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Triska J, Maitra N, Deshotels MR, Haddadin F, Angiolillo DJ, Vilahur G, Jneid H, Atar D, Birnbaum Y. A Comprehensive Review of the Pleiotropic Effects of Ticagrelor. Cardiovasc Drugs Ther 2024; 38:775-797. [PMID: 36001200 DOI: 10.1007/s10557-022-07373-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/03/2022]
Abstract
AIMS This review summarizes the findings of preclinical studies evaluating the pleiotropic effects of ticagrelor. These include attenuation of ischemia-reperfusion injury (IRI), inflammation, adverse cardiac remodeling, and atherosclerosis. In doing so, it aims to provide novel insights into ticagrelor's mechanisms and benefits over other P2Y12 inhibitors. It also generates viable hypotheses for the results of seminal clinical trials assessing ticagrelor use in acute and chronic coronary syndromes. METHODS AND RESULTS A comprehensive review of the preclinical literature demonstrates that ticagrelor protects against IRI in the setting of both an acute myocardial infarction (MI), and when MI occurs while on chronic treatment. Maintenance therapy with ticagrelor also likely mitigates adverse inflammation, cardiac remodeling, and atherosclerosis, while improving stem cell recruitment. These effects are probably mediated by ticagrelor's ability to increase local interstitial adenosine levels which activate downstream cardio-protective molecules. Attenuation and augmentation of these pleiotropic effects by high-dose aspirin and caffeine, and statins respectively may help explain variable outcomes in PLATO and subsequent randomized controlled trials (RCTs). CONCLUSION Most RCTs and meta-analyses have not evaluated the pleiotropic effects of ticagrelor. We need further studies comparing cardiovascular outcomes in patients treated with ticagrelor versus other P2Y12 inhibitors that are mindful of the unique pleiotropic advantages afforded by ticagrelor, as well as possible interactions with other therapies (e.g., aspirin, statins, caffeine).
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Affiliation(s)
- Jeffrey Triska
- The Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Neil Maitra
- The Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Faris Haddadin
- The Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Gemma Vilahur
- Cardiovascular Program, Research Institute Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau, Barcelona, Spain
- CiberCV, Institute Carlos III, Madrid, Spain
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Dan Atar
- The Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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Oral anticoagulants and antiplatelet treatment in different settings. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:171-172. [PMID: 38563454 DOI: 10.1093/ehjcvp/pvae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
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Ning C, Ling F, Liu D, Zhi Z. Ticagrelor monotherapy after a short course of dual antiplatelet therapy with ticagrelor plus aspirin following percutaneous coronary intervention in patients with versus without diabetes mellitus: a meta-analysis of randomized trials. BMC Cardiovasc Disord 2024; 24:166. [PMID: 38504170 PMCID: PMC10949623 DOI: 10.1186/s12872-024-03836-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is one among the major causes of mortality all round the globe. Several anti-platelet regimens have been proposed following percutaneous coronary intervention (PCI). In this analysis, we aimed to show the adverse clinical outcomes associated with ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) with ticagrelor and aspirin following PCI in patients with versus without diabetes mellitus (DM). METHODS Electronic databases were searched by four authors from September to November 2023. Cardiovascular outcomes and bleeding events were the endpoints of this analysis. Revman 5.4 software was used to conduct this meta-analysis. Risk ratio (RR) and 95% confidence intervals (CI) were used to represent the results which were generated. RESULTS Three studies with a total number of 22,574 participants enrolled from years 2013 to 2019 were included in this analysis. Results of this analysis showed that DM was associated with significantly higher risks of major adverse cardiovascular events (RR: 1.73, 95% CI: 1.49 - 2.00; P = 0.00001), all-cause mortality (RR: 2.15, 95% CI: 1.73 - 2.66; P = 0.00001), cardiac death (RR: 2.82, 95% CI: 1.42 - 5.60; P = 0.003), stroke (RR: 1.78, 95% CI: 1.16 - 2.74; P = 0.009), myocardial infarction (RR: 1.63, 95% CI: 1.17 - 2.26; P = 0.004) and stent thrombosis (RR: 1.74, 95% CI: 1.03 - 2.94; P = 0.04) when compared to patients without DM. However, thrombolysis in myocardial infarction (TIMI) defined minor and major bleedings, bleeding defined according to the academic research consortium (BARC) type 3c (RR: 1.31, 95% CI: 0.14 - 11.90; P = 0.81) and BARC type 2, 3 or 5 (RR: 1.17, 95% CI: 0.85 - 1.62; P = 0.34) were not significantly different. CONCLUSION In patients who were treated with ticagrelor monotherapy after a short course of DAPT with ticagrelor and aspirin, DM was an independent risk factor for the significantly increased adverse cardiovascular outcomes. However, TIMI and BARC defined bleeding events were not significantly different in patients with versus without DM.
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Affiliation(s)
- Chen Ning
- Department of Cardiology, Shandong Tai An 88 Hospital, Shandong, Tai An, 271000, People's Republic of China
| | - Fang Ling
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Hubei, Yichang, 443000, People's Republic of China
| | - Deyi Liu
- Department of Cardiology, Shandong Tai An 88 Hospital, Shandong, Tai An, 271000, People's Republic of China
| | - Zhang Zhi
- Department of Cardiology, Shandong Tai An 88 Hospital, Shandong, Tai An, 271000, People's Republic of China.
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Hong SJ, Lee SJ, Suh Y, Yun KH, Kang TS, Shin S, Kwon SW, Lee JW, Cho DK, Park JK, Bae JW, Kang WC, Kim S, Lee YJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK. Stopping Aspirin Within 1 Month After Stenting for Ticagrelor Monotherapy in Acute Coronary Syndrome: The T-PASS Randomized Noninferiority Trial. Circulation 2024; 149:562-573. [PMID: 37878786 DOI: 10.1161/circulationaha.123.066943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Stopping aspirin within 1 month after implantation of a drug-eluting stent for ticagrelor monotherapy has not been exclusively evaluated for patients with acute coronary syndrome. The aim of this study was to investigate whether ticagrelor monotherapy after <1 month of dual antiplatelet therapy (DAPT) is noninferior to 12 months of ticagrelor-based DAPT for adverse cardiovascular and bleeding events in patients with acute coronary syndrome. METHODS In this randomized, open-label, noninferiority trial, 2850 patients with acute coronary syndrome who underwent drug-eluting stent implantation at 24 centers in South Korea were randomly assigned (1:1) to receive either ticagrelor monotherapy (90 mg twice daily) after <1 month of DAPT (n=1426) or 12 months of ticagrelor-based DAPT (n=1424) between April 24, 2019, and May 31, 2022. The primary end point was the net clinical benefit as a composite of all-cause death, myocardial infarction, definite or probable stent thrombosis, stroke, and major bleeding at 1 year after the index procedure in the intention-to-treat population. Key secondary end points were the individual components of the primary end point. RESULTS Among 2850 patients who were randomized (mean age, 61 years; 40% ST-segment-elevation myocardial infarction), 2823 (99.0%) completed the trial. Aspirin was discontinued at a median of 16 days (interquartile range, 12-25 days) in the group receiving ticagrelor monotherapy after <1 month of DAPT. The primary end point occurred in 40 patients (2.8%) in the group receiving ticagrelor monotherapy after <1-month DAPT, and in 73 patients (5.2%) in the ticagrelor-based 12-month DAPT group (hazard ratio, 0.54 [95% CI, 0.37-0.80]; P<0.001 for noninferiority; P=0.002 for superiority). This finding was consistent in the per-protocol population as a sensitivity analysis. The occurrence of major bleeding was significantly lower in the ticagrelor monotherapy after <1-month DAPT group compared with the 12-month DAPT group (1.2% versus 3.4%; hazard ratio, 0.35 [95% CI, 0.20-0.61]; P<0.001). CONCLUSIONS This study provides evidence that stopping aspirin within 1 month for ticagrelor monotherapy is both noninferior and superior to 12-month DAPT for the 1-year composite outcome of death, myocardial infarction, stent thrombosis, stroke, and major bleeding, primarily because of a significant reduction in major bleeding, among patients with acute coronary syndrome receiving drug-eluting stent implantation. Low event rates, which may suggest enrollment of relatively non-high-risk patients, should be considered in interpreting the trial. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03797651.
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Affiliation(s)
- Sung-Jin Hong
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Seung-Jun Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Yongsung Suh
- Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea (Y.S.)
| | | | - Tae Soo Kang
- Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea (T.S.K.)
| | - Sanghoon Shin
- Ewha Womans University College of Medicine Seoul Hospital, Korea (S.S.)
| | | | - Jun-Won Lee
- Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Korea (J.-W.L.)
| | - Deok-Kyu Cho
- Yongin Severance Hospital, Yonsei University College of Medicine, Korea (D.-K.C.)
| | - Jong-Kwan Park
- National Health Insurance Service Ilsan Hospital, Goyang, Korea (J.-K.P.)
| | - Jang-Whan Bae
- Chungbuk National University College of Medicine, Cheongju, Korea (J.-W.B.)
| | | | - Seunghwan Kim
- Inje University Haeundae Paik Hospital, Busan, Korea (S.K.)
| | - Yong-Joon Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Chul-Min Ahn
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Jung-Sun Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Byeong-Keuk Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Young-Guk Ko
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Donghoon Choi
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
| | - Yangsoo Jang
- CHA University College of Medicine, Seongnam, Korea (Y.J.)
| | - Myeong-Ki Hong
- Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (S.-J.H., S.-J.L., Y.-J.L., C.-M.A., J.-S.K., B.-K.K., Y.-G.K., D.C., M.-K.H.)
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Agewall S. Treating patients with anticoagulants and antiplatelet drugs is always a balance between risk for thrombosis vs. risk for bleeding. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:645-647. [PMID: 36172980 DOI: 10.1093/ehjcvp/pvac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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Xiang F, Lin Y, Chen B. Ticagrelor for patients undergoing coronary artery bypass grafting: A meta-analysis of randomized controlled trials. Perfusion 2022; 38:698-705. [PMID: 35403510 DOI: 10.1177/02676591221076284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Ticagrelor may be an alternative to aspirin as it provides robust and consistent platelet inhibition. However, the effect of ticagrelor treatment in patients undergoing coronary artery bypass grafting (CABG) has not been well confirmed. We conducted a meta-analysis to appraise whether ticagrelor therapy affects outcomes in CABG patients. METHODS We searched PubMed, Embase, EBSCO, and Cochrane databases from its inception up to 4 December 2020 for randomized controlled trials that assessed ticagrelor versus non-ticagrelor in patients undergoing CABG. The primary outcome was the incidence of saphenous vein graft (SVG) occlusion at 1 year after CABG. Secondary outcomes were SVG occlusion at 7 days, major adverse cardiovascular events (MACE), and bleeding requiring reoperation. RESULTS Seven trials including 4305 patients (2153 randomized to ticagrelor therapy and 2152 to non-ticagrelor therapy) were included. One-hundred and thirty of 1140 patients (11.4%) randomized to the ticagrelor group versus 175 of 1220 patients (14.3%) randomized to the non-ticagrelor group experienced SVG occlusion at 1 year after CABG. Compared to the control group, ticagrelor therapy yielded a significantly lower risk of SVG occlusion [RR 0.79 (0.64-0.97), p = 0.03]. In the subgroup analysis, ticagrelor plus aspirin compared with aspirin alone did not decrease the risk of SVG occlusion after 1 year [RR 0.65 (0.40-1.07), p = 0.09]. There was no difference in the incidence of SVG occlusion at 7 days [RR 0.67 (0.42-1.06), p = 0.09], MACE up to 1 year [RR 0.99 (0.81-1.21), p = 0.90], or bleeding requiring reoperation [RR 1.16 (0.80-1.70), p = 0.44]. CONCLUSIONS Compared with non-ticagrelor therapy, ticagrelor decreased the risk of saphenous vein graft occlusion after 1 year in patients undergoing elective CABG with saphenous vein grafting.
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Affiliation(s)
- Feng Xiang
- Department of Pharmacy, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yifeng Lin
- Department of Pharmacy, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Binwu Chen
- Department of Pharmacy, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Outcomes of prolonged dual anti-platelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A nationwide registry-based study. Am Heart J 2022; 245:81-89. [PMID: 34902311 DOI: 10.1016/j.ahj.2021.11.018] [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: 01/12/2021] [Revised: 09/29/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Randomized controlled trials have shown a reduced risk of ischemic events and an increased risk of bleeding in patients treated with prolonged dual anti-platelet therapy (DAPT) beyond 12 months following acute coronary syndrome (ACS). We aimed to investigate outcomes of prolonged DAPT vs aspirin monotherapy (ASA) in a real-world population. METHODS AND RESULTS Using nationwide registries, we identified all patients with ACS who underwent percutaneous coronary intervention and received 12-month DAPT between January 2013 and October 2016. Patients still on DAPT were compared to patients on ASA at index date (15 months after ACS-date) and followed for up to 2 years. Cox regression models were employed to calculate standardized risks of all-cause mortality, major adverse cardiovascular event (MACE), and major bleeding. The study included 7,449 patients, 1,901 on DAPT (median age 66, 72.1% male) and 5,548 on ASA (median age 65, 75.1% male). Standardized absolute 2-year risk of all-cause mortality, MACE, and major bleeding was 2.7%, 3.7%, and 5.4% for DAPT vs 2.2%, 3.8%, and 1.3% for ASA. DAPT was not associated with a significant standardized 2-year risk difference (SRD) of all-cause mortality (SRD: 0.5%, 95% confidence interval [CI]: -0.9 to 1.7) or MACE (SRD: -0.1%, 95% CI -1.8 to 1.6), but a significantly higher risk of major bleeding (SRD: 4.1%, 95% CI 1.8-6.6). CONCLUSIONS In a nationwide cohort of ACS patients undergoing percutaneous coronary intervention, prolonged DAPT was not significantly associated with a reduced risk of all-cause mortality or MACE, but an increased risk of major bleeding. Future randomized controlled trials should investigate the optimal anti-platelet regimen in this patient group.
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Wang R, Wu S, Gamal A, Gao C, Hara H, Kawashima H, Ono M, van Geuns RJ, Vranckx P, Windecker S, Onuma Y, Serruys PW, Garg S. Aspirin-free antiplatelet regimens after PCI: insights from the GLOBAL LEADERS trial and beyond. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:547-556. [PMID: 33930107 PMCID: PMC8566303 DOI: 10.1093/ehjcvp/pvab035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 01/16/2023]
Abstract
Historically, aspirin has been the primary treatment for the prevention of ischaemic events in patients with coronary artery disease. For patients undergoing percutaneous coronary intervention (PCI) standard treatment has been 12 months of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, followed by aspirin monotherapy; however, DAPT is undeniably associated with an increased risk of bleeding. For over a decade novel P2Y12 inhibitors, which have increased specificity, potency, and efficacy have been available, prompting studies which have tested whether these newer agents can be used in aspirin-free antiplatelet regimens to augment clinical benefits in patients post-PCI. Among these studies, the GLOBAL LEADERS trial is the largest by cohort size, and so far has provided a wealth of evidence in a variety of clinical settings and patient groups. This article summarizes the state-of-the-art evidence obtained from the GLOBAL LEADERS and other trials of aspirin-free strategies.
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Affiliation(s)
- Rutao Wang
- Department of Cardiology, Xijing hospital, Xi'an, China.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sijing Wu
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of cardiology, Beijing Anzhen hospital, Beijing, China.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Amr Gamal
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, North Cumbria University Hospitals NHS Trust, England, United Kingdom.,Department of Cardiology, Zagazig University, Egypt
| | - Chao Gao
- Department of Cardiology, Xijing hospital, Xi'an, China.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert-Jan van Geuns
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium.,Faculty of medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Imperial College London, London, United Kingdom
| | - Scot Garg
- East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, United Kingdom
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