1
|
Sola M, Mesenbring E, Glorioso TJ, Gualano S, Atkinson T, Duvernoy CS, Waldo SW. Sex Disparities in the Management of Acute Coronary Syndromes: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2024; 13:e034312. [PMID: 39206727 DOI: 10.1161/jaha.123.034312] [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: 02/22/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System. METHODS AND RESULTS We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow-up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794-0.928]) or 1 year (HR, 0.891 [95% CI, 0.842-0.943]), or receive prescriptions for guideline-indicated cardiovascular medications. Despite this, 1-year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747-0.948]). CONCLUSIONS Women are less likely to receive appropriate cardiovascular follow-up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.
Collapse
Affiliation(s)
- Michael Sola
- Division of Cardiology, Department of Medicine University of Colorado Aurora CO USA
- Department of Medicine Rocky Mountain Veterans Affairs Medical Center Aurora CO USA
| | - Elise Mesenbring
- CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA
- Denver Research institute Aurora CO USA
| | - Thomas J Glorioso
- CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA
| | - Sarah Gualano
- VA Ann Arbor Healthcare System Ann Arbor MI USA
- University of Michigan Ann Arbor MI USA
| | - Tamara Atkinson
- Portland VA Medical Center Portland OR USA
- Knight Cardiovascular Institute, Oregon Health Sciences University Portland OR USA
| | - Claire S Duvernoy
- VA Ann Arbor Healthcare System Ann Arbor MI USA
- University of Michigan Ann Arbor MI USA
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine University of Colorado Aurora CO USA
- Department of Medicine Rocky Mountain Veterans Affairs Medical Center Aurora CO USA
- CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA
| |
Collapse
|
2
|
Review of the differences in outcomes between males and females after revascularization. Curr Opin Cardiol 2021; 36:652-660. [PMID: 34009807 DOI: 10.1097/hco.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review aims to compare outcomes of males and females undergoing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB), and robotic total endoscopic CABG (TECAB). RECENT FINDINGS Females demonstrated increased rates of morbidity and mortality post PCI and CABG. In studies that performed risk adjustments, these differences were reduced. Although inferior outcomes were observed for females in some measures, generally outcomes between males and females were comparable post OPCAB, MIDCAB, and TECAB. SUMMARY Previous literature has demonstrated that females undergoing coronary revascularization experience inferior postoperative outcomes when compared to their male counterparts. The discrepancies between males and females narrow, but do not disappear when preoperative risks are accounted for and when considering minimally invasive approaches such as MIDCAB, OPCAB, and TECAB. Minimally invasive cardiac surgery has demonstrated numerous benefits with reduced morbidity, mortality, and shorter recovery times. In patients with increased comorbidities, minimally invasive approaches confer a greater advantage. As females often fall within this category, it is paramount that the diagnosis and referral process be optimized to account for preoperative differences to provide the most beneficial approach if the disparity between the sexes is to be addressed.
Collapse
|
3
|
Sex difference in clinical outcomes of Chinese patients with atrial fibrillation and coronary stenting according to age. Anatol J Cardiol 2020; 25:17-23. [PMID: 33382053 DOI: 10.14744/anatoljcardiol.2020.80930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Sex differences in the clinical outcomes of patients with atrial fibrillation (AF) and coronary stenting should be assessed according to age. METHODS We analyzed the clinical data of all patients with nonvalvular AF who underwent coronary stenting between January 2010 and June 2015 in 12 hospitals of Beijing, China. RESULTS A total of 2,146 patients (71.8% men and 28.2% women) were included in the study. The mean age of the patients was 66.6±9.4 years. Women in this study were older and had higher prevalence of hypertension, diabetes, chronic kidney disease (CKD), and anemia. Smoking history was found to be higher in men, and women were less likely to be current smokers. The mean follow-up duration was 39.7 months. Women younger than 65 years had a remarkably higher mortality (11.2% vs. 5.3%, p=0.012) and a significantly lower rate of repeat revascularization (1.6% vs. 6.3%, p=0.034) than men. Female gender remained an independent predictor for all-cause mortality [hazard ratio (HR)=2.03, 95% confidence interval (CI): 1.09-3.79, p=0.025], along with heart failure (HR=3.64, 95% CI: 2.02-6.57, p<0.001) and CKD (HR=2.46, 95% CI: 1.09-5.57, p=0.031) after multivariate regression analysis. No significant difference was noted between men and women with regard to mortality, ischemic events, and major bleeding in elderly patients. CONCLUSION In Chinese patients younger than 65 years with AF and coronary stenting, female gender was independently associated with increased mortality; men were more likely to receive repeat revascularization possibly due to the current smoking. Whether it was a biological difference or a recognition disparity of the disease between men and women warrants further investigation.
Collapse
|
4
|
Whitehead AM, Maher NH, Goldstein K, Bean-Mayberry B, Duvernoy C, Davis M, Safdar B, Saechao F, Lee J, Frayne SM, Haskell SG. Sex Differences in Veterans' Cardiovascular Health. J Womens Health (Larchmt) 2019; 28:1418-1427. [DOI: 10.1089/jwh.2018.7228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Alison M. Whitehead
- Department of Veterans Affairs, Central Office, Washington, District of Columbia
| | - Nancy H. Maher
- Department of Veterans Affairs, Central Office, Washington, District of Columbia
| | - Karen Goldstein
- Durham VA and Duke University School of Medicine, Durham, North Carolina
| | - Bevanne Bean-Mayberry
- VA Greater Los Angeles and Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Claire Duvernoy
- VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, Michigan
| | - Melinda Davis
- Department of Medicine, Cardiology Clinic, University of Michigan, Ann Arbor, Michigan
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Fay Saechao
- VA Health Services Research and Development (HSR&D) Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Jimmy Lee
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Susan M. Frayne
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Sally G. Haskell
- Department of Veterans Affairs, Central Office, Washington, District of Columbia
- VA Connecticut Healthcare System and Yale University, West Haven, Connecticut
| |
Collapse
|
5
|
Kwok CS, Narain A, Pacha HM, Lo TS, Holroyd EW, Alraies MC, Nolan J, Mamas MA. Readmissions to Hospital After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Factors Associated with Readmissions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:375-391. [PMID: 31196797 DOI: 10.1016/j.carrev.2019.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/05/2019] [Accepted: 05/17/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Readmissions after PCI are a burden to patients and health services that are not well understood. METHODS A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. RESULTS A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%-15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6-50.4% at 12 months and 26.3-71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%-75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%-9.5%, 5.9%-12%, 6.7-38.1% and 0.7-7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20-1.30), I2 = 65.2%), diabetes (RR 1.22(1.20-1.25), I2 = 0%), heart failure (RR 1.43(CI 1.28-1.60), I2 = 92.8%), renal failure (RR 1.50(1.45-1.55), I2 = 0%), chronic lung disease (RR 1.34(1.26-1.44), I2 = 87.5%), peripheral artery disease (RR 1.20(1.15-1.25), I2 = 46.5%) and cancer (RR 1.35(1.15-1.58), I2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. CONCLUSIONS We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.
Collapse
Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Aditya Narain
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Ted S Lo
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit, MI, USA
| | - Jim Nolan
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
| |
Collapse
|
6
|
Affiliation(s)
- Janet K. Han
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, CA (J.K.H., R.E.)
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| | - Elizabeth M. Yano
- Veterans Affairs Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, CA (E.M.Y.)
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health (E.M.Y.)
| | - Karol E. Watson
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| | - Ramin Ebrahimi
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, CA (J.K.H., R.E.)
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| |
Collapse
|
7
|
Guo Y, Yin F, Fan C, Wang Z. Gender difference in clinical outcomes of the patients with coronary artery disease after percutaneous coronary intervention: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11644. [PMID: 30045311 PMCID: PMC6078653 DOI: 10.1097/md.0000000000011644] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Previous researches have reported the controversial results regarding the gender difference in clinical outcomes of patients with coronary artery disease after percutaneous coronary intervention. Hence, this systematic review and meta-analysis was designed to investigate whether gender difference existed in patients with coronary artery disease after percutaneous coronary intervention. METHODS PubMed, Embase, and the Cochrane Library database were searched up to February 10, 2018. Studies comparing the gender-specific effect on clinical outcomes of patients with coronary artery disease after percutaneous coronary intervention were identified, to analyze mortality, major adverse cardiovascular events (MACE) and revascularization. Statistical software RevMan was utilized in this meta-analysis. RESULTS A total of 49 studies, involving 1,032,828 patients (774,115 males and 258,713 females) reporting gender-specific outcomes, were included in this study. The in-hospital mortality, 30-day mortality, 1-year mortality, and at least 2-years mortality in male patients with coronary artery disease after percutaneous coronary intervention were significantly lower than those of females (odds ratio [OR] 0.58 95% confidence interval [CI] 0.52-0.63, P < .001; OR 0.64, 95% CI 0.61-0.66, P = .04; OR 0.67, 95% CI 0.60-0.75, P < .001 and OR 0.71, 95% CI 0.63-0.79, P = .005, respectively). The MACE was significantly decreased in male subjects after initial percutaneous coronary intervention compared with females in <1-year or at least 1-year (OR 0.67, 95% CI 0.56-0.80, P < .001 and OR 0.84, 95% CI 0.76-0.93, P < .001). The male patients after percutaneous coronary intervention harbored higher rate of revascularization compared with females for at least 1-year (OR 1.17, 95% CI 1.00-1.36, P < .001), while the rate of revascularization in male patients for < 1-year was lower than that of females (OR 0.93, 95% CI 0.69-1.26, P < .001). CONCLUSIONS The systematic review and meta-analysis suggests that the prognosis of male patients with coronary artery disease after percutaneous coronary intervention is better than that of females, except for long-term revascularization.
Collapse
Affiliation(s)
- Yaya Guo
- The First Medical Clinical College of Lanzhou University
| | - Fahui Yin
- The First Medical Clinical College of Lanzhou University
| | - Chunlei Fan
- The First Medical Clinical College of Lanzhou University
| | - Zhilu Wang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| |
Collapse
|
8
|
Gunja A, Stanislawski MA, Barón AE, Maddox TM, Bradley SM, Vidovich MI. The implications of cocaine use and associated behaviors on adverse cardiovascular outcomes among veterans: Insights from the VA Clinical Assessment, Reporting, and Tracking (CART) Program. Clin Cardiol 2018; 41:809-816. [PMID: 29652077 DOI: 10.1002/clc.22961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. HYPOTHESIS Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1-year all-cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. RESULTS 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08-1.39), MI (HR: 1.40, 95% CI: 1.07-1.83), and CVA (HR: 1.88, 95% CI: 1.38-2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. CONCLUSIONS Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.
Collapse
Affiliation(s)
- Ateka Gunja
- Division of Cardiology, University of Illinois at Chicago.,Division of Cardiology, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | | | - Anna E Barón
- University of Colorado School of Medicine, Aurora.,Colorado CV Health Care System, Denver, Colorado.,Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.,Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Steven M Bradley
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.,Minneapolis Heart Institute, Center for Healthcare Delivery Innovation, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota (work completed while at VA Eastern Colorado Health Care System)
| | - Mladen I Vidovich
- Division of Cardiology, University of Illinois at Chicago.,Division of Cardiology, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| |
Collapse
|
9
|
Sanner J, Grove ML, Yu E, Moeller FG, Cron SG, Boerwinkle E, Morrison AC, Frazier L. Effects of Gender-Specific Differences, Inflammatory Response, and Genetic Variation on the Associations Among Depressive Symptoms and the Risk of Major Adverse Coronary Events in Patients With Acute Coronary Syndrome. Biol Res Nurs 2018; 20:168-176. [PMID: 29298497 DOI: 10.1177/1099800417751662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Depressive symptoms independently contribute to major adverse coronary events (MACEs), with the biological immune response to depression being a likely mediator of this relationship. To determine whether genetic- and/or gender-specific phenotypic differences contribute to associations among depressive symptoms, inflammatory response, and risk of MACE in patients with acute coronary syndrome (ACS), we conducted a prospective study of 1,117 ACS patients to test a gender-specific model in which depressive symptoms (Beck Depression Inventory-II [BDI-II]) are associated with risk of MACE. Cox proportional hazards models were used to model time to incident MACE and determine whether single-nucleotide polymorphisms (SNPs) in specific inflammatory protein-coding genes and depressive symptoms interact to influence levels of inflammatory proteins or risk of MACE. Females had significantly higher high-sensitivity C-reactive protein and monocyte chemoattractant protein-1 levels. Depression status differed by gender (29.9% of females and 21.1% of males had BDI-II scores indicative of depression [ p = .0014]). Depressive symptoms were associated with MACE; however, the interaction between these symptoms and gender was not significant. SNPs and depressive symptoms did not interact to influence inflammation or MACE. More females than males had BDI-II scores indicative of depression, yet the association between positive depressive symptom status and MACE did not vary by gender. Nor did the SNPs interact with depressive symptoms to influence inflammation or MACE. It remains of interest to identify a high-risk subgroup of ACS patients with genetic polymorphisms that result in immunoinflammatory dysregulation in the presence of depressive symptoms.
Collapse
Affiliation(s)
- Jennifer Sanner
- 1 The University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, TX, USA.,These authors contributed equally to this work
| | - Megan L Grove
- 2 Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA.,These authors contributed equally to this work
| | - Erica Yu
- 1 The University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, TX, USA
| | | | - Stanley G Cron
- 4 Center for Nursing Research, The University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, TX, USA
| | - Eric Boerwinkle
- 2 Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA.,5 Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Alanna C Morrison
- 2 Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lorraine Frazier
- 1 The University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, TX, USA
| |
Collapse
|
10
|
Mrsic Z, Hulten E. Toward Gender Equality in Outcomes After Percutaneous Coronary Intervention. J Womens Health (Larchmt) 2017; 26:1043-1044. [PMID: 28745548 DOI: 10.1089/jwh.2017.6508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zorana Mrsic
- Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - Edward Hulten
- Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center , Bethesda, Maryland
| |
Collapse
|