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Mazzoli R, Chiari A, Vitolo M, Garuti C, Adani G, Vinceti G, Zamboni G, Tondelli M, Galli C, Costa M, Salemme S, Boriani G, Vinceti M, Filippini T. Atrial Fibrillation and Other Cardiovascular Factors and the Risk of Dementia: An Italian Case-Control Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:688. [PMID: 38928935 PMCID: PMC11203794 DOI: 10.3390/ijerph21060688] [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: 05/09/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/28/2024]
Abstract
Dementia is a major neurologic syndrome characterized by severe cognitive decline, and it has a detrimental impact on overall physical health, leading to conditions such as frailty, changes in gait, and fall risk. Depending on whether symptoms occur before or after the age of 65, it can be classified as early-onset (EOD) or late-onset (LOD) dementia. The present study is aimed at investigating the role of cardiovascular factors on EOD and LOD risk in an Italian population. Using a case-control study design, EOD and LOD cases were recruited at the Modena Cognitive Neurology Centers in 2016-2019. Controls were recruited among caregivers of all the dementia cases. Information about their demographics, lifestyles, and medical history were collected through a tailored questionnaire. We used the odds ratio (OR) and 95% confidence interval (CI) to estimate the EOD and LOD risk associated with the investigated factors after adjusting for potential confounders. Of the final 146 participants, 58 were diagnosed with EOD, 34 with LOD, and 54 were controls. According to their medical history, atrial fibrillation was associated with increased disease risk (ORs 1.90; 95% CI 0.32-11.28, and 3.64; 95% CI 0.32-41.39 for EOD and LOD, respectively). Dyslipidemia and diabetes showed a positive association with EOD, while the association was negative for LOD. We could not evaluate the association between myocardial infarction and EOD, while increased risk was observed for LOD. No clear association emerged for carotid artery stenosis or valvular heart disease. In this study, despite the limited number of exposed subjects and the high imprecision of the estimates, we found positive associations between cardiovascular disease, particularly dyslipidemia, diabetes, and atrial fibrillation, and EOD.
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Affiliation(s)
- Riccardo Mazzoli
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41225 Modena, Italy; (R.M.)
| | - Annalisa Chiari
- Neurology Unit, Baggiovara Hospital, AOU Modena, 41126 Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41124 Modena, Italy
| | - Caterina Garuti
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41225 Modena, Italy; (R.M.)
- Post Graduate School of Pediatrics, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Giorgia Adani
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41225 Modena, Italy; (R.M.)
| | - Giulia Vinceti
- Neurology Unit, Baggiovara Hospital, AOU Modena, 41126 Modena, Italy
| | - Giovanna Zamboni
- Neurology Unit, Baggiovara Hospital, AOU Modena, 41126 Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Manuela Tondelli
- Neurology Unit, Baggiovara Hospital, AOU Modena, 41126 Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Chiara Galli
- Neurology Unit, Baggiovara Hospital, AOU Modena, 41126 Modena, Italy
- Primary Care Department, Modena Local Health Authority, 41124 Modena, Italy
| | - Manuela Costa
- Neurology Unit of Carpi Hospital, Modena Local Health Authority, 41012 Carpi, Italy
| | - Simone Salemme
- Neurology Unit, Baggiovara Hospital, AOU Modena, 41126 Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- School of Advanced Studies, University of Camerino, 62032 Camerino, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41124 Modena, Italy
| | - Marco Vinceti
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41225 Modena, Italy; (R.M.)
- Department of Epidemiology, Boston University School of Public Health, Boston, MA 02118, USA
| | - Tommaso Filippini
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41225 Modena, Italy; (R.M.)
- School of Public Health, University of California Berkeley, Berkeley, CA 94704, USA
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Zhai Y, Hu F, Yuan L, Ye X, Shi W, Yang R, Cao Y, Sun J, He J, Xu F. Atrial fibrillation increases the risk of all-cause dementia, Alzheimer's disease, and vascular dementia: A cohort study of 373, 415 participants in the UK Biobank. J Affect Disord 2024; 351:323-330. [PMID: 38286227 DOI: 10.1016/j.jad.2024.01.224] [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] [Received: 10/12/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Accumulated evidence has highlighted the association between atrial fibrillation and the risk of developing dementia. METHODS This current cohort study utilized data from the UK Biobank to explore the association between atrial fibrillation (AF) and all-cause dementia (ACD), encompassing its main subtypes (Alzheimer's disease (AD), and vascular dementia (VD)). Cox proportional hazards models were applied to examine the association of AF and dementia with its primary subtypes after adjusting for different sets of covariates. Hazard ratios (HRs) with 95 % confidential intervals (CIs) were estimated to quantify the associated risks. Competing risk model was applied in sensitivity analysis. RESULTS After exclusion, 373, 415 participants entered the primary analysis. Among these, 27, 934 (7.48 %) were with a history AF at baseline, while 345, 481 (92.52 %) were without. During a mean follow-up of 13.45 years, ACD was diagnosed in 1215 individuals with AF and 3988 individuals without AF. Participants with AF had higher risks of ACD (1.79 [1.67-1.91]), AD (1.48 [1.32-1.65]), and VD (2.46 [2.17-2.80]) in the fully adjusted Cox regression models. Results of subgroup and sensitivity analyses predominantly aligned with the positive associations in primary analysis. LIMITATIONS The applicability of our findings to diverse ethnicities might require careful consideration and the behind biological mechanisms need to be further revealed. CONCLUSIONS It indicated that people with atrial fibrillation had an increased future risk of all-cause dementia, Alzheimer's disease, vascular dementia. Atrial fibrillation screening and prevention strategies should take into account to prevent and delay the onset of dementia.
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Affiliation(s)
- Yinghong Zhai
- Clinical Research Unit, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Fangyuan Hu
- Department of Medical Service, Naval Hospital of Eastern theater, Zhoushan, Zhejiang 316000, China; Department of Health Statistics, Naval Medical University, Shanghai 200433, China
| | - Lei Yuan
- Department of Health Management, Naval Medical University, Shanghai 200433, China
| | - Xiaofei Ye
- Department of Health Statistics, Naval Medical University, Shanghai 200433, China
| | - Wentao Shi
- Clinical Research Unit, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Rongqing Yang
- Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro 70182, Sweden
| | - Jinhai Sun
- Department of Health Management, Naval Medical University, Shanghai 200433, China.
| | - Jia He
- Department of Health Statistics, Naval Medical University, Shanghai 200433, China.
| | - Feng Xu
- Clinical Research Unit, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China.
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Åkerström F, Charitakis E, Paul-Nordin A, Braunschweig F, Friberg L, Tabrizi F, Jensen-Urstad M, Drca N. Reduced dementia risk in patients with optimized anticoagulation therapy undergoing atrial fibrillation ablation. Heart Rhythm 2024:S1547-5271(24)02365-8. [PMID: 38604586 DOI: 10.1016/j.hrthm.2024.04.038] [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: 03/12/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with the development of dementia, and observational studies have shown that oral anticoagulation and catheter ablation reduce dementia risk. However, such studies did not consistently report on periprocedural anticoagulation and long-term oral anticoagulation coverage, for which reason the separate effect of AF ablation on dementia risk could not be established. OBJECTIVE We evaluated the protective effect of AF ablation in a large cohort of patients who received optimized anticoagulation and compared them with patients who were managed medically. METHODS We retrospectively included 5912 consecutive patients who underwent first-time catheter ablation for AF between 2008 and 2018 and compared them with 52,681 control individuals from the Swedish Patient Register. Propensity score matching produced 2 cohorts of equal size (n = 3940) with similar baseline characteristics. Dementia diagnosis was identified by International Classification of Diseases codes from the patient register. RESULTS Most propensity score-matched patients were taking an oral anticoagulant at the start (94.5%) and end (75.0%) of the study. Mean follow-up was 4.9 ± 2.8 years. Catheter ablation was associated with lower risk for the dementia diagnosis compared with the control group (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.22-0.86; P = .017). The result was similar when including patients with a stroke diagnosis before inclusion (HR, 0.50; 95% CI, 0.28-0.89; P = .019) and after adjustment for the competing risk of death (HR, 0.41; 95% CI, 0.20-0.86; P = .018). CONCLUSION Catheter ablation of AF in patients with optimized oral anticoagulation therapy was associated with a reduction in dementia diagnosis, even after adjustment for potential confounders and for competing risk of death.
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Affiliation(s)
- Finn Åkerström
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Heart and Lung Diseases Unit, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.
| | - Emmanouil Charitakis
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Heart and Lung Diseases Unit, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Astrid Paul-Nordin
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Heart and Lung Diseases Unit, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Heart and Lung Diseases Unit, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Leif Friberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institute Danderyd Hospital, Stockholm, Sweden
| | | | - Mats Jensen-Urstad
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Heart and Lung Diseases Unit, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Nikola Drca
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Heart and Lung Diseases Unit, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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Escobar-Cervantes C, Reino AP, Díez-Villanueva P, Facila L, Freixa-Pamias R, Valle A, Almendro-Delia M, Bonanad C, Vivas D, Suarez C. Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach. Expert Rev Cardiovasc Ther 2023; 21:779-790. [PMID: 37874226 DOI: 10.1080/14779072.2023.2272652] [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] [Received: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention. AREAS COVERED In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed. EXPERT OPINION The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.
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Affiliation(s)
| | - Antonio Pose Reino
- Hypertension and vascular risk unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia, Valencia,Spain
| | | | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Health Research Institute of the Valencia Clinical Hospital (INCLIVA), Valencia, Spain
| | - David Vivas
- Cardiology Department, Instituto Cardiovascular Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Suarez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Li GY, Chen YY, Lin YJ, Chien KL, Hsieh YC, Chung FP, Lo LW, Chang SL, Chao TF, Hu YF, Lin CY, Chen SA. Ablation of atrial fibrillation and dementia risk reduction during long-term follow-up: a nationwide population-based study. Europace 2023; 25:euad109. [PMID: 37097046 PMCID: PMC10228604 DOI: 10.1093/europace/euad109] [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] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
AIMS This study investigated the epidemiological characteristics of new-onset dementia in patients with atrial fibrillation (AF) and the association of catheter ablation with different subtypes of dementia. METHODS AND RESULTS We conducted a population-based, retrospective cohort study using data from the Taiwan National Health Insurance Research Database. In total, 136 774 patients without a history of dementia were selected after 1:1 propensity score matching based on age (with AF vs. without AF). A competing risk model was used to investigate the three subtypes of dementia: Alzheimer's disease, vascular dementia, and other/mixed dementia. Inverse probability of treatment weighting (IPTW) was performed to minimize the impact on dementia risk due to the imbalanced baseline characteristics. After a median follow-up period of 6.6 years, 8704 events of new-onset dementia occurred. Among all AF patients developing dementia, 73% were classified as having Alzheimer's disease, 16% as having vascular dementia, and 11% as having other/mixed dementia. The cumulative incidence of dementia in AF patients was higher than those without AF (log-rank test: P < 0.001 for both before and after IPTW). In patients with AF undergoing catheter ablation, the total dementia risk decreased significantly [P = 0.015, hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.58-0.94] after multivariable adjustment, but not for the subtype of vascular dementia (P = 0.59, HR: 0.86, 95% CI: 0.49-1.50). CONCLUSION Patients with AF have a higher incidence of all types of dementia, including Alzheimer's disease, vascular dementia, and a mixed type of dementia. Alzheimer's disease is less likely to occur in patients with AF undergoing catheter ablation.
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Affiliation(s)
- Guan-Yi Li
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Yun-Yu Chen
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yenn-Jiang Lin
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Cheng Hsieh
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Fa-Po Chung
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Li-Wei Lo
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Shih-Lin Chang
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Tze-Fan Chao
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Yu-Feng Hu
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Chin-Yu Lin
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
| | - Shih-Ann Chen
- Cardiovascular Center, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan
- Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St. Beitou Dist., Taipei 112304, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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