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Sullivan S, Hammadah M, Al Mheid I, Wilmot K, Ramadan R, Alkhoder A, Isakadze N, Shah A, Levantsevych O, Pimple PM, Kutner M, Ward L, Garcia EV, Nye J, Mehta PK, Lewis TT, Bremner JD, Raggi P, Quyyumi AA, Vaccarino V. Sex Differences in Hemodynamic and Microvascular Mechanisms of Myocardial Ischemia Induced by Mental Stress. Arterioscler Thromb Vasc Biol 2017; 38:473-480. [PMID: 29269515 PMCID: PMC5785428 DOI: 10.1161/atvbaha.117.309535] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 10/24/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate sex-specific vascular mechanisms for mental stress-induced myocardial ischemia (MSIMI). APPROACH AND RESULTS Baseline data from a prospective cohort study of 678 patients with coronary artery disease underwent myocardial perfusion imaging before and during a public speaking stressor. The rate-pressure product response was calculated as the difference between the maximum value during the speech minus the minimum value during rest. Peripheral vasoconstriction by peripheral arterial tonometry was calculated as the ratio of pulse wave amplitude during the speech over the resting baseline; ratios <1 indicate a vasoconstrictive response. MSIMI was defined as percent of left ventricle that was ischemic and as a dichotomous variable. Men (but not women) with MSIMI had a higher rate-pressure product response than those without MSIMI (6500 versus 4800 mm Hg bpm), whereas women (but not men) with MSIMI had a significantly lower peripheral arterial tonometry ratio than those without MSIMI (0.5 versus 0.8). In adjusted linear regression, each 1000-U increase in rate-pressure product response was associated with 0.32% (95% confidence interval, 0.22-0.42) increase in inducible ischemia among men, whereas each 0.10-U decrease in peripheral arterial tonometry ratio was associated with 0.23% (95% confidence interval, 0.11-0.35) increase in inducible myocardial ischemia among women. Results were independent of conventional stress-induced myocardial ischemia. CONCLUSIONS Women and men have distinct cardiovascular reactivity mechanisms for MSIMI. For women, stress-induced peripheral vasoconstriction with mental stress, and not increased hemodynamic workload, is associated with MSIMI, whereas for men, it is the opposite. Future studies should examine these pathways on long-term outcomes.
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Affiliation(s)
- Samaah Sullivan
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Muhammad Hammadah
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Ibhar Al Mheid
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Kobina Wilmot
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Ronnie Ramadan
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Ayman Alkhoder
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Nino Isakadze
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Amit Shah
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Oleksiy Levantsevych
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Pratik M Pimple
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Michael Kutner
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Laura Ward
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Ernest V Garcia
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Jonathon Nye
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Puja K Mehta
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Tené T Lewis
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - J Douglas Bremner
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Paolo Raggi
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Arshed A Quyyumi
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.)
| | - Viola Vaccarino
- From the Department of Epidemiology (S.S., A.S., P.M.P., T.T.L., V.V.) and Department of Biostatistics and Bioinformatics (M.K., L.W.), Rollins School of Public Health, Emory University, Atlanta, GA; Atlanta Veterans Affairs Medical Center, Decatur, GA (A.S., J.D.B.); Department of Psychiatry and Behavioral Sciences (J.D.B.), Department of Radiology (E.V.G., J.N.), and Department of Medicine, Division of Cardiology (M.H., I.A.M., K.W., R.R., A.A., N.I., A.S., O.L., P.K.M., A.A.Q., V.V.), Emory University School of Medicine, Atlanta, GA; and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.).
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7
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Hammadah M, Alkhoder A, Al Mheid I, Wilmot K, Isakadze N, Abdulhadi N, Chou D, Obideen M, O'Neal WT, Sullivan S, Tahhan AS, Kelli HM, Ramadan R, Pimple P, Sandesara P, Shah AJ, Ward L, Ko YA, Sun Y, Uphoff I, Pearce B, Garcia EV, Kutner M, Bremner JD, Esteves F, Sheps DS, Raggi P, Vaccarino V, Quyyumi AA. Hemodynamic, catecholamine, vasomotor and vascular responses: Determinants of myocardial ischemia during mental stress. Int J Cardiol 2017; 243:47-53. [PMID: 28571621 PMCID: PMC5532063 DOI: 10.1016/j.ijcard.2017.05.093] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/13/2017] [Accepted: 05/23/2017] [Indexed: 01/07/2023]
Abstract
AIMS Mental stress-induced myocardial ischemia (MSIMI) in patients with coronary artery disease (CAD) is associated with adverse cardiovascular outcomes. We aim to assess hemodynamic, neuro-hormonal, endothelial, vasomotor and vascular predictors of MSIMI. METHODS AND RESULTS We subjected 660 patients with stable CAD to 99mTc sestamibi myocardial perfusion imaging at rest, with mental (speech task) and with conventional (exercise/pharmacological) stress. Endothelium-dependent flow-mediated dilation (FMD), microvascular reactivity [reactive hyperemia index (RHI)] and arterial stiffness [pulse wave velocity (PWV)] were measured at rest and 30-min after mental stress. The digital microvascular vasomotor response during mental stress was assessed using peripheral arterial tonometry (PAT). A total of 106(16.1%) patients had MSIMI. Mental stress was accompanied by significant increases in rate-pressure-product (heart rate x systolic blood pressure; RPP), epinephrine levels and PWV, and significant decreases in FMD and PAT ratio denoting microvascular constriction. In comparison to those with no MSIMI, patients with MSIMI had higher hemodynamic and digital vasoconstrictive responses (p<0.05 for both), but did not differ in epinephrine, endothelial or macrovascular responses. Only presence of ischemia during conventional stress (OR of 7.1, 95%CI of 4.2, 11.9), high hemodynamic response (OR for RPP response≥vs<ROC cutoff of 1.8, 95%CI of 1.1, 2.8), and high digital vasoconstriction (OR for PAT ratio<vs≥ROC cutoff of 2.1, 95%CI of 1.3, 3.3) were independent predictors of MSIMI. CONCLUSION Ischemia during conventional stress testing and hemodynamic and vasoconstrictive responses to mental stress can help predict subjects with CAD at greater risk of developing MSIMI.
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Affiliation(s)
- Muhammad Hammadah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ayman Alkhoder
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ibhar Al Mheid
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kobina Wilmot
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Nino Isakadze
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Naser Abdulhadi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Danielle Chou
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Malik Obideen
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Wesley T O'Neal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Samaah Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Ayman Samman Tahhan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Heval Mohamed Kelli
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ronnie Ramadan
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Pratik Pimple
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Pratik Sandesara
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Amit J Shah
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Atlanta VA Medical Center, Decatur, GA, United States
| | - Laura Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Yan Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Irina Uphoff
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Brad Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Ernest V Garcia
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - J Douglas Bremner
- Atlanta VA Medical Center, Decatur, GA, United States; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, United States
| | - Fabio Esteves
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - David S Sheps
- University of Florida Health Science Center, Department of Medicine, Division of Cardiovascular Medicine, United States
| | - Paolo Raggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Viola Vaccarino
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States.
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