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Zulet P, Islas F, Ferrández-Escarabajal M, Bustos A, Cabeza B, Gil-Abizanda S, Vidal M, Martín-Lores I, Hernández-Mateo P, de Agustín JA, Olmos C. Diabetes mellitus is associated to high-risk late gadolinium enhancement and worse outcomes in patients with nonischemic dilated cardiomyopathy. Cardiovasc Diabetol 2024; 23:35. [PMID: 38245750 PMCID: PMC10800059 DOI: 10.1186/s12933-024-02127-z] [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: 10/10/2023] [Accepted: 01/08/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with a worse prognosis in patients with heart failure. Our aim was to analyze the clinical and imaging features of patients with DM and their association with outcomes in comparison to nondiabetic patients in a cohort of patients with nonischemic dilated cardiomyopathy (DCM). METHODS This is a prospective cohort study of patients with DCM evaluated in a tertiary care center from 2018 to 2021. Transthoracic echocardiography and cardiac magnetic resonance findings were assessed. A high-risk late gadolinium enhancement (LGE) pattern was defined as epicardial, transmural, or septal plus free-wall. The primary outcome was a composite of heart failure hospitalizations and all-cause mortality. Multivariable analyses were performed to evaluate the impact of DM on outcomes. RESULTS We studied 192 patients, of which 51 (26.6%) had DM. The median left ventricular ejection fraction was 30%, and 106 (55.2%) had LGE. No significant differences were found in systolic function parameters between patients with and without DM. E/e values were higher (15 vs. 11.9, p = 0.025), and both LGE (68.6% vs. 50.4%; p = 0.025) and a high-risk LGE pattern (31.4% vs. 18.5%; p = 0.047) were more frequently found in patients with DM. The primary outcome occurred more frequently in diabetic patients (41.2% vs. 23.6%, p = 0.017). DM was an independent predictor of outcomes (OR 2.01; p = 0.049) and of LGE presence (OR 2.15; p = 0.048) in the multivariable analysis. Patients with both DM and LGE had the highest risk of events (HR 3.1; p = 0.003). CONCLUSION DM is related to a higher presence of LGE in DCM patients and is an independent predictor of outcomes. Patients with DM and LGE had a threefold risk of events. A multimodality imaging approach allows better risk stratification of these patients and may influence therapeutic options.
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Affiliation(s)
- Pablo Zulet
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), C/Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Fabián Islas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), C/Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Marcos Ferrández-Escarabajal
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), C/Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Ana Bustos
- Servicio de Diagnóstico por la Imagen, Hospital Clínico San Carlos, Madrid, Spain
| | - Beatriz Cabeza
- Servicio de Diagnóstico por la Imagen, Hospital Clínico San Carlos, Madrid, Spain
| | - Sandra Gil-Abizanda
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), C/Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - María Vidal
- Servicio de Diagnóstico por la Imagen, Hospital Clínico San Carlos, Madrid, Spain
| | - Irene Martín-Lores
- Servicio de Diagnóstico por la Imagen, Hospital Clínico San Carlos, Madrid, Spain
| | | | - J Alberto de Agustín
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), C/Profesor Martín Lagos s/n, Madrid, 28040, Spain
| | - Carmen Olmos
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), C/Profesor Martín Lagos s/n, Madrid, 28040, Spain.
- Universidad Europea de Madrid, Madrid, Spain.
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Gao Y, Shi R, Li Y, Guo YK, Xu HY, Shi K, Yang ZG. Association of diabetes mellitus and glycemic control with left ventricular function and deformation in patients after acute myocardial infarction: a 3 T cardiac magnetic resonance study. Cardiovasc Diabetol 2023; 22:55. [PMID: 36906549 PMCID: PMC10008587 DOI: 10.1186/s12933-023-01785-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/25/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is considered a major risk factor for myocardial infarction (MI), and MI patients with DM have a poor prognosis. Accordingly, we aimed to investigate the additive effects of DM on LV deformation in patients after acute MI. MATERIALS AND METHODS One hundred thirteen MI patients without DM [MI (DM-)], 95 with DM [MI (DM+)] and 71 control subjects who underwent CMRscanning were included. LV function, infarct size and LV global peak strains in the radial, circumferential and longitudinal directions were measured. MI (DM+) patients were divided into two subgroups based on the HbA1c level (< 7.0% and ≥ 7.0%). The determinants of reduced LV global myocardial strain for all MI patients and MI (DM+) patients were assessed using multivariable linear regression analyses. RESULTS Compared with control subjects, both MI (DM-) and MI (DM+) patients presented higher LV end-diastolic and end-systolic volume index and lower LV ejection fraction. LV global peak strains progressively declined from the control group to the MI(DM-) group to the MI(DM+) group (all p < 0.05). Subgroup analysis showed that LV global radial PS and longitudinal PS were worse in MI(MD+) patients with poor glycemic control than in those with good glycemic control (all p < 0.05). DM was an independent determinant of impaired LV global peak strain in radial, circumferential and longitudinal directions in patients after acute MI (β = - 0.166, 0.164 and 0.262, both p < 0.05). The HbA1c level was independently associated with a decreased LV global radial PS (β = - 0.209, p = 0.025) and longitudinal PS (β = 0.221, p = 0.010) in MI (DM+) patients. CONCLUSIONS DM has an additive deleterious effect on LV function and deformation in patients after acute MI, and HbA1c was independently associated with impaired LV myocardial strain.
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Affiliation(s)
- Yue Gao
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Rui Shi
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ke Shi
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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Brown LAE, Wahab A, Ikongo E, Saunderson CED, Jex N, Thirunavukarasu S, Chowdhary A, Das A, Craven TP, Levelt E, Dall’Armellina E, Knott KD, Greenwood JP, Moon JC, Xue H, Kellman P, Plein S, Swoboda PP. Cardiovascular magnetic resonance phenotyping of heart failure with mildly reduced ejection fraction. Eur Heart J Cardiovasc Imaging 2022; 24:38-45. [PMID: 36285884 PMCID: PMC9762938 DOI: 10.1093/ehjci/jeac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 09/14/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS The 2016 European Society of Cardiology Heart Failure Guidelines defined a new category: heart failure with mid-range ejection fraction (HFmrEF) of 40-49%. This new category was highlighted as having limited evidence and research was advocated into underlying characteristics, pathophysiology, and diagnosis. We used multi-parametric cardiovascular magnetic resonance (CMR) to define the cardiac phenotype of presumed non-ischaemic HFmrEF. METHODS AND RESULTS Patients (N = 300, 62.7 ± 13 years, 63% males) with a clinical diagnosis of heart failure with no angina symptoms, history of myocardial infarction, or coronary intervention were prospectively recruited. Patients underwent clinical assessment and CMR including T1 mapping, extracellular volume (ECV) mapping, late gadolinium enhancement, and measurement of myocardial blood flow at rest and maximal hyperaemia. Of 273 patients in the final analysis, 93 (34%) patients were categorized as HFmrEF, 46 (17%) as heart failure with preserved ejection fraction (HFpEF), and 134 (49%) as heart failure with reduced ejection fraction (HFrEF). Nineteen (20%) patients with HFmrEF had evidence of occult ischaemic heart disease. Diffuse fibrosis and hyperaemic myocardial blood flow were similar in HFmrEF and HFpEF, but HFmrEF showed significantly lower native T1 (1311 ± 32 vs. 1340 ± 45 ms, P < 0.001), ECV (24.6 ± 3.2 vs. 26.3 ± 3.1%, P < 0.001), and higher myocardial perfusion reserve (2.75 ± 0.84 vs. 2.28 ± 0.84, P < 0.001) compared with HFrEF. CONCLUSION Patients with HFmrEF share most phenotypic characteristics with HFpEF, including the degree of microvascular impairment and fibrosis, but have a high prevalence of occult ischaemic heart disease similar to HFrEF. Further work is needed to confirm how the phenotype of HFmrEF responds to medical therapy.
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Affiliation(s)
- Louise A E Brown
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Ali Wahab
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Eunice Ikongo
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Chirstopher E D Saunderson
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Nicholas Jex
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Sharmaine Thirunavukarasu
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Arka Das
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Thomas P Craven
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Erica Dall’Armellina
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - Kristopher D Knott
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
| | - James C Moon
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD, USA
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD, USA
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
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Simple Predictors for Cardiac Fibrosis in Patients with Type 2 Diabetes Mellitus: The Role of Circulating Biomarkers and Pulse Wave Velocity. J Clin Med 2022; 11:jcm11102843. [PMID: 35628969 PMCID: PMC9147134 DOI: 10.3390/jcm11102843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 12/29/2022] Open
Abstract
Cardiac fibrosis is the basis of structural and functional disorders in patients with diabetes mellitus (T2DM). A wide range of laboratory and instrumental methods is used for its prediction. The study aimed to identify simple predictors of cardiac fibrosis in patients with T2DM based on the analysis of circulating fibrosis biomarkers and arterial stiffness. The study included patients with T2DM (n = 37) and cardiovascular risk factors (RF, n = 27) who underwent ECHO, cardiac magnetic resonance imaging (MRI), pulse wave analysis (PWV), reactive hyperemia (RH), peripheral arterial tonometry, carotid ultrasonography, and assessment of serum fibrosis biomarkers. As a control group, 15 healthy subjects were examined. Left ventricular concentric hypertrophy was accompanied by an increased serum galectin-3 level in T2DM patients. There was a relationship between the PICP and HbA1c levels in both main groups (R2 = 0.309; p = 0.014). A negative correlation between PICP level and the global longitudinal strain (GLS) was found (r = −0.467; p = 0.004). The RH index had a negative correlation with the duration of diabetes (r = −0.356; p = 0.03), the carotid-femoral PWV (r = −0.371; p = 0.024), and the carotid intima-media thickness (r = −0.622; p < 0.001). The late gadolinium-enhanced (LGE) cardiac MRI was detected in 22 (59.5%) T2DM and in 4 (14.85%) RF patients. Diabetes, its baseline treatment with metformin, HbA1c and serum TIMP-1 levels, and left ventricle hypertrophy had moderate positive correlations with LGE findings (p < 0.05). Using the multivariate regression analysis, increased TIMP-1 level was identified as an independent factor associated with cardiac fibrosis.
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Fyyaz S, Papadakis M. Arrhythmogenesis of Sports: Myth or Reality? Arrhythm Electrophysiol Rev 2022; 11:e05. [PMID: 35734145 PMCID: PMC9194918 DOI: 10.15420/aer.2021.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/17/2022] [Indexed: 11/09/2022] Open
Abstract
Regular exercise confers health benefits with cardiovascular mortality risk reduction through a variety of mechanisms. At a population level, evidence suggests that undertaking more exercise has greater benefits. In the modern era of sport, there has been an exponential rise in professional and amateur athletes participating in endurance events, with a progressively better understanding of the associated cardiac adaptations, collectively termed ‘athletes heart’. However, emerging data raise questions regarding the risk of potential harm from endurance exercise, with an increased risk of arrhythmia from adverse cardiac remodelling. Cross-sectional studies have demonstrated that athletes may exhibit a higher burden of AF, conduction tissue disease, ventricular arrhythmias, a cardiomyopathy-like phenotype and coronary artery disease. In an attempt to separate myth from reality, this review reports on the evidence supporting the notion of ‘too much exercise’, the purported mechanisms of exercise-induced cardiac arrhythmia and complex interplay with sporting discipline, demographics, genetics and acquired factors.
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Affiliation(s)
- Saad Fyyaz
- Cardiovascular Clinical Academic Group, St George's, University of London, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St George's, University of London, St George's University Hospitals NHS Foundation Trust, London, UK
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Yang Z, Xu R, Wang JR, Xu HY, Fu H, Xie LJ, Yang MX, Zhang L, Wen LY, Liu H, Li H, Yang ZG, Guo YK. Association of myocardial fibrosis detected by late gadolinium-enhanced MRI with clinical outcomes in patients with diabetes: a systematic review and meta-analysis. BMJ Open 2022; 12:e055374. [PMID: 35017252 PMCID: PMC8753417 DOI: 10.1136/bmjopen-2021-055374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This meta-analysis assessed the associations of myocardial fibrosis detected by late gadolinium-enhanced (LGE)-MRI with the risk of major adverse cardiac and cerebrovascular events (MACCEs) and major adverse cardiac events (MACEs) in patients with diabetes. DESIGN Systematic review and meta-analysis reported in accordance with the guidelines of the Meta-analysis of Observational Studies in Epidemiology statement. DATA SOURCES We searched the Medline, Embase and Cochrane by Ovid databases for studies published up to 27 August 2021. ELIGIBILITY CRITERIA Prospective or respective cohort studies were included if they reported the HR and 95% CIs for MACCEs/MACEs in patients with either type 1 or 2 diabetes and LGE-MRI-detected myocardial fibrosis compared with patients without LGE-MRI-detected myocardial fibrosis and if the articles were published in the English language. DATA EXTRACTION AND SYNTHESIS Two review authors independently extracted data and assessed the quality of the included studies. Pooled HRs and 95% CIs were analysed using a random effects model. Heterogeneity was assessed using forest plots and I2 statistics. RESULTS Eight studies with 1121 patients with type 1 or type 2 diabetes were included in this meta-analysis, and the follow-up ranged from 17 to 70 months. The presence of myocardial fibrosis detected by LGE-MRI was associated with an increased risk for MACCEs (HR: 2.58; 95% CI 1.42 to 4.71; p=0.002) and MACEs (HR: 5.28; 95% CI 3.20 to 8.70; p<0.001) in patients with diabetes. Subgroup analysis revealed that ischaemic fibrosis detected by LGE was associated with MACCEs (HR 3.80, 95% CI 2.38 to 6.07; p<0.001) in patients with diabetes. CONCLUSIONS This study demonstrated that ischaemic myocardial fibrosis detected by LGE-MRI was associated with an increased risk of MACCEs/MACEs in patients with diabetes and may be an imaging biomarker for risk stratification. Whether LGE-MRI provides incremental prognostic information with respect to MACCEs/MACEs over risk stratification by conventional cardiovascular risk factors requires further study.
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Affiliation(s)
- Zhi Yang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
- Department of Radiology, Chengdu Fifth People's Hospital, Chengdu, Sichuan, China
| | - Rong Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Jia-Rong Wang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Hang Fu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Ling-Jun Xie
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Meng-Xi Yang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Lu Zhang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Ling-Yi Wen
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Hui Liu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Hong Li
- Key Laboratory of Obstetrics & Gynecology and Pediatric Disease and Birth Defects of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Zhi-Gang Yang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
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Joseph JJ, Deedwania P, Acharya T, Aguilar D, Bhatt DL, Chyun DA, Di Palo KE, Golden SH, Sperling LS. Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association. Circulation 2022; 145:e722-e759. [PMID: 35000404 DOI: 10.1161/cir.0000000000001040] [Citation(s) in RCA: 191] [Impact Index Per Article: 95.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.
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Laohabut I, Songsangjinda T, Kaolawanich Y, Yindeengam A, Krittayaphong R. Myocardial Extracellular Volume Fraction and T1 Mapping by Cardiac Magnetic Resonance Compared Between Patients With and Without Type 2 Diabetes, and the Effect of ECV and T2D on Cardiovascular Outcomes. Front Cardiovasc Med 2021; 8:771363. [PMID: 34950715 PMCID: PMC8688762 DOI: 10.3389/fcvm.2021.771363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/01/2021] [Indexed: 01/16/2023] Open
Abstract
Background: To investigate the difference in myocardial extracellular volume fraction (ECV) by cardiac magnetic resonance (CMR) T1 mapping between patients with and without type 2 diabetes (T2D), and the effect of ECV and T2D on cardiovascular (CV) outcomes. Methods: All patients aged > 18 years with known or suspected coronary artery disease who underwent CMR for assessment of myocardial ischemia or myocardial viability at the Department of Cardiology of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from September 2017 to December 2018 were screened for inclusion eligibility. Left ventricular ejection fraction (LVEF), late gadolinium enhancement, and T1 mapping were performed. ECV values were derived from myocardial native T1 and contrast-enhanced T1 values that were obtained using modified Look-Locker inversion recovery at the septum of the mid-cavity short-axis map. Demographic data, clinical characteristics, and CV outcomes were collected by retrospective chart review. Composite CV outcomes included CV death, acute coronary syndrome, heart failure hospitalization, or ventricular tachycardia (VT)/ventricular fibrillation. Results: A total of 739 subjects (mean age: 69.5 ± 14.0 years, 49.3% men) were included. Of those, 188 subjects had T2D (25.4%). ECV was significantly higher in T2D than in non-T2D (30.0 ± 5.9% vs. 28.8 ± 4.7%, p = 0.004). During the mean follow-up duration of 26.2 ± 8.5 months, 43 patients (5.8%) had a clinical composite outcome, as follows: three CV death (0.4%), seven acute coronary syndrome (0.9%), 33 heart failure hospitalization (4.5%), and one VT (0.1%). T2D, low LVEF, and high ECV were all identified as independent predictors of CV events. Patients with T2D and high ECV had the highest risk of CV events. Conclusion: Among patients with known or suspected coronary artery disease, patients with T2D had a higher ECV. T2D and high ECV were both found to be independent risk factors for adverse CV outcomes.
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Affiliation(s)
- Issarayus Laohabut
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thammarak Songsangjinda
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yodying Kaolawanich
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ahthit Yindeengam
- Faculty of Medicine Siriraj Hospital, Her Majesty Cardiac Center, Mahidol University, Bangkok, Thailand
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. Arch Cardiovasc Dis 2020; 114:150-172. [PMID: 33309203 DOI: 10.1016/j.acvd.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
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Bojer AS, Sørensen MH, Vejlstrup N, Goetze JP, Gæde P, Madsen PL. Distinct non-ischemic myocardial late gadolinium enhancement lesions in patients with type 2 diabetes. Cardiovasc Diabetol 2020; 19:184. [PMID: 33092588 PMCID: PMC7583253 DOI: 10.1186/s12933-020-01160-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/14/2020] [Indexed: 01/20/2023] Open
Abstract
Background Cardiovascular magnetic resonance imaging (CMR) have described localised non-ischemic late gadolinium enhancement (LGE) lesions of prognostic importance in various non-ischemic cardiomyopathies. Ischemic LGE lesions are prevalent in diabetes (DM), but non-ischemic LGE lesions have not previously been described or systematically studied in DM. Methods 296 patients with type 2 DM (T2DM) and 25 sex-matched control subjects underwent echocardiography and CMR including adenosine-stress perfusion, T1-mapping and LGE. Results 264 patients and all control subjects completed the CMR protocol. 78.4% of patients with T2DM had no LGE lesions; 11.0% had ischemic LGE lesions only; 9.5% had non-ischemic LGE lesions only; and 1.1% had both one ischemic and one non-ischemic lesion. The non-ischemic LGE lesions were situated mid-myocardial in the basal lateral or the basal inferolateral part of the left ventricle and the affected segments showed normal to high wall thickness and normal contraction. Patients with non-ischemic LGE lesions in comparison with patients without LGE lesions had increased myocardial mass (150 ± 34 vs. 133 ± 33 g, P = 0.02), average E/e’(9.9 IQR8.7–12.6 vs. 8.8 IQR7.4–10.7, P = 0.04), left atrial maximal volume (102 IQR84.6–115.2 vs. 91 IQR75.2–100.0 mL, P = 0.049), NT-proBNP (8.9 IQR5.9–19.7 vs. 5.9 IQR5.9–10.1 µmol/L, P = 0.02) and high-sensitive troponin (15.6 IQR13.0–26.1 vs. 13.0 IQR13.0–14.6 ng/L, P = 0.007) and a higher prevalence of retinopathy (48 vs. 25%, P = 0.009) and autonomic neuropathy (52 vs. 30.5%, P = 0.005). Conclusion A specific LGE pattern with lesions in the basal lateral or the basal inferolateral part of the left ventricle was found in patients with type 2 diabetes. Trial registrationhttps://www.clinicaltrials.gov. Unique identifier: NCT02684331.
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Affiliation(s)
- Annemie Stege Bojer
- Department of Cardiology and Endocrinology, Slagelse Hospital, Ingemannsvej 32, 4200, Slagelse, Region Zealand, Denmark. .,Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Martin Heyn Sørensen
- Department of Cardiology and Endocrinology, Slagelse Hospital, Ingemannsvej 32, 4200, Slagelse, Region Zealand, Denmark.,Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Peter Gæde
- Department of Cardiology and Endocrinology, Slagelse Hospital, Ingemannsvej 32, 4200, Slagelse, Region Zealand, Denmark.,Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Per Lav Madsen
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Capital Region of Denmark, Herlev-Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Valensi P, Henry P, Boccara F, Cosson E, Prevost G, Emmerich J, Ernande L, Marcadet D, Mousseaux E, Rouzet F, Sultan A, Ferrières J, Vergès B, Van Belle E. Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. DIABETES & METABOLISM 2020; 47:101185. [PMID: 32846201 DOI: 10.1016/j.diabet.2020.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Paul Valensi
- Unit of Endocrinology Diabetology Nutrition, AP-HP, Jean Verdier hospital, CINFO, CRNH-IdF, Paris 13 University, Sorbonne Paris Cité, Bondy, France
| | - Patrick Henry
- Department of Cardiology, Inserm U942, Lariboisiere Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris, Paris, France.
| | - Franck Boccara
- AP-HP, Hôpitaux de l'Est Parisien, Hôpital Saint-Antoine, Department of Cardiology, Sorbonne Université-Inserm UMR S_938, Centre de Recherche Saint-Antoine, Paris, France
| | - Emmanuel Cosson
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, UMR U557 Inserm/U11125 INRAE/CNAM/Université Paris13, Unité de Recherche Epidémiologique Nutritionnelle, Bobigny, France
| | - Gaetan Prevost
- Department of Endocrinology, Diabetes and Metabolic Diseases, Normandie Univ, UNIROUEN, Rouen University Hospital, Centre d'Investigation Clinique (CIC-CRB)-Inserm 1404, Rouen University Hospital, 76000 Rouen, France
| | - Joseph Emmerich
- Service de Médecine Vasculaire, Groupe Hospitalier Paris Saint-Joseph, Université de Paris, Inserm UMR1153-CRESS, 75674 Paris cedex 14, France
| | - Laura Ernande
- Service des explorations fonctionnelles, Hôpital Henri Mondor, AP-HP et Inserm U955, Université Paris-Est Créteil, France
| | - Dany Marcadet
- Centre Coeur et Santé Bernoulli - Cardiologie du sport et Réadaptation Cardiaque, 3, rue Bernoulli, 75008 Paris, France
| | - Elie Mousseaux
- Radiology Department, Hôpital Européen Georges Pompidou & Inserm U 970; Assistance Publique - Hôpitaux de Paris, University of Paris, French Society of Cardiovascular Imaging (SFICV), Paris, France
| | - François Rouzet
- Nuclear Medicine Department, Bichat Hospital, AP-HP Paris - Université de Paris, Laboratory for Vascular Translational Science, Inserm, UMR 1148, 75018 Paris, France
| | - Ariane Sultan
- Physiologie et Médecine Expérimentale du Coeur et des Muscles (PHYMEDEX), U1046 Inserm, UMR9214 CNRS, Université de Montpellier, 34295 Montpellier; Département Endocrinologie, Nutrition, Diabète, Equipe Nutrition, Diabète, CHRU Montpellier, 34090 Montpellier, France
| | - Jean Ferrières
- Department of Cardiology and UMR Inserm 1027, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Bruno Vergès
- Service Endocrinologie-Diabétologie, CHU Dijon - Inserm LNC-UMR 1231, Dijon, France
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France; Inserm, U1011, Institut Pasteur de Lille, EGID, Lille, France; Department of Medicine, Université de Lille, Lille, France
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12
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Schmacht L, Traber J, Grieben U, Utz W, Dieringer MA, Kellman P, Blaszczyk E, von Knobelsdorff-Brenkenhoff F, Spuler S, Schulz-Menger J. Cardiac Involvement in Myotonic Dystrophy Type 2 Patients With Preserved Ejection Fraction: Detection by Cardiovascular Magnetic Resonance. Circ Cardiovasc Imaging 2017; 9:CIRCIMAGING.115.004615. [PMID: 27363857 DOI: 10.1161/circimaging.115.004615] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 05/24/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Myotonic dystrophy type 2 (DM2) is a genetic disorder characterized by skeletal muscle symptoms, metabolic changes, and cardiac involvement. Histopathologic alterations of the skeletal muscle include fibrosis and fatty infiltration. The aim of this study was to investigate whether subclinical cardiac involvement in DM2 is already detectable in preserved left ventricular function by cardiovascular magnetic resonance. METHODS AND RESULTS Twenty-seven patients (mean age, 54±10 years; 20 females) with a genetically confirmed diagnosis of DM2 were compared with 17 healthy age- and sex-matched controls using a 1.5 T magnetic resonance imaging. For myocardial tissue differentiation, T1 and T2 mapping, fat/water-separated imaging, focal fibrosis imaging (late gadolinium enhancement [LGE]), and (1)H magnetic resonance spectroscopy were performed. Extracellular volume fraction was calculated. Conduction abnormalities were diagnosed based on Groh criteria. LGE located subepicardial basal inferolateral was detectable in 22% of the patients. Extracellular volume was increased in this region and in the adjacent medial inferolateral segment (P=0.03 compared with healthy controls). In 21% of patients with DM2, fat deposits were detectable (all women). The control group showed no abnormalities. Myocardial triglycerides were not different in LGE-positive and LGE-negative subjects (P=0.47). Six patients had indicators for conduction disease (60% of LGE-positive patients and 12.5% of LGE-negative patients). CONCLUSIONS In DM2, subclinical myocardial injury was already detectable in preserved left ventricular ejection fraction. Extracellular volume was also increased in regions with no focal fibrosis. Myocardial fibrosis was related to conduction abnormalities.
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Affiliation(s)
- Luisa Schmacht
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Julius Traber
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Ulrike Grieben
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Wolfgang Utz
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Matthias A Dieringer
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Peter Kellman
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Edyta Blaszczyk
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Florian von Knobelsdorff-Brenkenhoff
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Simone Spuler
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.)
| | - Jeanette Schulz-Menger
- From the Working Group on Cardiovascular Magnetic Resonance, Experimental, and Clinical Research Center, a joint cooperation between the Charité University Medicine Berlin and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Germany (L.S., J.T., W.U., M.A.D., E.B., F.v.K.-B., J.S.-M.); DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (L.S., F.v.K.-B, J.S.-M.); Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany (U.G., S.S.); and Laboratory of Cardiac Energetics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.K.).
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