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De Luca L, Di Fusco SA, Iannopollo G, Mistrulli R, Rizzello V, Aimo A, Navazio A, Bilato C, Corda M, Di Marco M, Geraci G, Iacovoni A, Milli M, Pascale V, Riccio C, Scicchitano P, Tizzani E, Gabrielli D, Grimaldi M, Colivicchi F, Oliva F. Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on the simplification of the drug regimen for secondary cardiovascular prevention. Eur Heart J Suppl 2024; 26:ii236-ii251. [PMID: 38784670 PMCID: PMC11110452 DOI: 10.1093/eurheartjsupp/suae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socio-economic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Stefania Angela Di Fusco
- UOC Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | | | - Raffaella Mistrulli
- Dipartimento di Medicina Clinica e Molecolare, Università degli studi di Roma La Sapienza, Rome, Italy
| | | | - Alberto Aimo
- UOC Cardiologia, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alessandro Navazio
- SOC Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia—IRCCS, Reggio Emilia, Italy
| | - Claudio Bilato
- UOC Cardiologia, Ospedali dell'Ovest Vicentino, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Marco Corda
- SC Cardiologia, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | | | - Giovanna Geraci
- UOC Cardiologia, Ospedale Sant'Antonio Abate, Trapani, Italy
| | - Attilio Iacovoni
- SSD Chirurgia dei Trapianti e del Trattamento Chirurgico dello Scompenso, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Massimo Milli
- Cardiologia Firenze 1 (Ospedali S. Maria Nuova e Nuovo San Giovanni di Dio), Azienda USL Toscana Centro, Firenze, Italy
| | - Vittorio Pascale
- UTIC-Emodinamica e Cardiologia Interventistica, Ospedale Civile Pugliese, Catanzaro, Italy
| | - Carmine Riccio
- U.O.S.D. Follow-up del Paziente Post-Acuto, Dipartimento Cardio-Vascolare, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | | | - Emanuele Tizzani
- Dipartimento di Cardiologia, Ospedale degli Infermi, Rivoli, TO, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Grimaldi
- U.O.C. Cardiologia-UTIC, Ospedale Miulli, Acquaviva delle Fonti, BA, Italy
| | - Furio Colivicchi
- UOC Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | - Fabrizio Oliva
- Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
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Wu H, Xu L, Zhao X, Zhang H, Cheng K, Wang X, Chen M, Li G, Huang J, Lan J, Wei G, Zhang C, Wang Y, Qian J, Ge J. Indobufen or Aspirin on Top of Clopidogrel After Coronary Drug-Eluting Stent Implantation (OPTION): A Randomized, Open-Label, End Point-Blinded, Noninferiority Trial. Circulation 2023; 147:212-222. [PMID: 36335890 DOI: 10.1161/circulationaha.122.062762] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin as a background therapy has become the standard care after percutaneous coronary intervention. However, some adverse noncardiac effects limited the use of aspirin in clinical practice. Thus, evaluation of pharmacological alternatives to aspirin is attractive. Previous data indicated that indobufen could lessen the unwanted side effects of aspirin while retaining the antithrombotic efficacy, but its combination with a P2Y12 inhibitor still lacks randomized clinical trial evidence. METHODS In this randomized, open-label, noninferiority trial, patients with negative cardiac troponin undergoing coronary drug-eluting stent implantation were randomly assigned in a 1:1 ratio to receive either indobufen-based DAPT (indobufen 100 mg twice a day plus clopidogrel 75 mg/d for 12 months) or conventional DAPT (aspirin 100 mg/d plus clopidogrel 75 mg/d for 12 months). The primary end point was a 1-year composite of cardiovascular death, nonfatal myocardial infarction, ischemic stroke, definite or probable stent thrombosis, or Bleeding Academic Research Consortium criteria type 2, 3, or 5 bleeding. The end points were adjudicated by an independent Clinical Event Committee. RESULTS Between January 11, 2018, and October 12, 2020, 4551 patients were randomized in 103 cardiovascular centers: 2258 patients to the indobufen-based DAPT group and 2293 to the conventional DAPT group. The primary end point occurred in 101 patients (4.47%) in the indobufen-based DAPT group and 140 patients (6.11%) in the conventional DAPT group (absolute difference, -1.63%; Pnoninferiority<0.001; hazard ratio, 0.73 [95% CI, 0.56-0.94]; P=0.015). Cardiovascular death, nonfatal myocardial infarction, ischemic stroke, and stent thrombosis were observed in 0.13%, 0.40%, 0.80%, and 0.22% of patients in the indobufen-based DAPT group and 0.17%, 0.44%, 0.83%, and 0.17% of patients in the conventional DAPT group (all P>0.05). The occurrence of Bleeding Academic Research Consortium criteria type 2, 3, or 5 bleeding events was lower in the indobufen-based DAPT group compared with the conventional DAPT group (2.97% versus 4.71%; hazard ratio, 0.63 [95% CI, 0.46-0.85]; P=0.002), with the main decrease in type 2 bleeding (1.68% versus 3.49%; hazard ratio, 0.48 [95% CI, 0.33-0.70]; P<0.001). CONCLUSIONS In Chinese patients with negative cardiac troponin undergoing drug-eluting stent implantation, indobufen plus clopidogrel DAPT compared with aspirin plus clopidogrel DAPT significantly reduced the risk of 1-year net clinical outcomes, which was driven mainly by a reduction in bleeding events without an increase in ischemic events. REGISTRATION URL: https://www.chictr.org.cn; Unique identifier: ChiCTR-IIR-17013505.
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Affiliation(s)
- Hongyi Wu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Lili Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Xin Zhao
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Huanyi Zhang
- Department of Cardiology, Taian City Central Hospital, Shandong, China (H.Y.Z.)
| | - Kang Cheng
- Department of Cardiology, Xi'an No. 3 Hospital, Affiliated Hospital of Northwest University, Xi'an, Shanxi, China (K.C.)
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China (X.Y.W.)
| | - Manhua Chen
- Department of Cardiology, Central Hospital of Wuhan, Hubei, China (M.H.C.)
| | - Guangping Li
- Department of Cardiology, Second Hospital of Tianjin Medical University, China (G.P.L.)
| | - Jiangnan Huang
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China (J.N.H.)
| | - Jun Lan
- Department of Cardiology, Dongguan Third People's Hospital, Guangdong, China (J.L.)
| | - Guanghe Wei
- Department of Cardiology, Affiliated Hospital of Jining Medical University, Shandong, China (G.H.W.)
| | - Chi Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Yinman Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
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Gaciong Z. Preference and Adherence to a Fixed-Dose Combination of Bisoprolol-Aspirin and Blood Pressure Control: Results of an Open-Label, Multicentre Study. J Clin Med 2022; 12:jcm12010017. [PMID: 36614818 PMCID: PMC9820999 DOI: 10.3390/jcm12010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
This study assessed blood pressure (BP) control and adherence in patients given a fixed-dose combination (FDC) of bisoprolol (BIS) + aspirin (ASA) compared to those given these two drugs as separate tablets. Patients with hypertension and/or coronary heart disease treated with two-pill BIS (5−10 mg) and ASA (75−100 mg) were switched to FDC BIS + ASA (either 5/75 mg or 10/75 mg) ≥4 weeks prior to study initiation. Adherence was estimated from pill counts and patients’ diaries (1−2 months and 3 months after inclusion) and using Morisky’s Medication Adherence Scale (MMAS) at 3 months. BP control with the two treatments was compared. A total of 356 patients were enrolled (mean (SD) age: 64.3 ± 11.9 years, 56.5% male). Mean (SD) duration of prior treatment with two-pill BIS and ASA was 17.8 ± 26.6 months. FDC adherence was excellent or good (≥76%) in 98.3% and 98.0% of patients based on pill counts and patients’ diaries, respectively. Overall MMAS score was 3.1 ± 1.0. A significant decrease was observed in mean systolic BP, mean diastolic BP and heart rate over the 3-month period (all p < 0.001). FDC BIS + ASA was associated with excellent adherence and improved BP control. The majority (78.7%) of patients preferred the FDC.
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Affiliation(s)
- Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, 02-091 Warsaw, Poland
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Kang J, Koo BK, Park KW, Shin ES, Kim HS. Aspirin versus clopidogrel after percutaneous coronary intervention - Authors' reply. Lancet 2021; 398:1685-1686. [PMID: 34742381 DOI: 10.1016/s0140-6736(21)02016-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/31/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Jeehoon Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
| | | | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea.
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Koo BK, Kang J, Park KW, Rhee TM, Yang HM, Won KB, Rha SW, Bae JW, Lee NH, Hur SH, Yoon J, Park TH, Kim BS, Lim SW, Cho YH, Jeon DW, Kim SH, Han JK, Shin ES, Kim HS. Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST-EXAM): an investigator-initiated, prospective, randomised, open-label, multicentre trial. Lancet 2021; 397:2487-2496. [PMID: 34010616 DOI: 10.1016/s0140-6736(21)01063-1] [Citation(s) in RCA: 162] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Optimal antiplatelet monotherapy during the chronic maintenance period in patients who undergo coronary stenting is unknown. We aimed to compare head to head the efficacy and safety of aspirin and clopidogrel monotherapy in this population. METHODS We did an investigator-initiated, prospective, randomised, open-label, multicentre trial at 37 study sites in South Korea. We enrolled patients aged at least 20 years who maintained dual antiplatelet therapy without clinical events for 6-18 months after percutaneous coronary intervention with drug-eluting stents (DES). We excluded patients with any ischaemic and major bleeding complications. Patients were randomly assigned (1:1) to receive a monotherapy agent of clopidogrel 75 mg once daily or aspirin 100 mg once daily for 24 months. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater, in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02044250. FINDINGS Between March 26, 2014, and May 29, 2018, we enrolled 5530 patients. 5438 (98·3%) patients were randomly assigned to either the clopidogrel group (2710 [49·8%]) or to the aspirin group (2728 [50·2%]). Ascertainment of the primary endpoint was completed in 5338 (98·2%) patients. During 24-month follow-up, the primary outcome occurred in 152 (5·7%) patients in the clopidogrel group and 207 (7·7%) in the aspirin group (hazard ratio 0·73 [95% CI 0·59-0·90]; p=0·0035). INTERPRETATION Clopidogrel monotherapy, compared with aspirin monotherapy during the chronic maintenance period after percutaneous coronary intervention with DES significantly reduced the risk of the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC bleeding type 3 or greater. In patients requiring indefinite antiplatelet monotherapy after percutaneous coronary intervention, clopidogrel monotherapy was superior to aspirin monotherapy in preventing future adverse clinical events. FUNDING ChongKunDang, SamJin, HanMi, DaeWoong, and the South Korea Ministry of Health and Welfare.
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Affiliation(s)
- Bon-Kwon Koo
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea
| | - Tae-Min Rhee
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea
| | - Han-Mo Yang
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea
| | - Ki-Bum Won
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | | | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Nam Ho Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University, Seoul, South Korea
| | - Seung-Ho Hur
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Junghan Yoon
- Department of Internal Medicine, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - Tae-Ho Park
- Department of Internal Medicine, Dong-A University Hospital, Busan, South Korea
| | - Bum Soo Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, South Korea
| | - Sang Wook Lim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Yoon Haeng Cho
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Dong Woon Jeon
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Sang-Hyun Kim
- Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Kyu Han
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea
| | - Eun-Seok Shin
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiology Centre, Seoul National University Hospital, Seoul, South Korea.
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Koh JS, Park Y, Tantry US, Ahn JH, Kang MG, Kim K, Jang JY, Park HW, Park JR, Hwang SJ, Kwak CH, Hwang JY, Gurbel PA, Jeong YH. Pharmacodynamic effects of a new fixed-dose clopidogrel-aspirin combination compared with separate administration of clopidogrel and aspirin in patients treated with coronary stents: The ACCEL-COMBO trial. Platelets 2016; 28:187-193. [PMID: 27560946 DOI: 10.1080/09537104.2016.1206197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is a widely prescribed regimen to prevent ischemic events in patients undergoing percutaneous coronary intervention (PCI). A fixed-dose combination (FDC) capsule (HCP0911) has been developed to provide dosing convenience and improve adherence. We compared the antiplatelet effects of single daily dose HCP0911 with separate treatment with daily 75 mg clopidogrel plus 100 mg aspirin. This was a randomized, open-label, two-period, crossover, non-inferiority study conducted in stented patients who had been treated for at least 6 months with clopidogrel and aspirin. Thirty patients were randomly assigned to receive either daily 75 mg clopidogrel plus 100 mg aspirin treatment or HCP0911 for 2 weeks and then were crossed over to the other treatment for 2 weeks. Pharmacodynamic effects were measured with VerifyNow, light transmittance aggregometry (LTA), and thromboelastography (TEG®). The primary endpoint was P2Y12 Reaction Units (PRU) measured by VerifyNow. PRUs during treatment with HCP0911 were not inferior to those during separate treatment (202 ± 52 vs. 207 ± 60 PRU; mean difference, -5 PRU; 90% confidence interval of difference, -23 to 13 PRU; P for non-inferiority = 0.015 for predetermined limit). "BASE" and Aspirin Reaction Units by VerifyNow did not differ between the two treatments. During each treatment, there were no differences in maximal and final platelet aggregations by LTA (all P values ≥0.822) and TEG® measurements. In conclusion, in stented patients, the antiplatelet effect of a fixed-dose clopidogrel-aspirin combination, HCP0911, was not inferior to separate administration of clopidogrel and aspirin.
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Affiliation(s)
- Jin-Sin Koh
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Yongwhi Park
- b Department of Internal Medicine , Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital , Changwon , Republic of Korea
| | - Udaya S Tantry
- c Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute , Fairfax , VA , USA
| | - Jong-Hwa Ahn
- b Department of Internal Medicine , Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital , Changwon , Republic of Korea
| | - Min Gyu Kang
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Kyehwan Kim
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Jeong Yoon Jang
- b Department of Internal Medicine , Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital , Changwon , Republic of Korea
| | - Hyun Woong Park
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Jeong Rang Park
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Seok-Jae Hwang
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Choong Hwan Kwak
- b Department of Internal Medicine , Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital , Changwon , Republic of Korea
| | - Jin-Yong Hwang
- a Department of Internal Medicine , Gyeongsang National University School of Medicine and Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Paul A Gurbel
- c Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute , Fairfax , VA , USA
| | - Young-Hoon Jeong
- b Department of Internal Medicine , Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital , Changwon , Republic of Korea.,d Institute of the Health Sciences , Gyeongsang National University , Jinju , Republic of Korea
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