in 78.7% of patients two weeks after discharge. Conclusion There was a high incidence of acute new-onset insomnia among hospitalised patients at a tertiary centre in Lebanon. Additional research is recommended to further examine inhospital sleep disturbance factors and to seek convenient solutions to limit insomnia.
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Affiliation(s)
- Nour Sakr
- Department of Medicine, School of Medicine & Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
| | - Souheil Hallit
- Department of Medicine, School of Medicine & Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon.,INSPECT-LB: National Institute of Public Health, Clinical Epidemiology and Toxicology, Beirut, Lebanon
| | - Hanna Mattar
- Department of Medicine, School of Medicine & Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon.,Department of Neurology, Notre-Dame des Secours University Hospital, Byblos, Lebanon
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Ritmala-Castren M, Salanterä S, Holm A, Heino M, Lundgrén-Laine H, Koivunen M. Sleep improvement intervention and its effect on patients' sleep on the ward. J Clin Nurs 2021; 31:275-282. [PMID: 34114280 DOI: 10.1111/jocn.15906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 05/17/2021] [Indexed: 12/01/2022]
Abstract
AIM AND OBJECTIVE The aim of the study was to investigate how the sleep improvement interventions developed for the wards were associated with patients' sleep. The objective was to promote patients' sleep. BACKGROUND The quality of sleep is vital for patients' health and recovery from illness. However, patients generally sleep poorly during hospitalisation. Sleep-disturbing factors are connected to the hospital environment, patients' physical illness, emotional state and the activities of the staff. Many sleep-disturbing factors can be influenced by appropriate nursing interventions. DESIGN A two-group intervention study including the development of nursing interventions aimed at supporting patients' sleep. One group received a sleep promotion intervention and the other received standard care. Both groups evaluated their sleep in the morning. METHODS A survey of participants' sleep evaluations was collected with the five-item Richards-Campbell Sleep Questionnaire. The data were analysed statistically. The STROBE checklist was used to report the study. RESULTS From the participants' perspective, sleep was better in the intervention group, even though statistically significantly only among men. The pain intensity correlated with sleep quality. The number of patients in the room or whether participants had had an operation had no effect on their sleep evaluations. CONCLUSIONS Interventions targeted at supporting and promoting the sleep quality of hospital inpatients may be effective. They should be developed in collaboration with patients and nurses. Several nursing interventions can be proposed to promote better sleep among patients; however, more research is needed to confirm the results. Sleep promotion should include both standardised protocols and individualised sleep support. RELEVANCE TO CLINICAL PRACTICE Investing in nursing interventions to promote patients' sleep is important. Patients' individual sleep-related needs should be part of their care plan. Training programmes that support nurses' knowledge and skills of patients' sleep promotion should be part of nursing education in healthcare organisations.
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Affiliation(s)
- Marita Ritmala-Castren
- Department of Nursing Science, University of Turku, Turku, Finland.,Helsinki University Hospital, Nursing Administration, Helsinki, Finland
| | - Sanna Salanterä
- Department of Nursing Science, University of Turku, Turku, Finland.,Turku University Hospital, Turku, Finland
| | - Anu Holm
- Unit of Clinical Neurophysiology, Satakunta Hospital District, Pori, Finland.,Faculty of Health and Welfare, Satakunta University of Applied Sciences, Pori, Finland
| | | | - Heljä Lundgrén-Laine
- Department of Nursing Science, University of Turku, Turku, Finland.,Central Finland Hospital Nova, Central Finland Health Care District, Jyvaskyla, Finland
| | - Marita Koivunen
- Department of Nursing Science, University of Turku, Turku, Finland.,Satakunta Hospital District, Pori, Finland
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Aparício C, Panin F. Interventions to improve inpatients' sleep quality in intensive care units and acute wards: a literature review. ACTA ACUST UNITED AC 2021; 29:770-776. [PMID: 32649254 DOI: 10.12968/bjon.2020.29.13.770] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sleep is essential for the physical and psychological restoration of inpatients, and lack of sleep results in sleep deprivation and poor sleep quality, with potentially harmful consequences. AIM To summarise sleep-promoting interventions in the Intensive care unit (ICU) and acute ward setting. METHOD AND RESULTS Six databases were searched to obtain studies for review and eight studies were selected, appraised, analysed and produced two themes: sleep-disturbing factors and sleep-promoting strategies. Sleep-disturbing factors included environmental factors (such as light and noise), illness-related factors (such as pain, anxiety and discomfort), clinical care and diagnostics. Sleep-promoting strategies included using pharmacological aids (medication) and non-pharmacological aids (reducing noise and disturbances, eye masks, earplugs and educational and behavioural changes). CONCLUSION The literature review showed that both ICU and acute ward settings affect patients' sleep and both use similar strategies to improve this. Nevertheless, noise and sleep disturbances remain the most critical sleep-inhibiting factors in both settings. The review recommended future research should focus on behavioural changes among health professionals to reduce noise and improve patients' sleep.
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Affiliation(s)
- Carlos Aparício
- Professional Doctorate Student, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge
| | - Francesca Panin
- Lecturer, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge
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Bellon F, Mora-Noya V, Pastells-Peiró R, Abad-Corpa E, Gea-Sánchez M, Moreno-Casbas T. The efficacy of nursing interventions on sleep quality in hospitalized patients: A systematic review of randomized controlled trials. Int J Nurs Stud 2020; 115:103855. [PMID: 33383270 DOI: 10.1016/j.ijnurstu.2020.103855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/04/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effect of interventions that could be performed by nurses to improve the sleep quality of hospitalized patients in acute and semi-acute units. DESIGN A systematic review of randomized controlled trials and narrative synthesis. DATA SOURCES Seven electronic databases (PubMed, CINAHL Plus, Scopus, ISI WoS, CENTRAL, PsycInfo, and Embase) were accessed on 20 May 2019 with a temporal limit of 10 years prior. REVIEW METHODS Original research studies of interventions that could be delivered by nurses to improve sleep quality during hospitalization in acute and semi-acute units were included. Study selection, data extraction, and risk of bias assessment were performed by two independent reviewers. RESULTS Seventeen studies met the inclusion criteria and were included in this review. The interventions carried out in the trials were classified into four categories of measurement: environmental, physical, behavioural, and combined. Fourteen studies obtained statistically significant improvements; two showed a blend of significant and non-significant improvements; and one reported non-significant results. However, only four trials of the seventeen were judged as having a low risk of bias. CONCLUSIONS Overall evidence about interventions that could be performed by nurses to improve perceived sleep quality in hospitalized patients was found to be positive, and no negative effects were reported. However, higher quality research using both subjective and objective measures is needed, in order to strengthen the evidence.
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Affiliation(s)
- Filip Bellon
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida. Montserrat Roig, 25198 Lleida, Spain; Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain.
| | - Veronica Mora-Noya
- Department of formation and research, Foundation "Hospital de Campdevànol", Ctra, de Gombrèn, s/n, 17530 Campdevànol, Girona, Spain
| | - Roland Pastells-Peiró
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida. Montserrat Roig, 25198 Lleida, Spain; Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain.
| | - Eva Abad-Corpa
- University of Murcia-Murcia Health Service (IMIB-Arrixaca), Campus Universitario, 1, 30100 Murcia, Spain; Biomedical Research Center for Fragility and Healthy Aging (CIBERFES), Av. Monforte de Lemos, 5. Pabellón 11, 28029 Madrid, Spain.
| | - Montserrat Gea-Sánchez
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida. Montserrat Roig, 25198 Lleida, Spain; Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain; Biomedical Research Center for Fragility and Healthy Aging (CIBERFES), Av. Monforte de Lemos, 5. Pabellón 11, 28029 Madrid, Spain.
| | - Teresa Moreno-Casbas
- Nursing and Healthcare Research Unit (Investén-isciii), Av. Monforte de Lemos, 5. Pabellón 13, 28029 Madrid, Spain; Biomedical Research Center for Fragility and Healthy Aging (CIBERFES), Av. Monforte de Lemos, 5. Pabellón 11, 28029 Madrid, Spain.
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Cao X, Müller A, Dirschinger RJ, Dommasch M, Steger A, Barthel P, Laugwitz KL, Schmidt G, Sinnecker D. Risk Prediction After Myocardial Infarction by Cyclic Variation of Heart Rate, a Surrogate of Sleep-Disordered Breathing Assessed From Holter ECGs. Front Physiol 2020; 10:1570. [PMID: 32009979 PMCID: PMC6974555 DOI: 10.3389/fphys.2019.01570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/13/2019] [Indexed: 11/17/2022] Open
Abstract
Aims Sleep-disordered breathing (SDB) is common among cardiac patients, but its role as an independent risk predictor after myocardial infarction (MI) is unclear. SDB causes cyclic variation of heart rate (CVHR). The aim of this study was to score Holter ECGs of a large cohort of MI survivors for SDB-related CVHR to investigate its value for mortality prediction. Methods A total of 1590 survivors of acute MI in sinus rhythm were prospectively enrolled and followed for 5-year all-cause mortality. Heart rate (HR) tachograms were generated from nocturnal (00:00–06.00 am) segments of Holter ECGs, and the minutes with CVHR were quantified by a previously developed algorithm. According to a pre-specified cutpoint, SDB was assumed if CVHR was present during ≥72 min. Results Seventy-seven patients (4.8%) had flat HR tachograms which prohibited analysis for SDB. Of the remaining 1513 patients, 584 (38.6%) were classified as having SDB. Mortality rates in groups stratified according to ECG-derived SDB did not differ significantly. Taken as a continuous variable, low CVHR duration was associated with increased mortality. The mortality of patients with flat HR tachograms was significantly increased, even after adjustment for age, sex, LVEF, GRACE score and diabetes mellitus. Mortality prediction by a flat HR tachogram was also independent of heart rate variability (HRV), heart rate turbulence (HRT), and deceleration capacity (DC). Conclusion In Holter ECG recordings of survivors of acute MI, signs suggestive of SDB were frequently present, but not associated with mortality. A flat nocturnal HR tachogram was a strong, independent predictor of 5-year all-cause mortality.
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Affiliation(s)
- Xu Cao
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Müller
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ralf J Dirschinger
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Dommasch
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Steger
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Petra Barthel
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Georg Schmidt
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Daniel Sinnecker
- Klinik und Poliklinik für Innere Medizin I, University Hospital Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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