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Zhu R, Zheng R, Deng B, Liu P, Wang Y. Association of N-acetylcysteine use with contrast-induced nephropathy: an umbrella review of meta-analyses of randomized clinical trials. Front Med (Lausanne) 2023; 10:1235023. [PMID: 37790125 PMCID: PMC10543416 DOI: 10.3389/fmed.2023.1235023] [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: 06/07/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Background The effectiveness of N-acetylcysteine (NAC) in treating contrast-induced nephropathy (CIN) has been the subject of conflicting meta-analyses, but the strength of the evidence for these correlations between NAC use and CIN has not been measured overall. Objective To evaluate the data from randomized clinical studies (RCTs) that examined the relationships between NAC use and CIN in meta-analyses. Methods Between the creation of the database and April 2023, searches were made in PubMed, Cochrane Library, EMBASE, and Web of Science. N-acetylcysteine, contrast-induced nephropathy, or contrast-induced renal disease were among the search keywords used, along with terms including systematic review and meta-analysis. The Assessment of Multiple Systematic Reviews, version 2, which assigned grades of extremely low, low, moderate, or high quality to each meta-analysis's scientific quality, was used to evaluate each meta-analysis. The confidence of the evidence in meta-analyses of RCTs was evaluated using the Grading of Recommendation, Assessment, Development and Evaluations method, with evidence being rated as very low, low, moderate, or high. Results In total, 493 records were screened; of those, 46 full-text articles were assessed for eligibility, and 12 articles were selected for evidence synthesis as a result of the screening process. Based on the pooled data, which was graded as moderate-quality evidence, it can be concluded that NAC can decrease CIN (OR 0.72, 95% CI 0.65-0.79, p < 0.00001) and blood levels of serum creatinine (MD -0.09, 95% CI -0.17 to -0.01, p = 0.03). In spite of this, there were no associations between NAC and dialysis requirement or mortality in these studies. Conclusion The results of this umbrella review supported that the renal results were enhanced by NAC. The association was supported by moderate-quality evidence. Systematic review registration [https://clinicaltrials.gov/], identifier [CRD42022367811].
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Affiliation(s)
| | | | | | - Ping Liu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiru Wang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Danışan G, Taydaş O, Özdemir M, Ateş ÖF, Küpeli A, Öğüşlü U, Erkin A, Neşelioğlu S, Eren F. Dynamic thiol-disulphide homeostasis as a biomarker for predicting the development of contrast medium-associated acute kidney injury in the endovascular treatment of peripheral arterial disease: should intravenous N-acetylcysteine be given before the procedure? Clin Radiol 2023; 78:466-472. [PMID: 36941180 DOI: 10.1016/j.crad.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/15/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
AIM To determine the predictive ability of serum thiol-disulphide levels for contrast medium-associated acute kidney injury (CA-AKI) after endovascular treatment (EVT) of peripheral arterial disease (PAD) and evaluate the efficacy of intravenous N-acetylcysteine (NAC) in preventing CA-AKI. MATERIAL AND METHODS This double-blind, randomised controlled study included 85 consecutive adult patients who underwent EVT for PAD. Patients were divided into NAC negative (NAC-) and positive (NAC+) groups. While the NAC- group received only 500 ml saline, the NAC + group received 500 ml saline plus intravenous 600 mg NAC before the procedure. Intra- and intergroup patient characteristics, procedural details, preoperative thiol-disulphide levels, and ischaemia-modified albumin (IMA) levels were recorded. RESULTS There was a significant difference between NAC- and NAC + groups regarding native thiol, total thiol, disulphide/native thiol ratio (D/NT), and disulphide/total thiol ratio (D/TT). There was also a significant difference between the NAC- (33.3%) and NAC+ (13%) groups in CA-AKI development. Logistic regression analysis showed that the D/TT (OR 2.463) and D/NT (OR 2.121) were the most influential parameters for CA-AKI development. In the receiver operating characteristic (ROC) curve analysis, the sensitivity of native thiol to detect the development of CA-AKI was 89.1%. The negative predictive values of native thiol and total thiol were 95.6% and 94.1%, respectively. CONCLUSION The serum thiol-disulphide level can be used as a biomarker to detect CA-AKI development and reveal patients with a low risk for CA-AKI development before EVT of PAD. Furthermore, thiol-disulphide levels allow for the indirect quantitative monitoring of NAC. Preprocedural intravenous NAC administration significantly inhibits CA-AKI development.
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Affiliation(s)
- G Danışan
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey.
| | - O Taydaş
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey
| | - M Özdemir
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey
| | - Ö F Ateş
- Sakarya University Faculty of Medicine, Department of Radiology, Sakarya, Turkey
| | - A Küpeli
- Kanuni Training and Research Hospital, Department of Radiology, Trabzon, Turkey
| | - U Öğüşlü
- Medicana International Hospital, Department of Radiology, Istanbul, Turkey
| | - A Erkin
- Sakarya University Faculty of Medicine, Department of Cardiovascular Surgery, Sakarya, Turkey
| | - S Neşelioğlu
- Ankara City Hospital, Department of Biochemistry, Ankara, Turkey
| | - F Eren
- Ankara City Hospital, Department of Biochemistry, Ankara, Turkey
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N-Acetylcysteine: more than preventing contrast-induced nephropathy in uremic patients-focus on the antioxidant and anti-inflammatory properties. Int Urol Nephrol 2023; 55:1481-1492. [PMID: 36593372 DOI: 10.1007/s11255-022-03455-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
Oxidative stress (OS) has been recognized as a pathophysiologic mechanism underlying the development and progression of chronic kidney disease (CKD). OS, which results from the disturbance of balance among pro-oxidants and antioxidants favoring the pro-oxidants, is present even in early CKD and increases progressively along with deterioration of kidney function to end-stage kidney disease (ESKD). In ESKD, OS is further exacerbated mainly due to dialysis procedures per se and predisposes to increased cardiovascular morbidity and mortality. Therefore, since OS plays a pivotal role in the pathogenesis and progression of atherosclerosis in uremic patients, several strategies aiming to ameliorate OS in these patients have been proposed. Among those, N-acetylcysteine (NAC), a thiol-containing antioxidant agent, has attracted special attention due to its pleiotropic functions and beneficial effect in various OS-related entities including paracetamol overdose and prevention of contrast-induced nephropathy. In this review, we present the currently available literature on the antioxidant and anti-inflammatory properties of NAC in CKD, including hemodialysis and peritoneal dialysis.
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Renoprotective Effect of Vardenafil and Avanafil in Contrast-Induced Nephropathy: Emerging Evidence from an Animal Model. J Pers Med 2022; 12:jpm12050670. [PMID: 35629096 PMCID: PMC9144719 DOI: 10.3390/jpm12050670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 02/04/2023] Open
Abstract
The potential renoprotective effects of vardenafil (VAR) have been evaluated in a very limited number of studies using acute kidney injury animal models other than contrast-induced nephropathy (CIN) with promising results, while avanafil (AVA) has not been evaluated in this respect before. The purpose of this study was to evaluate for the first time the potential renoprotective effect of VAR and AVA in a rat model of CIN. Twenty-five male Wistar rats were equally assigned into five groups: control, CIN, CIN+N-acetyl cysteine (NAC) (100 mg/kg/day) as a positive control, CIN+VAR (10 mg/kg/day) and CIN+AVA (50 mg/kg/day). CIN was induced by dehydration, inhibition of prostaglandin and nitric oxide synthesis as well as exposure to the contrast medium (CM). Serum Cr (sCr) levels were measured at 24 and 48 h after CIN induction. At 48 h of CM exposure, animals were sacrificed. Matrix metalloproteinase (MMP) 2 (MMP-2) and MMP-9, kidney injury molecule 1 (KIM-1) and cystatin-C (Cys-C) were measured on renal tissue. Histopathological findings were evaluated on kidney tissue. All treatment groups had close to normal kidney appearance. sCr levels subsided in all treatment groups compared to CIN group at 48 h following CIN induction. A significant decline in the levels of MMP-2, MMP-9, KIM-1 and Cys-C compared to CIN group was observed. These results provide emerging evidence that VAR and AVA may have the potential to prevent CIN.
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Li Q, Pan S. Contrast-Associated Acute Kidney Injury: Advances and Challenges. Int J Gen Med 2022; 15:1537-1546. [PMID: 35210826 PMCID: PMC8857968 DOI: 10.2147/ijgm.s341072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
A decrease in renal function that follows intravascular administration of contrast medium (CM) within a few days is reported as contrast-induced acute kidney injury (CI-AKI). In clinical practice, the imaging procedure is frequently deferred when clinicians consider that the renal risks caused by CM outweigh the benefits of enhanced imaging. However, with an in-depth understanding of AKI and contrast medium, scholars have realized that the decrease in renal function after CM is caused by contrast medium factors and noncontrast medium factors (such as anemia and hemodynamic instability). Therefore, acute kidney injury caused by CM has been overestimated in the past. The term “contrast-associated acute kidney injury (CA-AKI)” has been increasingly used to indicate AKI after intravascular administration of contrast medium compared with CI-AKI. CA-AKI can increase the risk of death and chronic kidney disease. However, its pathophysiological mechanism has not been fully elucidated, and the effectiveness of various preventive and therapeutic measures have been questioned. These present challenges for us. In this article, we will review the diagnostic criteria, epidemiology, risk factors, pathophysiological mechanisms and treatment of CA-AKI to provide optimized imaging procedures in clinical practice.
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Affiliation(s)
- Qingqing Li
- Department of Intensive Care Medicine, Qingdao Municipal Hospital, Qingdao, People’s Republic of China
- Correspondence: Qingqing Li, Department of Intensive Care Medicine, Qingdao Municipal Hospital, Qingdao, People’s Republic of China, Email
| | - Shengqi Pan
- Department of Intensive Care Medicine, Qingdao Municipal Hospital, Qingdao, People’s Republic of China
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Sandilands EA, Rees JM, Raja K, Dhaun N, Morrison EE, Hickson K, Wraight J, Gray T, Briody L, Cameron S, Thompson AP, Johnston NR, Uren N, Goddard J, Treweeke A, Rushworth G, Webb DJ, Bateman DN, Norrie J, Megson IL, Eddleston M. Acetylcysteine has No Mechanistic Effect in Patients at Risk of Contrast-Induced Nephropathy - A Failure of Academic Clinical Science. Clin Pharmacol Ther 2022; 111:1222-1238. [PMID: 35098531 PMCID: PMC9306485 DOI: 10.1002/cpt.2541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/10/2022] [Indexed: 11/25/2022]
Abstract
Contrast‐induced nephropathy (CIN) is a major complication of imaging in patients with chronic kidney disease (CKD). The publication of an academic randomized controlled trial (RCT; n = 83) reporting oral (N)‐acetylcysteine (NAC) to reduce CIN led to > 70 clinical trials, 23 systematic reviews, and 2 large RCTs showing no benefit. However, no mechanistic studies were conducted to determine how NAC might work; proposed mechanisms included renal artery vasodilatation and antioxidant boosting. We evaluated the proposed mechanisms of NAC action in participants with healthy and diseased kidneys. Four substudies were performed. Two randomized, double‐blind, placebo‐controlled, three‐period crossover studies (n = 8) assessed the effect of oral and intravenous (i.v.) NAC in healthy kidneys in the presence/absence of iso‐osmolar contrast (iodixanol). A third crossover study in patients with CKD stage III (CKD3) (n = 8) assessed the effect of oral and i.v. NAC without contrast. A three‐arm randomized, double‐blind, placebo‐controlled parallel‐group study, recruiting patients with CKD3 (n = 66) undergoing coronary angiography, assessed the effect of oral and i.v. NAC in the presence of contrast. We recorded systemic (blood pressure and heart rate) and renal (renal blood flow (RBF) and glomerular filtration rate (GFR)) hemodynamics, and antioxidant status, plus biomarkers of renal injury in patients with CKD3 undergoing angiography. Primary outcome for all studies was RBF over 8 hours after the start of i.v. NAC/placebo. NAC at doses used in previous trials of renal prophylaxis was essentially undetectable in plasma after oral administration. In healthy volunteers, i.v. NAC, but not oral NAC, increased blood pressure (mean area under the curve (AUC) mean arterial pressure (MAP): mean difference 29 h⋅mmHg, P = 0.019 vs. placebo), heart rate (28 h⋅bpm, P < 0.001), and RBF (714 h⋅mL/min, 8.0% increase, P = 0.006). Renal vasodilatation also occurred in the presence of contrast (RBF 917 h⋅mL/min, 12% increase, P = 0.005). In patients with CKD3 without contrast, only a rise in heart rate (34 h⋅bpm, P = 0.010) and RBF (288 h⋅mL/min, 6.0% increase, P = 0.001) occurred with i.v. NAC, with no significant effect on blood pressure (MAP rise 26 h⋅mmHg, P = 0.156). Oral NAC showed no effect. In patients with CKD3 receiving contrast, i.v. NAC increased blood pressure (MAP rise 52 h⋅mmHg, P = 0.008) but had no effect on RBF (151 h⋅mL/min, 3.0% increase, P = 0.470), GFR (29 h⋅mL/min/1.73m², P = 0.122), or markers of renal injury. Neither i.v. nor oral NAC affected plasma antioxidant status. We found oral NAC to be poorly absorbed and have no reno‐protective effects. Intravenous, not oral, NAC caused renal artery vasodilatation in healthy volunteers but offered no protection to patients with CKD3 at risk of CIN. These findings emphasize the importance of mechanistic clinical studies before progressing to RCTs for novel interventions. Thousands were recruited to academic clinical trials without the necessary mechanistic studies being performed to confirm the approach had any chance of working.
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Affiliation(s)
- Euan A Sandilands
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jessica Mb Rees
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Khuram Raja
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Neeraj Dhaun
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Emma E Morrison
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Kirsty Hickson
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Jonathan Wraight
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tanya Gray
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Lesley Briody
- Wellcome Trust Clinical Research Facility, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sharon Cameron
- Wellcome Trust Clinical Research Facility, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adrian P Thompson
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Neil R Johnston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Neal Uren
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jane Goddard
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andy Treweeke
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Gordon Rushworth
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - David J Webb
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - D Nicholas Bateman
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Ian L Megson
- Free Radical Research Facility, University of the Highlands & Islands, Inverness, UK
| | - Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service (Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
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Raffort J, Lareyre F, Katsiki N, Mikhailidis DP. Contrast-induced nephropathy in non-cardiac vascular procedures, a narrative review: Part 1. Curr Vasc Pharmacol 2021; 20:3-15. [PMID: 34238194 DOI: 10.2174/1570161119666210708165119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 11/22/2022]
Abstract
Contrast-induced nephropathy (CIN) is an important complication of iodinated contrast medium (CM) administration, which is associated with both short- and long-term adverse outcomes (e.g., cardiorenal events, longer hospital stay, and mortality). CIN has been mainly studied in relation to cardiac procedures, but it can also occur following non-cardiac vascular interventions. This is Part 1 of a narrative review summarizing the available literature on CIN after non-cardiac vascular diagnostic or therapeutic procedures for aortic aneurysm and carotid stenosis. We discuss the definition, pathophysiology, incidence, risk factors, biomarkers, and consequences of CIN in these settings, as well as preventive strategies and alternatives to limit iodinated CM use. Physicians and vascular surgeons should be aware of CM-related adverse events and the potential strategies to avoid them. Clearly, more research in this important field is required.
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Affiliation(s)
- Juliette Raffort
- Clinical Chemistry Laboratory, University Hospital of Nice. France
| | - Fabien Lareyre
- Université Côte d'Azur, CHU, Inserm U1065, C3M, Nice. France
| | - Niki Katsiki
- First Department of Internal Medicine, Diabetes Center, Division of Endocrinology and Metabolism, AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
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Efe SC, Karagöz A, Doğan C, Bayram Z, Cakmak EO, Kalkan S, Aslan K, Güven S, Tanboga HI, Ayca B, Karabağ T, Kaymaz C, Ozdemir N. Prognostic significance of malnutrition scores in elderly patients for the prediction of contrast-induced acute kidney injury. Int J Clin Pract 2021; 75:e14274. [PMID: 33908146 DOI: 10.1111/ijcp.14274] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/22/2021] [Accepted: 04/22/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Malnutrition reflects the general condition of a patient including physical condition, protein turnover, and immune competence. Contrast-induced acute kidney injury (CI-AKI) is a disorder that adversely affects the prognosis of older adults. In our study, we aimed to show the relationship between CI-AKI and malnutrition status in elderly patients over 65 years of age with chronic coronary artery disease (CAD). METHODS Study enrolled 360 consecutive patients with coronary angiography performed because of chronic coronary artery disease. Patients pre-procedural and post-procedural blood samples were taken and prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, and geriatric nutritional risk index (GNRI) malnutrition scores were calculated. RESULTS The median age of the patients included in the study was 69 (67-72, IQR) and CI-AKI was seen in 91 (25.2%) patients. Univariate regression analysis showed that age, diabetes mellitus, baseline creatinine, body weight-adapted contrast agent, haemoglobin, left ventricular ejection fraction, CONUT score, PNI score, and GNRI score were independent predictors of CI-AKI. In model 1, increase in CONUT score (2 to 5) (OR: 3.21 (2.11-4.88), in model 2, increase in PNI score (37.4 to 45) (OR: 0.34, (0.24-0.49)), and in model 3, increase in GNRI score (89.5 to 103.8) (OR: 0.55, (0.38-0.81)) were independently associated with the presence of CI-AKI. PNI showed better results than other models in discriminating the predictable capability for CI-AKI. CONCLUSION Malnutrition assessment of elderly patients before performing diagnostic or interventional coronary procedures could help clinicians to identify patients with elevated risk for CI-AKI.
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Affiliation(s)
- Süleyman C Efe
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | - Ali Karagöz
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | - Cem Doğan
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | - Zübeyde Bayram
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | - Ender O Cakmak
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | - Sedat Kalkan
- Department of Cardiology, Pendik State Hospital, Istanbul, Turkey
| | - Kürsat Aslan
- Department of Cardiology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Saadet Güven
- Department of Cardiology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | | | - Burak Ayca
- Department of Cardiology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Turgut Karabağ
- Department of Cardiology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | - Nihal Ozdemir
- Department of Cardiology, Kartal Kosuyolu Education and Research Hospital, Istanbul, Turkey
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