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Choi HG, Kwon MJ, Kim JH, Kim SY, Kim JH, Park JY, Hwang YI, Jang SH. Association between asthma and cardiovascular diseases: A longitudinal follow-up study using a national health screening cohort. World Allergy Organ J 2024; 17:100907. [PMID: 38873616 PMCID: PMC11170141 DOI: 10.1016/j.waojou.2024.100907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/14/2024] [Accepted: 04/16/2024] [Indexed: 06/15/2024] Open
Abstract
Background Asthma has been suggested to be a risk factor for cardiovascular diseases (CVDs), although the evidence supporting this relationship is inconclusive. This study aimed to explore the long-term associations between asthma and asthma exacerbations with the occurrence of cardiovascular diseases (CVDs) such as ischemic heart disease (IHD), heart failure (HF), and cerebral stroke, utilizing data from a nationwide cohort. Materials and methods This study utilized data from the Korean National Health Insurance Service-Health Screening Cohort database (2002-2015), including information on 111,316 asthma patients and an equal number of 1:1 matched control participants. A propensity score overlap-weighted Cox proportional hazards regression model was used to analyze the overlap-weighted hazard ratios (HRs) of asthma and exacerbated asthma for cardiovascular diseases (CVDs) within this cohort. Results During the follow-up period, the incidence rate (IR) of IHD per 1000 person-years (PYs) was 7.82 in patients with asthma and 5.79 in controls. The IR of HF was 2.53 in asthmatic patients and 1.36 in controls. After adjustment for covariates, asthmatic patients exhibited 1.27-fold and 1.56-fold higher HRs for IHD (95% confidence interval (CI) = 1.23-1.37, P < 0.001) and HF (95% CI = 1.36-1.63, P < 0.001) than the controls, respectively. In addition, there was an increased HR for IHD and HF in the asthma exacerbation group compared with the nonexacerbated asthma group (adjusted HR, 1.29, 95% CI = 1.24-1.34, P < 0.001 for IHD and aHR 1.68, 95% CI = 1.58-1.79, P < 0.001 for HF). However, the occurrence of stroke was decreased in asthmatic patients compared with controls (aHR = 0.96, 95% CI = 0.93-0.99, P = 0.008). Conclusions Adults with asthma are more likely to develop CVDs. Additionally, severe asthma exacerbations are significantly associated with an increased occurrence of CVDs.
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Affiliation(s)
- Hyo Geun Choi
- Suseo Seoul E.N.T. Clinic and MD Analytics, Seoul, South Korea
| | - Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - So Young Kim
- Department of Otorhinolaryngology-Head & Neck Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Joo-Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - Ji Young Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - Yong Il Hwang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - Seung Hun Jang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
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Dou H, Wang R, Tavallaie M, Xiao T, Olszewska M, Papapetrou EP, Tall AR, Wang N. Hematopoietic and eosinophil-specific LNK(SH2B3) deficiency promotes eosinophilia and arterial thrombosis. Blood 2024; 143:1758-1772. [PMID: 38096361 DOI: 10.1182/blood.2023021055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/28/2023] [Accepted: 12/03/2023] [Indexed: 03/25/2024] Open
Abstract
ABSTRACT Increased eosinophil counts are associated with cardiovascular disease and may be an independent predictor of major cardiovascular events. However, the causality and underlying mechanisms are poorly understood. Genome-wide association studies have shown an association of a common LNK variant (R262W, T allele) with eosinophilia and atherothrombotic disorders. LNK(TT) reduces LNK function, and Lnk-deficient mice display accelerated atherosclerosis and thrombosis. This study was undertaken to assess the role of eosinophils in arterial thrombosis in mice with hematopoietic Lnk deficiency. Hematopoietic Lnk deficiency increased circulating and activated eosinophils, JAK/STAT signaling in eosinophils, and carotid arterial thrombosis with increased eosinophil abundance and extracellular trap formation (EETosis) in thrombi. Depletion of eosinophils by anti-Siglec-F antibody or by the ΔdbIGata1 mutation eliminated eosinophils in thrombi and markedly reduced thrombosis in mice with hematopoietic Lnk deficiency but not in control mice. Eosinophil depletion reduced neutrophil abundance and NETosis in thrombi without altering circulating neutrophil counts. To assess the role of Lnk specifically in eosinophils, we crossed Lnkf/f mice with eoCre mice. LnkΔeos mice displayed isolated eosinophilia, increased eosinophil activation, and accelerated arterial thrombosis associated with increased EETosis and NETosis in thrombi. DNase I infusion abolished EETs and neutrophil extracellular traps (NETs) in thrombi and reversed the accelerated thrombosis. Human induced pluripotent stem cell-derived LNK(TT) eosinophils showed increased activation and EETosis relative to isogenic LNK(CC) eosinophils, demonstrating human relevance. These studies show a direct link between eosinophilia, EETosis, and atherothrombosis in hematopoietic Lnk deficiency and an essential role of eosinophil LNK in suppression of arterial thrombosis.
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Affiliation(s)
- Huijuan Dou
- Molecular Medicine, Columbia University Medical Center, New York, NY
| | - Ranran Wang
- Molecular Medicine, Columbia University Medical Center, New York, NY
| | - Mojdeh Tavallaie
- Molecular Medicine, Columbia University Medical Center, New York, NY
| | - Tong Xiao
- Molecular Medicine, Columbia University Medical Center, New York, NY
| | - Malgorzata Olszewska
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Black Family Stem Cell Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Center for Advancement of Blood Cancer Therapies, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eirini P Papapetrou
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Black Family Stem Cell Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Center for Advancement of Blood Cancer Therapies, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alan R Tall
- Molecular Medicine, Columbia University Medical Center, New York, NY
| | - Nan Wang
- Molecular Medicine, Columbia University Medical Center, New York, NY
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Chen L, Li H, Liu X, Zhang N, Wang K, Shi A, Gao H, Akdis D, Saguner AM, Xu X, Osto E, Van de Veen W, Li G, Bayés-Genís A, Duru F, Song J, Li X, Hu S. PBX/Knotted 1 homeobox-2 (PKNOX2) is a novel regulator of myocardial fibrosis. Signal Transduct Target Ther 2024; 9:94. [PMID: 38644381 PMCID: PMC11033280 DOI: 10.1038/s41392-024-01804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 02/08/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
Much effort has been made to uncover the cellular heterogeneities of human hearts by single-nucleus RNA sequencing. However, the cardiac transcriptional regulation networks have not been systematically described because of the limitations in detecting transcription factors. In this study, we optimized a pipeline for isolating nuclei and conducting single-nucleus RNA sequencing targeted to detect a higher number of cell signal genes and an optimal number of transcription factors. With this unbiased protocol, we characterized the cellular composition of healthy human hearts and investigated the transcriptional regulation networks involved in determining the cellular identities and functions of the main cardiac cell subtypes. Particularly in fibroblasts, a novel regulator, PKNOX2, was identified as being associated with physiological fibroblast activation in healthy hearts. To validate the roles of these transcription factors in maintaining homeostasis, we used single-nucleus RNA-sequencing analysis of transplanted failing hearts focusing on fibroblast remodelling. The trajectory analysis suggested that PKNOX2 was abnormally decreased from fibroblast activation to pathological myofibroblast formation. Both gain- and loss-of-function in vitro experiments demonstrated the inhibitory role of PKNOX2 in pathological fibrosis remodelling. Moreover, fibroblast-specific overexpression and knockout of PKNOX2 in a heart failure mouse model induced by transverse aortic constriction surgery significantly improved and aggravated myocardial fibrosis, respectively. In summary, this study established a high-quality pipeline for single-nucleus RNA-sequencing analysis of heart muscle. With this optimized protocol, we described the transcriptional regulation networks of the main cardiac cell subtypes and identified PKNOX2 as a novel regulator in suppressing fibrosis and a potential therapeutic target for future translational studies.
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Affiliation(s)
- Liang Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Haotong Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Xiaorui Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Ningning Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Kui Wang
- School of Statistics and Data Science, Nankai University, Tianjin, China
| | - Anteng Shi
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Hang Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Deniz Akdis
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Xinjie Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Elena Osto
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Institute for Clinical Chemistry, University Hospital Zurich and University of Zürich, Zurich, Switzerland
| | - Willem Van de Veen
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Guangyu Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, CIBERCV, Spain
| | - Firat Duru
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jiangping Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China.
| | - Xiangjie Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China.
| | - Shengshou Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China.
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Schuermans A, Truong B, Ardissino M, Bhukar R, Slob EAW, Nakao T, Dron JS, Small AM, Cho SMJ, Yu Z, Hornsby W, Antoine T, Lannery K, Postupaka D, Gray KJ, Yan Q, Butterworth AS, Burgess S, Wood MJ, Scott NS, Harrington CM, Sarma AA, Lau ES, Roh JD, Januzzi JL, Natarajan P, Honigberg MC. Genetic Associations of Circulating Cardiovascular Proteins With Gestational Hypertension and Preeclampsia. JAMA Cardiol 2024; 9:209-220. [PMID: 38170504 PMCID: PMC10765315 DOI: 10.1001/jamacardio.2023.4994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/01/2023] [Indexed: 01/05/2024]
Abstract
Importance Hypertensive disorders of pregnancy (HDPs), including gestational hypertension and preeclampsia, are important contributors to maternal morbidity and mortality worldwide. In addition, women with HDPs face an elevated long-term risk of cardiovascular disease. Objective To identify proteins in the circulation associated with HDPs. Design, Setting, and Participants Two-sample mendelian randomization (MR) tested the associations of genetic instruments for cardiovascular disease-related proteins with gestational hypertension and preeclampsia. In downstream analyses, a systematic review of observational data was conducted to evaluate the identified proteins' dynamics across gestation in hypertensive vs normotensive pregnancies, and phenome-wide MR analyses were performed to identify potential non-HDP-related effects associated with the prioritized proteins. Genetic association data for cardiovascular disease-related proteins were obtained from the Systematic and Combined Analysis of Olink Proteins (SCALLOP) consortium. Genetic association data for the HDPs were obtained from recent European-ancestry genome-wide association study meta-analyses for gestational hypertension and preeclampsia. Study data were analyzed October 2022 to October 2023. Exposures Genetic instruments for 90 candidate proteins implicated in cardiovascular diseases, constructed using cis-protein quantitative trait loci (cis-pQTLs). Main Outcomes and Measures Gestational hypertension and preeclampsia. Results Genetic association data for cardiovascular disease-related proteins were obtained from 21 758 participants from the SCALLOP consortium. Genetic association data for the HDPs were obtained from 393 238 female individuals (8636 cases and 384 602 controls) for gestational hypertension and 606 903 female individuals (16 032 cases and 590 871 controls) for preeclampsia. Seventy-five of 90 proteins (83.3%) had at least 1 valid cis-pQTL. Of those, 10 proteins (13.3%) were significantly associated with HDPs. Four were robust to sensitivity analyses for gestational hypertension (cluster of differentiation 40, eosinophil cationic protein [ECP], galectin 3, N-terminal pro-brain natriuretic peptide [NT-proBNP]), and 2 were robust for preeclampsia (cystatin B, heat shock protein 27 [HSP27]). Consistent with the MR findings, observational data revealed that lower NT-proBNP (0.76- to 0.88-fold difference vs no HDPs) and higher HSP27 (2.40-fold difference vs no HDPs) levels during the first trimester of pregnancy were associated with increased risk of HDPs, as were higher levels of ECP (1.60-fold difference vs no HDPs). Phenome-wide MR analyses identified 37 unique non-HDP-related protein-disease associations, suggesting potential on-target effects associated with interventions lowering HDP risk through the identified proteins. Conclusions and Relevance Study findings suggest genetic associations of 4 cardiovascular disease-related proteins with gestational hypertension and 2 associated with preeclampsia. Future studies are required to test the efficacy of targeting the corresponding pathways to reduce HDP risk.
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Affiliation(s)
- Art Schuermans
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Buu Truong
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Maddalena Ardissino
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rohan Bhukar
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Eric A. W. Slob
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
- Department of Applied Economics, Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Erasmus University Rotterdam Institute for Behavior and Biology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Tetsushi Nakao
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jacqueline S. Dron
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Aeron M. Small
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - So Mi Jemma Cho
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zhi Yu
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Whitney Hornsby
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Tajmara Antoine
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Kim Lannery
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Darina Postupaka
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Kathryn J. Gray
- Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Qi Yan
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Adam S. Butterworth
- BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- BHF Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, United Kingdom
| | - Stephen Burgess
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Malissa J. Wood
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
- Lee Health, Fort Myers, Florida
| | - Nandita S. Scott
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Colleen M. Harrington
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Amy A. Sarma
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Emily S. Lau
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Jason D. Roh
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - James L. Januzzi
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Michael C. Honigberg
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
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