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Abuelazm M, Badr A, Turkmani M, Amin MA, Amin AM, Aboutaleb A, Gowaily I, Soliman Y, Abdelazeem B. The efficacy and safety of new potassium binders on renin-angiotensin-aldosterone system inhibitor optimization in heart failure patients: a systematic review and meta-analysis. ESC Heart Fail 2024; 11:28-43. [PMID: 38012095 PMCID: PMC10804144 DOI: 10.1002/ehf2.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/08/2023] [Accepted: 10/29/2023] [Indexed: 11/29/2023] Open
Abstract
Guideline-directed medical therapy (GDMT) has improved outcomes in patients with heart failure, including the use of renin-angiotensin-aldosterone system inhibitors, which can hinder the excretion of potassium, resulting in hyperkalaemia. New potassium binders (NPBs) can prevent this adverse effect; however, the efficacy and safety of NPB for this indication have not been fully established. We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching PubMed, Web of Science, Scopus, and Cochrane through 26 April 2023. The risk of bias assessment was conducted, following Cochrane's updated Risk of Bias 2 assessment tool. We used the fixed-effects model to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023426113). We included six RCTs with a total of 1432 patients. NPB was significantly associated with successful mineralocorticoid receptor antagonist (MRA) optimization [RR: 1.13 with 95% CI (1.02-1.25), P = 0.02], decreased patients with MRA at less than the target dose [RR: 0.72 with 95% CI (0.57-0.90), P = 0.004], and decreased hyperkalaemic episodes [RR: 0.42 with 95% CI (0.24-0.72), P = 0.002]. However, there was no difference between NPB and placebo regarding angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB)/angiotensin receptor/neprilysin inhibitor (ANRi) optimization [RR: 1.02 with 95% CI (0.89-1.17), P = 0.76] and serum potassium change [MD: -0.31 with 95% CI (-0.61 to 0.00), P = 0.05], with an acceptable safety profile except for the increased incidence of hypokalaemia with NPB [RR: 1.57 with 95% CI (1.12-2.21), P = 0.009]. NPB has been shown to improve GDMT outcomes by enhancing MRA optimization and reducing hyperkalaemic episodes. However, there are limited data on the effects of NPB on ACEi/ARB/ANRi optimization. Future RCTs should investigate ACEi/ARB/ANRi optimization and conduct head-to-head comparisons of NPB (patiromer and sodium zirconium cyclosilicate).
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Affiliation(s)
| | - Amr Badr
- Department of CardiologyBanha Teaching HospitalBanhaEgypt
| | - Mustafa Turkmani
- Department of Internal MedicineMcLaren Health CareOaklandMIUSA
- Department of Internal MedicineMichigan State UniversityEast LansingMIUSA
| | | | | | | | | | | | - Basel Abdelazeem
- Department of Internal MedicineMichigan State UniversityEast LansingMIUSA
- Department of CardiologyWest Virginia UniversityMorgantownWVUSA
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2
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Zhou J, Jin X, Zhou J, Xu Y, Cui X, Fu M, Hu K, Ge J. Clinical outcomes by serum potassium levels for patients hospitalized for heart failure: Secondary analysis of data from the China National Heart Failure Registry. Clin Cardiol 2023; 46:1345-1352. [PMID: 37577821 PMCID: PMC10642319 DOI: 10.1002/clc.24114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Dyskalemia is a mortality risk factor in patients with heart failure (HF). HYPOTHESIS We described the prevalence of dyskalemia, and clinical outcomes by serum potassium (sK) levels, in Chinese patients hospitalized for HF. METHODS In this secondary analysis of the prospective China National Heart Failure Registry, adult patients hospitalized between January 1, 2013 and June 30, 2015 who had at least one baseline sK measurement were followed for up to 3 years after discharge. The use of renin-angiotensin-aldosterone system inhibitors at baseline and clinical outcomes during follow-up were compared among sK groups. RESULTS Among 6950 patients, 5529 (79.6%) had normokalemia (sK >3.5-5.0 mmol/L), 1113 (16.0%) had hypokalemia (sK 0-3.5 mmol/L), and 308 (4.4%) had hyperkalemia (sK >5.0 mmol/L). Baseline characteristics that were most common in patients with hyperkalemia than those with hypo- and normokalemia included older age, HF with reduced ejection fraction, New York Heart Association Class III/IV status, hypertension, and chronic kidney disease. Use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) differed across sK groups (p = .0001); reported in 64.1%, 63.4%, and 54.5% of patients with hypo-, normo-, and hyperkalemia, respectively. Overall, 26.6%, 28.6%, and 36.0% of patients with hypo-, normo-, and hyperkalemia had rehospitalization for worsened HF, or cardiovascular mortality; p = .0057 for between-group comparison. CONCLUSIONS Patients with hyperkalemia received ACEIs or ARBs for HF treatment at baseline less frequently than those with hypo- or normokalemia, and had worse prognoses. This warrants further investigation into effective hyperkalemia management in HF.
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Affiliation(s)
- Jingmin Zhou
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Xuejuan Jin
- Department of Epidemiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Jun Zhou
- Department of Epidemiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Yamei Xu
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Xiaotong Cui
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra HospitalUniversity of GothenburgGothenburgSweden
| | - Kai Hu
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
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Kang SH, Kim BY, Son EJ, Kim GO, Do JY. Association of Renin-Angiotensin System Blockers with Survival in Patients on Maintenance Hemodialysis. J Clin Med 2023; 12:jcm12093301. [PMID: 37176742 PMCID: PMC10179028 DOI: 10.3390/jcm12093301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Additional studies are needed to confirm whether the use of renin-angiotensin system blockers (RASBs) induces survival benefits in patients on hemodialysis (HD). This study aimed to evaluate patient survival with the use of RASBs in a large sample of maintenance HD patients. This study used data from the national HD quality assessment program and claim data from South Korea (n = 54,903). A patient using RASBs was defined as someone who had received more than one prescription during the 6 months of each HD quality assessment period. The patients were divided into three groups as follows: Group 1, no prescription for anti-hypertensive drugs; Group 2, prescription for anti-hypertensive drugs other than RASBs; and Group 3, prescription for RASBs. The five-year survival rates in Groups 1, 2, and 3 were 72.1%, 64.5%, and 66.6%, respectively (p < 0.001 for Group 1 vs. Group 2 or 3; p = 0.001 for Group 2 vs. Group 3). Group 1 had the highest patient survival rates among the three groups, and Group 3 had higher patient survival rates compared to Group 2. Group 3 had higher patient survival rates than Group 2; however, the difference in patient survival rates between Group 2 and Group 3 was relatively small. Multivariate Cox regression analyses showed similar trends as those of univariate analyses. The highest survival rates from our study were those of patients who had not used anti-hypertensive drugs. Between patients treated with RASBs and those with other anti-hypertensive drugs, patient survival rates were higher in patients treated with RASBs.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Bo Yeon Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Eun Jung Son
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Gui Ok Kim
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
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Rashid AM, Khan MS, Fudim M, DeWald TA, DeVore A, Butler J. Management of Heart Failure With Reduced Ejection Fraction. Curr Probl Cardiol 2023; 48:101596. [PMID: 36681212 DOI: 10.1016/j.cpcardiol.2023.101596] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a complex and progressive clinical condition characterized by dyspnea and functional impairment. HFrEF has a high burden of mortality and readmission rate making it one of the most significant public health challenges. Basic treatment strategies include diuretics for symptom relief and use of quadruple therapy (Angiotensin receptor blocker/neprilysin inhibitors, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors) for reduction in hospitalizations, all-cause mortality, and cardiovascular mortality. Despite compelling evidence of clinical benefit, guideline directed medical therapy is vastly underutilized in the real-world clinical practice. Other medications such as intravenous iron, ivabradine, hydralazine/nitrates and vericiguat may also have a role in certain subgroup of HFrEF patients. Specific groups of patients with HFrEF may also be candidates for various device therapies such as implanted cardioverter defibrillators, cardiac resynchronization therapy and trans catheter mitral valve repair. This review provides a comprehensive overview of drug and device management approaches for patients with HFrEF, recommendations for initiation and titrations of therapies, and challenges associated with guideline directed medical therapy in the management of patients with HFrEF (Graphical abstract).
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Affiliation(s)
| | | | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Tracy A DeWald
- Division of Clinical Pharmacology, Duke University School of Medicine, Durham, NC
| | - Adam DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Baylor Scott and White Research Institute, Dallas, TX.
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Ward T, Brown T, Lewis RD, Kliess MK, de Arellano AR, Quinn CM. The Cost Effectiveness of Patiromer for the Treatment of Hyperkalaemia in Patients with Chronic Kidney Disease with and without Heart Failure in Ireland. PHARMACOECONOMICS - OPEN 2022; 6:757-771. [PMID: 35925491 PMCID: PMC9440184 DOI: 10.1007/s41669-022-00357-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Hyperkalaemia can be a life-threatening condition, particularly in patients with advanced chronic kidney disease with and without heart failure. Renin-angiotensin-aldosterone system inhibitor therapy offers cardiorenal protection in chronic kidney disease and heart failure; however, it may also cause hyperkalaemia subsequently resulting in down-titration or discontinuation of treatment. Hence, there is an unmet need for hyperkalaemia treatment in patients with chronic kidney disease with and without heart failure to enable renin-angiotensin-aldosterone system inhibitor use in this patient population. In this study, we develop a de novo disease progression and cost-effectiveness model to evaluate the clinical and economic outcomes associated with the use of patiromer for the treatment of hyperkalaemia in patients with chronic kidney disease with and without heart failure. METHODS A Markov model was developed using data from the OPAL-HK trial to assess the health economic impact of patiromer therapy in comparison to standard of care in controlling hyperkalaemia in patients with advanced chronic kidney disease with and without heart failure in the Irish setting. The model was designed to predict the natural history of chronic kidney disease and heart failure and quantify the costs and benefits associated with the use of patiromer for hyperkalaemia management over a lifetime horizon from a payer perspective. RESULTS Treatment with patiromer was associated with an increase in discounted life-years (8.62 vs 8.37) and an increase in discounted quality-adjusted life-years (6.15 vs 5.95). Incremental discounted costs were predicted at €4979 per patient, with an incremental cost-effectiveness ratio of €25,719 per quality-adjusted life-year gained. Patients remained taking patiromer treatment for an average of 7.7 months, with treatment associated with reductions in the overall clinical event incidence and a delay in chronic kidney disease progression. Furthermore, patiromer was associated with lower overall rates of hospitalisation, major adverse cardiovascular events, dialysis, renin-angiotensin-aldosterone system inhibitor discontinuation episodes and renin-angiotensin-aldosterone system inhibitor down-titration episodes. At a willingness-to-pay threshold of €45,000 per quality-adjusted life-year in Ireland, treatment with patiromer was estimated to have a 100% chance of cost effectiveness compared with standard of care. CONCLUSIONS This study has demonstrated an economic case for the reimbursement of patiromer for the treatment of hyperkalaemia in patients with chronic kidney disease with and without heart failure in Ireland. Patiromer was estimated to improve life expectancy and quality-adjusted life expectancy, whilst incurring marginal additional costs when compared with current standard of care. Results are predominantly attributed to the ability of patiromer to enable the continuation of renin-angiotensin-aldosterone system inhibitor treatment whilst also reducing potassium levels.
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Affiliation(s)
- Thomas Ward
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
- Health Economics Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Tray Brown
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK.
| | - Ruth D Lewis
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
| | - Melodi Kosaner Kliess
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
| | | | - Carol M Quinn
- Vifor Pharma Group, Medical Department, Glattbrugg, Switzerland
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Chong NJ, Yamamoto S, Wong RCC. Treatment for hyperkalaemia in heart failure: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Shuhei Yamamoto
- Department of Rehabilitation; Shinshu University Hospital; Matsumoto Japan
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Gallo-Bernal S, Calixto CA, Molano-González N, Moreno MPD, Tamayo MF, Contreras JP, Medina HM, Rodríguez MJ. Impact of a pharmacist-based multidimensional intervention aimed at decreasing the risk of hyperkalemia in heart failure patients: A Latin-American experience. Int J Cardiol 2021; 329:136-143. [PMID: 33412183 DOI: 10.1016/j.ijcard.2020.12.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/26/2022]
Abstract
AIMS Hyperkalemia is a potentially life-threatening condition associated with the use of heart failure (HF) medications, which can lead to increased morbidity and mortality. Novel approaches for hyperkalemia prevention are needed, especially in limited-resource settings. Despite multiple studies showing the beneficial impact of pharmaceutical-counseling in several outcomes, there is a knowledge-gap regarding its impact on hyperkalemia prevention. METHODS A case-control study was performed in patients from the Adult Heart Failure Clinic Registry in our institution. Cases were selected using a definition of serum potassium K+ ≥5.5 mmol/L. To study the association between hyperkalemia and relevant risk factors, we performed a multivariate logistic regression analysis using the Least Absolute Shrinkage and Selection Operator (LASSO) method for variable selection. We also fitted a Classification and Regression Tree (CART) to establish complex interactions and effect modifiers between the selected variables. RESULTS We matched 483 controls (eligible HF patients without hyperkalemia) to 132 cases (eligible HF patients with hyperkalemia based on age and calendar, yielding a total sample size of 615 patients (270 females) for this study. Cases had statistically significant lower odds of receiving a pharmacist-based multidimensional intervention (PBMI) (OR 0.57; 95% CI, 0.43-0.80) or having HF with reduced ejection fraction (OR 0.56; 95% CI, 0.18-0.72). On the other hand, patients who presented hyperkalemia had statistically significant higher odds of having a history of chronic kidney disease stage 4 (OR 4.97; 95% CI, 2.24-11.01) or 5 (OR 6.73; 95% CI, 1.69-26.84) and being on enalapril at doses =40 mg/day (OR, 9.90; 95% CI 5.81-16.87). CONCLUSIONS PBMI is a practical approach to prevent hyperkalemia in HF patients in a limited-resource setting. However, clinical trials are needed to assess its effectiveness.
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Affiliation(s)
- Sebastian Gallo-Bernal
- Division of Cardiology, Fundación Cardio-infantil - Instituto de Cardiología, Bogotá, Colombia; School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia.
| | - Camilo A Calixto
- Division of Cardiology, Fundación Cardio-infantil - Instituto de Cardiología, Bogotá, Colombia; School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | | | | | - María Fernanda Tamayo
- Division of Cardiology, Fundación Cardio-infantil - Instituto de Cardiología, Bogotá, Colombia
| | | | - Hector M Medina
- Division of Cardiology, Fundación Cardio-infantil - Instituto de Cardiología, Bogotá, Colombia; School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - María Juliana Rodríguez
- Division of Cardiology, Fundación Cardio-infantil - Instituto de Cardiología, Bogotá, Colombia.
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Fudim M, Brooksbank J, Giczewska A, Greene SJ, Grodin JL, Martens P, Ter Maaten JM, Sharma A, Verbrugge FH, Chakraborty H, Bart BA, Butler J, Hernandez AF, Felker GM, Mentz RJ. Ultrafiltration in Acute Heart Failure: Implications of Ejection Fraction and Early Response to Treatment From CARRESS-HF. J Am Heart Assoc 2020; 9:e015752. [PMID: 33289458 PMCID: PMC7955382 DOI: 10.1161/jaha.119.015752] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Ultrafiltration is not commonly used because of higher incidence of worsening renal function without improved decongestion. We examined differential outcomes of high versus low fluid removal and preserved versus reduced ejection fraction (EF) in CARRESS‐HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure). Methods and Results Baseline characteristics in the ultrafiltration arm were compared according to 24‐hour ultrafiltration‐based fluid removal above versus below the median. Patients were stratified by EF (≤40% or >40%). We compared clinical parameters of clinical decongestion during the hospitalization based on initial (≤24 hours) response to ultrafiltration. Cox‐proportional hazards models were used to identify associations between fluid removal <24 hours and composite of death, hospitalization, or unscheduled outpatient/emergency department visit during study follow‐up. The intention‐to‐treat analysis included 93 patients. Within 24 hours, median fluid removal was 1.89 L (Q1, Q3: 1.22, 3.16). The high fluid removal group had a greater urine output (9.08 versus 6.23 L, P=0.027) after 96 hours. Creatinine change from baseline to 96 hours was similar in both groups (0.10 mg/dL increase, P=0.610). The EF >40% group demonstrated larger increases of change in creatinine (P=0.023) and aldosterone (P=0.038) from baseline to 96 hours. Among patients with EF >40%, those with above median fluid removal (n=17) when compared with below median (n=17) had an increased rate of the combined end point (87.5% versus 47.1%, P=0.014). Conclusions In patients with acute heart failure, higher initial fluid removal with ultrafiltration had no association with worsening renal function. In patients with EF >40%, ultrafiltration was associated with worsening renal function irrespective of fluid removal rate and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
| | | | | | - Stephen J Greene
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
| | | | - Pieter Martens
- Department of Cardiology Ziekenhuis Oost-Limburg Genk Belgium
| | - Jozine M Ter Maaten
- Department of Cardiology Ziekenhuis Oost-Limburg Genk Belgium.,Department of Cardiology University Medical Center GroningenUniversity of Groningen Groningen The Netherlands
| | - Abhinav Sharma
- Department of Cardiology Ziekenhuis Oost-Limburg Genk Belgium.,Division of Cardiology McGill University Health Centre Montreal Quebec Canada
| | - Frederik H Verbrugge
- Department of Nephrology Dialysis and Renal Transplantation, University Hospitals Leuven Leuven Belgium.,Biomedical Research Institute Faculty of Medicine and Life Sciences, Hasselt University Hasselt Belgium
| | | | - Bradley A Bart
- Division of Cardiology Hennepin County Medical Center Minneapolis MN
| | - Javed Butler
- University of Mississippi School of Medicine Jackson MI
| | - Adrian F Hernandez
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
| | - G Michael Felker
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
| | - Robert J Mentz
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
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