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Pagonis C, Sandstedt M, Dworeck C, Erlinge D, Fagman E, Adlam D, Andersson J, Fredriksson M, Glaser N, Henriksson L, Johnston N, Henareh L, Jonasson L, Ostenfeld E, Tornvall P, Venetsanos D, Welén-Schef K, Yndigegn T, Swahn E, Sederholm Lawesson S. Coronary Computed Tomography Angiography for the Diagnosis of Spontaneous Coronary Artery Dissection: A Prospective Study. JACC Cardiovasc Imaging 2024:S1936-878X(24)00198-0. [PMID: 38970596 DOI: 10.1016/j.jcmg.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 04/16/2024] [Accepted: 05/07/2024] [Indexed: 07/08/2024]
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Yang C, Offen S, Saw J. What Is New in Spontaneous Coronary Artery Dissection? CJC Open 2024; 6:417-424. [PMID: 38487071 PMCID: PMC10935686 DOI: 10.1016/j.cjco.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/03/2023] [Indexed: 03/17/2024] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is a condition that leads to tearing of the coronary vessel wall in the absence of trauma, iatrogenic injury, or atherosclerosis. SCAD is an important cause of myocardial infarction in young women, leading to significant cardiovascular morbidity and mortality. Within cohorts of women aged around 50 years on average, who experience acute coronary syndrome, the prevalence of SCAD is 22.5%- 35%. Over the past decade, SCAD research has expanded rapidly, leading to improved understanding of this condition. In this review, we provide a summary of the current body of knowledge, highlight areas of ongoing research, and identify existing knowledge gaps. Specifically, we provide a focused update on the pathogenesis of SCAD, including genetic and associated conditions, clinical presentation and diagnosis, prognosis, and short-term and long-term management. Highlighted areas include the following: insights from recent genome-wide association studies; intracoronary imaging for the diagnosis of SCAD; the role of cardiac computed tomography angiography to assess for vessel healing; revascularization strategies and challenges; cardiogenic shock in SCAD; and the increasingly recognized burden of anxiety, depression, and posttraumatic stress disorder among SCAD patients.
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Affiliation(s)
- Cathevine Yang
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sophie Offen
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Dell’Aversana F, Tedeschi C, Comune R, Gallo L, Ferrandino G, Basco E, Tamburrini S, Sica G, Masala S, Scaglione M, Liguori C. Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender. Diagnostics (Basel) 2023; 13:2611. [PMID: 37568974 PMCID: PMC10416986 DOI: 10.3390/diagnostics13152611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.
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Affiliation(s)
- Federica Dell’Aversana
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Carlo Tedeschi
- Operational Unit of Cardiology, Presidio Sanitario Intermedio Napoli Est, ASL-Napoli 1 Centro, 80144 Napoli, Italy;
| | - Rosita Comune
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Luigi Gallo
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Giovanni Ferrandino
- Department of Radiology, Ospedale del Mare-ASL Napoli 1, 80147 Napoli, Italy; (G.F.)
| | - Emilia Basco
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Stefania Tamburrini
- Department of Radiology, Ospedale del Mare-ASL Napoli 1, 80147 Napoli, Italy; (G.F.)
| | - Giacomo Sica
- Department of Radiology, Monaldi Hospital Azienda dei Colli, 80131 Napoli, Italy
| | - Salvatore Masala
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Mariano Scaglione
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
- Department of Radiology, James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - Carlo Liguori
- Department of Radiology, Ospedale del Mare-ASL Napoli 1, 80147 Napoli, Italy; (G.F.)
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Pergola V, Continisio S, Mantovani F, Motta R, Mattesi G, Marrazzo G, Dellino CM, Montonati C, De Conti G, Galzerano D, Parato VM, Gimelli A, Barchitta A, Campana M, D'Andrea A. Spontaneous coronary artery dissection: the emerging role of coronary computed tomography. Eur Heart J Cardiovasc Imaging 2023:7135507. [PMID: 37082977 DOI: 10.1093/ehjci/jead060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/12/2023] [Indexed: 04/22/2023] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome and myocardial infarction, more frequent among young women. Invasive coronary angiography (ICA) is the gold standard for the diagnosis of SCAD, although the risk of propagating dissection flap is considerable. Therefore, coronary computed tomography angiography (CCTA) is an emerging alternative modality to diagnose SCAD with the advantage of being a non-invasive technique. Clinicians should be aware of the predisposing conditions and pathophysiology to raise the pre-test probability of SCAD and select the most appropriate diagnostic tools. In recent times, improvements in spatial and temporal resolution and the use of semi-automated software providing quantitative assessment make CCTA a valid alternative to ICA also for the follow-up. Moreover, CCTA may be helpful to screen and evaluate extra-coronary arteriopathies closely related to SCAD. In this review, we illustrate the current and the potential role of CCTA in the diagnosis of SCAD, highlighting advantages and disadvantages of this imaging modality compared to ICA.
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Affiliation(s)
- Valeria Pergola
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Francesca Mantovani
- Department of Cardiology, Azienda USL, IRCCS di Reggio Emilia, Via Giovanni Amendola, 2, 42122 Reggio Emilia, Italy
| | - Raffaella Motta
- Unit of Radiology, Department of Medicine, Medical School, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Giulia Mattesi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Gemma Marrazzo
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Via Alfonso de Nicola, 84014, Nocera Inferiore, Italy
| | - Carlo Maria Dellino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Giorgio De Conti
- Unit of Radiology, Department of Medicine, Medical School, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Domenico Galzerano
- Cardiac Centre, King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, 11564 Riyadh, Saudi Arabia
| | - Vito Maurizio Parato
- Cardiology Unit, Emergency Dept, Hospital "Madonna del Soccorso", Via Luciano Manara, 8, 63074 San Benedetto del Tronto, Italy
| | - Alessia Gimelli
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy
| | - Agatella Barchitta
- Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Marco Campana
- U.O.C. Cardiologia, Fondazione Poliambulanza, Via Don Pinzoni, 1, 25124 Brescia, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Via Alfonso de Nicola, 84014, Nocera Inferiore, Italy
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Gupta S, Meyersohn NM, Wood MJ, Steigner ML, Blankstein R, Ghoshhajra BB, Hedgire SS. Role of Coronary CT Angiography in Spontaneous Coronary Artery Dissection. Radiol Cardiothorac Imaging 2020; 2:e200364. [PMID: 33778640 PMCID: PMC7978024 DOI: 10.1148/ryct.2020200364] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/30/2020] [Accepted: 09/25/2020] [Indexed: 05/04/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) is more common than previously thought and is present in up to 4% of patients presenting with acute coronary syndrome. SCAD predominantly occurs in relatively young women and is an important cause of myocardial infarction in young patients without traditional risk factors of atherosclerotic coronary artery disease. There have been substantial improvements in spatial and temporal resolution and reduction in ionizing radiation dose with new generation scanners. The risk of dissection propagation with an invasive coronary angiogram, improved CT scanner parameters, and predominantly conservative management of SCAD make coronary CT angiography a useful noninvasive imaging modality for the assessment of SCAD. © RSNA, 2020.
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Lak H, Rehman KA, Jaber WA, Cho L. Three broken vessels in a peripartum patient: a rare case report of spontaneous triple vessel coronary artery dissection. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 33426445 PMCID: PMC7780451 DOI: 10.1093/ehjcr/ytaa319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/09/2020] [Accepted: 08/19/2020] [Indexed: 11/13/2022]
Abstract
Background Spontaneous coronary artery dissection (SCAD) is a frequently underdiagnosed entity that carries a significant risk of morbidity and mortality. Spontaneous coronary artery dissection is increasingly recognized as an important cause of acute coronary syndrome (ACS) and, the majority of SCAD patients are young healthy women. Case summary A 23-year-old female G5P4 presented to the emergency room for severe sub-sternal chest pain, associated with shortness of breath. Past medical history was significant for pre-eclampsia. Initial electrocardiogram was remarkable for ST depressions in V5–V6 with inverted T waves to V1–V2. Troponin I was elevated to 1.13 ng/mL. Two-dimensional echo showed reduced left ventricular function with an ejection fraction of 40%. Cardiac catheterization showed triple vessel dissection involving the left main trunk extending into mid-left anterior descending and dissection extending from ostium of left circumflex artery into large first obtuse marginal branch. She was started on aspirin and heparin. After 48 h she was loaded with clopidogrel. Computed tomography angiography of head, neck, abdomen, and pelvis showed findings compatible with fibromuscular dysplasia. She was haemodynamically stable and symptom free and did not want surgery. She was recommended to continue dual antiplatelet therapy for 12 months and subsequently aspirin and beta blocker only lifelong. Discussion Spontaneous coronary artery dissection is a rare condition which is underdiagnosed. A thorough history and high degree of suspicion is required to diagnose in a timely manner and it should be high on differential in a postpartum female presenting with signs and symptoms of ACS.
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Affiliation(s)
- Hassan Lak
- Department of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Karim Abdul Rehman
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Mail Code JB-1, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Wael A Jaber
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Mail Code JB-1, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Leslie Cho
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Mail Code JB-1, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Characteristic findings of acute spontaneous coronary artery dissection by cardiac computed tomography. Coron Artery Dis 2020; 31:293-299. [DOI: 10.1097/mca.0000000000000819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Tornvall P, Brolin EB, Caidahl K, Cederlund K, Collste O, Daniel M, Ekenbäck C, Jensen J, Y-Hassan S, Henareh L, Hofman-Bang C, Lyngå P, Maret E, Sarkar N, Spaak J, Sundqvist M, Sörensson P, Ugander M, Agewall S. The value of a new cardiac magnetic resonance imaging protocol in Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) - a case-control study using historical controls from a previous study with similar inclusion criteria. BMC Cardiovasc Disord 2017; 17:199. [PMID: 28738781 PMCID: PMC5525301 DOI: 10.1186/s12872-017-0611-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/22/2017] [Indexed: 12/22/2022] Open
Abstract
Background Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is common with a prevalence of 6% of all patients fulfilling the diagnosis of myocardial infarction. MINOCA should be considered a working diagnosis. Cardiac Magnetic Resonance (CMR) imaging has recently been suggested to be of great value to determine the cause behind MINOCA. The objectives of this paper are to describe the rationale behind the second Stockholm Myocardial Infarction with Normal Coronaries (SMINC-2) study and to discuss the protocol for investigation of MINOCA patients in the light of the recently published position paper from the European Society of Cardiology. Methods The SMINC-2 study is an open non-randomised study using historical controls for comparison. The primary aim is to prove that MINOCA patients investigated with the latest CMR imaging technique can achieve a diagnosis in 70% of all cases entirely by imaging. By including 150 patients we will have >80% chance to prove that the diagnostic accuracy can be improved by 20 absolute % with a p-value of less than 0.05 when compared with CMR imaging in the SMINC-1 study. Furthermore, in addition to invasive coronary angiography, coronary arteries are evaluated by computed tomography angiography to investigate coronary causes and questionnaires are used to describe Quality-of-Life (QoL). By January 1st 2017, 75 patients have been included. Discussion Whether CMR imaging can provide a diagnosis to an adequate proportion of MINOCA patients is unknown. Well-defined inclusion and exclusion criteria will be used to compare a MINOCA cohort from the population with an appropriate control group. Positive results are likely to influence future guidelines of the management of MINOCA. Furthermore, the study will give mechanistic insights into MINOCA in particular in patients with “true” myocardial infarction and describe QoL in this vulnerable group of patients. Trial registration Clinical Trials NCT02318498.
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Affiliation(s)
- Per Tornvall
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - E B Brolin
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - K Caidahl
- Molecular Medicine and Surgery, Karolinska Hospital, Stockholm, Sweden
| | - K Cederlund
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - O Collste
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - M Daniel
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - C Ekenbäck
- Clinical Sciences Danderyd Hospital, Karolinska Hospital, Stockholm, Sweden
| | - J Jensen
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - S Y-Hassan
- Medicine Huddinge, Karolinska Hospital, Stockholm, Sweden
| | - L Henareh
- Medicine Huddinge, Karolinska Hospital, Stockholm, Sweden
| | - C Hofman-Bang
- Clinical Sciences Danderyd Hospital, Karolinska Hospital, Stockholm, Sweden
| | - P Lyngå
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - E Maret
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - N Sarkar
- Medicine Solna, Karolinska Hospital, Stockholm, Sweden
| | - J Spaak
- Clinical Sciences Danderyd Hospital, Karolinska Hospital, Stockholm, Sweden
| | - M Sundqvist
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - P Sörensson
- Medicine Solna, Karolinska Hospital, Stockholm, Sweden
| | - M Ugander
- Molecular Medicine and Surgery, Karolinska Hospital, Stockholm, Sweden
| | - S Agewall
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Nishiguchi T, Tanaka A, Taruya A, Ozaki Y, Nakai M, Teraguchi I, Ota S, Kuroi A, Kameyama T, Yamano T, Yamaguchi T, Matsuo Y, Ino Y, Kubo T, Hozumi T, Akasaka T. Prognosis of spontaneous coronary artery dissection treated by percutaneous coronary intervention with optical coherence tomography. J Cardiol 2017; 70:524-529. [PMID: 28504113 DOI: 10.1016/j.jjcc.2017.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/19/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although about half of patients with spontaneous coronary artery dissection (SCAD) face ongoing necrosis, conservative therapy is recommended due to a high complication rate in angiography-guided percutaneous coronary intervention (PCI). The aim of this study was to investigate clinical outcomes of SCAD treated by optical coherence tomography (OCT)-guided PCI. METHODS This study consisted of consecutive 306 patients with acute coronary syndrome (ACS) who underwent OCT-guided PCI. Based on the culprit lesion morphology by OCT, patients were assigned to four groups: a SCAD group, a plaque rupture (PR) group, a calcified nodule (CN) group, and an undetermined etiology (UE) group. Successful PCI was defined as thrombolysis in myocardial infarction flow grade 3 in final angiography without any complications. Primary endpoint was defined as occurrence rate of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, and unstable angina pectoris. RESULTS OCT revealed 12 SCADs, 149 PRs, 16 CNs, and 129 UEs, respectively. No significant difference was observed in the success rate of PCI (SCAD 91.7%, PR 85.2%, CN 81.2%, UE 86.8%, p=0.88), while wire repositioning was needed in 2 SCAD cases (p<0.01). The mean follow-up periods were 17.1±13.3 months. No significant difference was observed in MACE among the groups (p=0.56). CONCLUSIONS The clinical outcomes of OCT-guided PCI for SCAD were favorable, as well as those for other ACS etiologies. OCT-guided PCI could become a therapeutic option for SCAD compromised with ongoing necrosis.
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Affiliation(s)
- Tsuyoshi Nishiguchi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuichi Ozaki
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Mai Nakai
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ikuko Teraguchi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shingo Ota
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akio Kuroi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takeyoshi Kameyama
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Yamano
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tomoyuki Yamaguchi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshiki Matsuo
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasushi Ino
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Hozumi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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