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Suen WL, Bhasin S, Betti V, Bruckel JT, Oldham MA. Mental health and transcatheter aortic valve replacement: A scoping systematic review. Gen Hosp Psychiatry 2024; 86:10-23. [PMID: 38043178 PMCID: PMC10842766 DOI: 10.1016/j.genhosppsych.2023.11.009] [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: 10/18/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To systematically review the literature on mental health symptoms before and after transcatheter aortic valve replacement (TAVR) and describe reported clinical associations with these symptoms. METHODS Using the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines, we reviewed studies involving pre- or post-TAVR mental health assessments or psychiatric diagnoses. RESULTS Eighteen studies were included. Before TAVR, clinically significant depression and anxiety prevalence is 15-30% and 25-30%, respectively, with only a third of these meeting diagnostic thresholds. These symptoms generally improve over the year post-TAVR. Depression is associated with functional impairment, multimorbidity, and lower physical activity; few associations have been described in relation to anxiety. Inconsistent evidence finds depression associated with post-TAVR mortality. One notable study found persistent depression independently predictive of 12-month mortality, and another found depression and cognition to have additive value in predicting mortality risk. CONCLUSIONS Mental health symptoms occur in a significant proportion of the TAVR population. Although symptoms tend to improve, the associations with depression, particularly persistent depression, call for further investigation to examine their associated outcomes. Research is also needed to understand the relationships between mental health conditions and cognition in TAVR-related outcomes.
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Affiliation(s)
- Wei-Li Suen
- Department of Psychiatry, University of Rochester Medical Center, USA
| | - Shreya Bhasin
- School of Medicine & Dentistry, University of Rochester Medical Center, USA
| | - Vincent Betti
- School of Medicine & Dentistry, University of Rochester Medical Center, USA
| | | | - Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, USA.
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2
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Zou J, Yuan J, Liu J, Geng Q. Impact of cardiac rehabilitation on pre- and post-operative transcatheter aortic valve replacement prognoses. Front Cardiovasc Med 2023; 10:1164104. [PMID: 38152609 PMCID: PMC10751363 DOI: 10.3389/fcvm.2023.1164104] [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: 02/12/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is a relatively new treatment method for aortic stenosis (AS) and has been demonstrated to be suitable for patients with varying risk levels. Indeed, among high-risk patients, TAVR outcomes are comparable to, or even better, than that of the traditional surgical aortic valve replacement (SAVR) method. TAVR outcomes, with respect to post-surgical functional capacity and quality of life, have also been found to be improved, especially when combined with cardiac rehabilitation (CR). CR is a multidisciplinary system, which integrates cardiology with other medical disciplines, such as sports, nutritional, mind-body, and behavioral medicine. It entails the development of appropriate medication, exercise, and diet prescriptions, along with providing psychological support, ensuring the cessation of smoking, and developing risk factor management strategies for cardiovascular disease patients. However, even with CR being able to improve TAVR outcomes and reduce post-surgical mortality rates, it still has largely been underutilized in clinical settings. This article reviews the usage of CR during both pre-and postoperative periods for valvular diseases, and the factors involved in influencing subsequent patient prognoses, thereby providing a direction for subsequent research and clinical applications.
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Affiliation(s)
- Jieru Zou
- The Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Jie Yuan
- The Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
- Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
- Department of Cardiology, Shenzhen Cardiovascular Minimally Invasive Medical Engineering Technology Research and Development Center, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
- Department of Geriatrics, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Jingjin Liu
- The Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
- Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
- Department of Cardiology, Shenzhen Cardiovascular Minimally Invasive Medical Engineering Technology Research and Development Center, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
- Department of Geriatrics, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Qingshan Geng
- The Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
- Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
- Department of Cardiology, Shenzhen Cardiovascular Minimally Invasive Medical Engineering Technology Research and Development Center, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
- Department of Geriatrics, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
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3
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El-Sabawi B, Cloud H, Patel JN, Bell SP, Elmariah S, Fearon WF, Kim JB, Piana RN, Kapadia SR, Kumbhani DJ, Gillam LD, Whisenant BK, Quader N, Zajarias A, Welt FG, Bavry AA, Coylewright M, Vatterott A, Jackson N, Huang S, Lindman BR. Association of Depression and Cognitive Dysfunction With Patient-Centered Outcomes After Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2023; 16:e012875. [PMID: 37503662 DOI: 10.1161/circinterventions.123.012875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Depression and cognitive dysfunction (CD) are not routinely screened for in patients before transcatheter aortic valve replacement (TAVR) and their association with postprocedural outcomes is poorly understood. The objectives of this study are to determine the prevalence of depression and CD in patients with aortic stenosis undergoing TAVR and evaluate their association with mortality and quality of life. METHODS We analyzed a prospective, multicenter TAVR registry that systematically screened patients for preexisting depression and CD with the Patient Health Questionnaire-2 and Mini-Cog, respectively. The associations with mortality were assessed with Cox proportional hazard models and quality of life (Kansas City Cardiomyopathy Questionnaire and EuroQol visual analogue scale) were evaluated using multivariable ordinal regression models. RESULTS A total of 884 patients were included; median follow-up was 2.88 years (interquartile range=1.2-3.7). At baseline, depression was observed in 19.6% and CD in 31.8%. In separate models, after adjustment, depression (HR, 1.45 [95% CI, 1.13-1.86]; P<0.01) and CD (HR, 1.27 [95% CI, 1.02-1.59]; P=0.04) were each associated with increased mortality. Combining depression and CD into a single model, mortality was greatest among those with both depression and CD (n=62; HR, 2.06 [CI, 1.44-2.96]; P<0.01). After adjustment, depression was associated with 6.6 (0.3-13.6) points lower on the Kansas City Cardiomyopathy Questionnaire 1-year post-TAVR and 6.7 (0.5-12.7) points lower on the EuroQol visual analogue scale. CD was only associated with lower EuroQol visual analogue scale. CONCLUSIONS Depression and CD are common in patients that undergo TAVR and are associated with increased mortality and worse quality of life. Depression may be a modifiable therapeutic target to improve outcomes after TAVR.
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Affiliation(s)
- Bassim El-Sabawi
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Harrison Cloud
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Jay N Patel
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Susan P Bell
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Sammy Elmariah
- Department of Medicine, Division of Cardiology, University of California San Francisco (S.E.)
| | - William F Fearon
- Department of Medicine, Division of Cardiology, Stanford Medical Center, Palo Alto, CA (W.F.F., J.B.K.)
| | - Juyong B Kim
- Department of Medicine, Division of Cardiology, Stanford Medical Center, Palo Alto, CA (W.F.F., J.B.K.)
| | - Robert N Piana
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Samir R Kapadia
- Department of Medicine, Division of Cardiology, Cleveland Clinic Foundation, OH (S.R.K.)
| | - Dharam J Kumbhani
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K., A.A.B.)
| | - Linda D Gillam
- Department of Cardiovascular Medicine, Morristown Medical Center, NJ (L.D.G.)
| | - Brian K Whisenant
- Department of Medicine, Division of Cardiology, Intermountain Heart Institute, Murray, UT (B.K.W.)
| | - Nishath Quader
- Department of Medicine, Division of Cardiology, Barnes-Jewish Hospital, St Louis, MO (N.Q., A.Z.)
| | - Alan Zajarias
- Department of Medicine, Division of Cardiology, Barnes-Jewish Hospital, St Louis, MO (N.Q., A.Z.)
| | - Frederick G Welt
- Department of Medicine, Division of Cardiology, University of Utah Hospital, Salt Lake City (F.G.W.)
| | - Anthony A Bavry
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K., A.A.B.)
| | - Megan Coylewright
- Department of Internal Medicine, Division of Cardiovascular Medicine, Erlanger Heart and Lung Institute, Chattanooga, TN (M.C.)
| | - Anna Vatterott
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Natalie Jackson
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (N.J., B.R.L.)
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN (S.H.)
| | - Brian R Lindman
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (N.J., B.R.L.)
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4
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Kocanda L, Schumacher TL, Plotnikoff RC, Whatnall MC, Fenwick M, Brown LJ, Rollo ME, Jansson A, Burrows TL, Duncan MJ, Britton B, May J, Kerr J, Rutherford J, Boyle A, Inder K, Collins CE. Effectiveness and reporting of nutrition interventions in cardiac rehabilitation programmes: a systematic review. Eur J Cardiovasc Nurs 2023; 22:1-12. [PMID: 35672581 DOI: 10.1093/eurjcn/zvac033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 01/14/2023]
Abstract
AIMS Dietary modification is essential for the secondary prevention of cardiovascular disease. However, there are limited published evidence syntheses to guide practice in the cardiac rehabilitation (CR) setting. This systematic review's objective was to assess effectiveness and reporting of nutrition interventions to optimize dietary intake in adults attending CR. METHODS AND RESULTS Randomized controlled trials (RCTs) of nutrition interventions within CR were eligible for inclusion and had to have measured change in dietary intake. MEDLINE, Embase, Emcare, PsycINFO, CINAHL, Scopus, and The Cochrane Library were searched from 2000 to June 2020, limited to publications in English. Evidence from included RCTs was synthesized descriptively. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. This review is registered on PROSPERO; CRD42020188723. Of 13 048 unique articles identified, 11 were eligible. Randomized controlled trials were conducted in 10 different countries, included 1542 participants, and evaluated 29 distinct dietary intake outcomes. Five studies reported statistically significant changes in diet across 13 outcomes. Most nutrition interventions were not reported in a manner that allowed replication in clinical practice or future research. CONCLUSION There is a gap in research testing high-quality nutrition interventions in CR settings. Findings should be interpreted in the light of limitations, given the overall body of evidence was heterogenous across outcomes and study quality; 6 of 11 studies were conducted more than 10 years old. Future research should investigate strategies to optimize and maintain nutrition improvements for patients attending CR. REGISTRATION PROSPERO; CRD42020188723.
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Affiliation(s)
- Lucy Kocanda
- Department of Rural Health, University of Newcastle, Tamworth, NSW 2340, Australia.,School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Tracy L Schumacher
- Department of Rural Health, University of Newcastle, Tamworth, NSW 2340, Australia.,Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Ronald C Plotnikoff
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Megan C Whatnall
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.,School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Matthew Fenwick
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Leanne J Brown
- Department of Rural Health, University of Newcastle, Tamworth, NSW 2340, Australia.,Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Megan E Rollo
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Anna Jansson
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,School of Education, College of Human and Social Futures, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Tracy L Burrows
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Mitch J Duncan
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.,Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Ben Britton
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Jennifer May
- Department of Rural Health, University of Newcastle, Tamworth, NSW 2340, Australia
| | - Jane Kerr
- Hunter New England Local Health District, Tamworth, NSW 2340, Australia
| | - Julie Rutherford
- Hunter New England Local Health District, Maitland, NSW 2320, Australia
| | - Andrew Boyle
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Kerry Inder
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Clare E Collins
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.,School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
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5
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Tamulevičiūtė-Prascienė E, Beigienė A, Lukauskaitė U, Gerulytė K, Kubilius R, Bjarnason-Wehrens B. Effectiveness of additional resistance and balance training and telephone support program in exercise-based cardiac rehabilitation on quality of life and physical activity: Randomized control trial. Clin Rehabil 2021; 36:511-526. [PMID: 34881670 DOI: 10.1177/02692155211065632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate 20 days and 3 months follow-up effectiveness of cardiac rehabilitation (CR) enhanced by resistance/balance training and telephone-support program compared to usual CR care in improving quality of life, clinical course and physical activity behavior. DESIGN Single-centre randomized controlled trial. SETTING Inpatient CR clinic. SUBJECTS 116 (76.1 ± 6.7 years, 50% male) patients 14.5 ± 5.9 days after valve surgery/intervention were randomized to intervention group (IG, n = 60) or control group (CG, n = 56). INTERVENTION Additional resistance/balance training (3 days/week) during phase-II CR and telephone-support program during 3-month follow-up. CG patients were provided with usual CR care. MAIN MEASURES Short Form 36 Health Survey scales, European Quality of Life 5 Dimensions 3 Level Version QoL index, visual analog scale, clinical course, and physical activity behavior assessed with standardized questionnaires. RESULTS IG reported statistically significant higher mental component score (48.5 ± 6.91 vs. 40.3 ± 11.21 at the baseline, 50.8 ± 9.76 vs. 42.6 ± 9.82 after 20 days, 49.4 ± 8.45 vs. 40.5 ± 8.9 after 12 weeks follow up), general health (48.6 ± 3.17 vs. 45.0 ± 2.95 at the baseline, 53.6 ± 3.02 vs. 43.8 ± 2.55 after 20 days, 53.2 ± 3.11 vs. 44.2 ± 3.07 after 12 weeks) and role limitations due to emotional problems (48.5 ± 15.2 vs. 27.7 ± 11.5 at the baseline, 72.7 ± 12.6 vs. 30.5 ± 11.2 after 20 days, 66.6 ± 14.2 vs. 36.1 ± 11.2 after 12 weeks) in all three assessments (p < 0.05). CG patients had more documented hospital admissions (4 (8%) vs 10 (25%), p = 0.027), atrial fibrillation paroxysms (3 (6.0%) vs. 10 (35.0%), p = 0.011) and blood pressure swings (13 (26%) vs. 20 (50%), p = 0.019). IG patients chose more different physical activities (1.7 ± 0.7 vs. 1.25 ± 0.63, p = 0.002), spent more time being physical active every day (195.6 ± 78.6 vs. 157.29 ± 78.8, p = 0.002). CONCLUSIONS The addition of resistance/balance exercises and telephone-support program 12 weeks after to the CR could linked to higher physical activity levels and fewer clinical complications but did not lead to a significant improvement in quality of life.
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Affiliation(s)
| | - Aurelija Beigienė
- Rehabilitation department, 230647Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Urtė Lukauskaitė
- Faculty of medicine, 230647Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kamilė Gerulytė
- Faculty of medicine, 230647Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Raimondas Kubilius
- Rehabilitation department, 230647Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Birna Bjarnason-Wehrens
- Department of Preventive and Rehabilitative Sport and Exercise Medicine, Institute of Cardiology and Sports Medicine, 14926German Sport University Cologne, Cologne, Germany
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Malik AH, Shetty SS, Yandrapalli S, Accaoui RE. Renin-angiotensin blockade after aortic valve replacement: A review based on current literature. Eur J Prev Cardiol 2019; 27:2113-2115. [PMID: 31349777 DOI: 10.1177/2047487319865949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aaqib H Malik
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, USA
| | - Suchith S Shetty
- Division of Cardiology, Department of Internal Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa City, USA
| | - Srikanth Yandrapalli
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, USA
| | - Ramzi El Accaoui
- Division of Cardiology, Department of Internal Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa City, USA
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7
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Affiliation(s)
- Massimo F Piepoli
- Heart Failure Unit, G da Saliceto Hospital, Italy
- Institute of Life Sciences, Scuola Superiore Sant Anna, Sant Anna School of Advanced Studies, Pisa, Italy
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8
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Affiliation(s)
- Roberto Fe Pedretti
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Institute of Pavia, Italy
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