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Wang C, Su J, Li J, Wei W, Yuan Z, Chen R, Wei W, Huang Y, Ye L, Liang H, Jiang J. Blood Lead Mediates the Relationship between Biological Aging and Hypertension: Based on the NHANES Database. Nutrients 2024; 16:2144. [PMID: 38999891 PMCID: PMC11243065 DOI: 10.3390/nu16132144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024] Open
Abstract
Hypertension remains a major global public health crisis due to various contributing factors, such as age and environmental exposures. This study delves into exploring the intricate association between biological aging, blood lead levels, and hypertension, along with examining the mediating role of blood lead levels in the relationship between biological aging and hypertension. We analyzed data from two cycles of the NHANES, encompassing 4473 individuals aged 18 years and older. Our findings indicate that biological aging potentially escalates the risk of hypertension and the incidences of systolic blood pressure (SBP) and diastolic blood pressure (DBP) abnormalities. Utilizing weighted quantile sum (WQS) and quantile g-computation (QGC) model analyses, we observed that exposure to heavy metal mixtures, particularly lead, may elevate the likelihood of hypertension, SBP, and DBP abnormalities. Further mediation analysis revealed that lead significantly mediated the relationship between biological aging and hypertension and between biological aging and SBP abnormalities, accounting for 64% (95% CI, 49% to 89%) and 64% (95% CI, 44% to 88%) of the effects, respectively. These outcomes emphasize the criticality of implementing environmental health measures.
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Affiliation(s)
- Cuixiao Wang
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Jinming Su
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical BioResource Development and Application Co-Constructed by the Province and Ministry, Life Science Institute, Guangxi Medical University, Nanning 530021, China
| | - Jinmiao Li
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Wenfei Wei
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Zongxiang Yuan
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Rongfeng Chen
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Wudi Wei
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Youjin Huang
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
| | - Li Ye
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical BioResource Development and Application Co-Constructed by the Province and Ministry, Life Science Institute, Guangxi Medical University, Nanning 530021, China
| | - Hao Liang
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical BioResource Development and Application Co-Constructed by the Province and Ministry, Life Science Institute, Guangxi Medical University, Nanning 530021, China
| | - Junjun Jiang
- Guangxi Crucial Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning 530021, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical BioResource Development and Application Co-Constructed by the Province and Ministry, Life Science Institute, Guangxi Medical University, Nanning 530021, China
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Li Y, Haseler E, McNally R, Sinha MD, Chowienczyk PJ. A meta-analysis of the haemodynamics of primary hypertension in children and adults. J Hypertens 2023; 41:212-219. [PMID: 36583348 PMCID: PMC9799046 DOI: 10.1097/hjh.0000000000003326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/22/2022] [Accepted: 10/21/2022] [Indexed: 12/31/2022]
Abstract
We performed a systematic review and meta-analysis to determine the relative contributions of elevated cardiac output and systemic vascular resistance to hypertension in children and adults. This included 27 studies on 11 765 hypertensive and normotensive children and adults in whom cardiac output was measured. Cardiac output but not systemic vascular resistance was elevated in hypertensive compared to normotensive children and young adults (difference in means 1.15 [0.78-1.52] l/min, P < 0.001). In older hypertensive adults, both were elevated compared to normotensive individuals (0.40 [0.26-0.55] l/min, P < 0.001 and 3.21 [1.91-4.51] mmHg min/l, P < 0.001 for cardiac output and systemic vascular resistance, respectively). The main haemodynamic alteration in primary hypertension (including obesity-hypertension) in both children and young to middle-aged adults is an elevation of cardiac output. With longer duration and greater severity of hypertension there may be progression from a 'cardiac' to a 'vascular' phenotype with increased systemic vascular resistance.
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Affiliation(s)
- Ye Li
- King's College London British Heart Foundation Centre, St. Thomas’ Hospital, Westminster Bridge
| | | | - Ryan McNally
- King's College London British Heart Foundation Centre, St. Thomas’ Hospital, Westminster Bridge
| | - Manish D. Sinha
- King's College London British Heart Foundation Centre, St. Thomas’ Hospital, Westminster Bridge
- Evelina Children's Hospital, London, UK
| | - Phil J. Chowienczyk
- King's College London British Heart Foundation Centre, St. Thomas’ Hospital, Westminster Bridge
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Ribeiro ASF, Zerolo BE, López-Espuela F, Sánchez R, Fernandes VS. Cardiac System during the Aging Process. Aging Dis 2023:AD.2023.0115. [PMID: 37163425 PMCID: PMC10389818 DOI: 10.14336/ad.2023.0115] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/15/2023] [Indexed: 05/12/2023] Open
Abstract
The aging process is accompanied by a continuous decline of the cardiac system, disrupting the homeostatic regulation of cells, organs, and systems. Aging increases the prevalence of cardiovascular diseases, thus heart failure and mortality. Understanding the cardiac aging process is of pivotal importance once it allows us to design strategies to prevent age-related cardiac events and increasing the quality of live in the elderly. In this review we provide an overview of the cardiac aging process focus on the following topics: cardiac structural and functional modifications; cellular mechanisms of cardiac dysfunction in the aging; genetics and epigenetics in the development of cardiac diseases; and aging heart and response to the exercise.
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Affiliation(s)
| | - Blanca Egea Zerolo
- Escuela de Enfermería y Fisioterapia San Juan de Dios. Universidad Pontificia Comillas, Madrid, Spain
| | - Fidel López-Espuela
- Metabolic Bone Diseases Research Group, Nursing and Occupational Therapy College, University of Extremadura, Caceres, Spain
| | - Raúl Sánchez
- Unidad de Cardiopatías Congénitas, Hospital Universitario La Paz, Madrid, Spain
| | - Vítor S Fernandes
- Departamento de Fisiología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
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Addetia K, Miyoshi T, Amuthan V, Citro R, Daimon M, Fajardo PG, Kasliwal RR, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Ronderos RE, Sadeghpour A, Scalia GM, Takeuchi M, Tsang W, Tucay ES, Tude Rodrigues AC, Zhang Y, Hitschrich N, Blankenhagen M, Degel M, Schreckenberg M, Mor-Avi V, Asch FM, Lang RM. Normal Values of Left Ventricular Size and Function on 3D Echocardiography: Results of the World Alliance of Societies of Echocardiography Study. J Am Soc Echocardiogr 2021; 35:449-459. [PMID: 34920112 DOI: 10.1016/j.echo.2021.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Echocardiography remains the most widely used modality to assess left ventricular (LV) chamber size and function. Currently this assessment is most frequently performed using 2D echocardiography (2DE). Yet, 3D echocardiography (3DE) has been shown to be more accurate and reproducible than 2DE. Current normative reference values for 3D LV analysis are predominantly based on data from North America and Europe. The World Alliance of Societies of Echocardiography (WASE) study was a designed to sample normal subjects from around the world to provide more universal global reference ranges. In this study we sought to assess the world-wide feasibility of LV 3DE and report on size and function measurements. METHODS 2262 healthy subjects were prospectively enrolled from 19 centers in 15 countries. 3D LV full-volume datasets were obtained and analyzed offline with vendor-neutral software. Measurements included end-diastolic and end-systolic volumes (EDV, ESV), ejection fraction (EF), global longitudinal and circumferential strain (GLS and GCS). Results were categorized by age (18-40, 41-65 and >65 years), sex and race. RESULTS 1589 subjects (feasibility 70%) had adequate LV datasets for analysis. Mean normal values for indexed EDV, ESV and EF in men and women were 70 ± 15 and 65 ± 12 mL, 28 ± 7 and 25 ± 6 mL and 60 ± 5, 62 ± 5% respectively. Men had larger LV volumes and lower EF than women. GLS and GCS were higher in magnitude in women. In both sexes, LV volumes were lower and EF tended to be higher with increasing age, especially considering the differences between the youngest and oldest age groups. While GLS was similar across age groups in men, in women, the youngest and middle-age cohorts revealed higher magnitudes of GLS when compared to the oldest age group. GCS was higher in magnitude at older age in both men and women. Finally, Asians had smaller chamber sizes and higher EF and absolute strain values than both blacks and whites. CONCLUSIONS Age, sex, and race should be considered when defining normal reference values for LV dimension and function parameters obtained by 3DE.
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Bojer AS, Soerensen MH, Gaede P, Myerson S, Madsen PL. Left Ventricular Diastolic Function Studied with Magnetic Resonance Imaging: A Systematic Review of Techniques and Relation to Established Measures of Diastolic Function. Diagnostics (Basel) 2021; 11:diagnostics11071282. [PMID: 34359363 PMCID: PMC8305340 DOI: 10.3390/diagnostics11071282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: In recent years, cardiac magnetic resonance (CMR) has been used to assess LV diastolic function. In this systematic review, studies were identified where CMR parameters had been evaluated in healthy and/or patient groups with proven diastolic dysfunction or known to develop heart failure with preserved ejection fraction. We aimed at describing the parameters most often used, thresholds where possible, and correlation to echocardiographic and invasive measurements. Methods and results: A systematic literature review was performed using the databases of PubMed, Embase, and Cochrane. In total, 3808 articles were screened, and 102 studies were included. Four main CMR techniques were identified: tagging; time/volume curves; mitral inflow quantification with velocity-encoded phase-contrast sequences; and feature tracking. Techniques were described and estimates were presented in tables. From published studies, peak change of torsion shear angle versus volume changes in early diastole (−dφ′/dV′) (from tagging analysis), early peak filling rate indexed to LV end-diastolic volume <2.1 s−1 (from LV time-volume curve analysis), enlarged LA maximal volume >52 mL/m2, lowered LA total (<40%), and lowered LA passive emptying fractions (<16%) seem to be reliable measures of LV diastolic dysfunction. Feature tracking, especially of the atrium, shows promise but is still a novel technique. Conclusion: CMR techniques of LV untwisting and early filling and LA measures of poor emptying are promising for the diagnosis of LV filling impairment, but further research in long-term follow-up studies is needed to assess the ability for the parameters to predict patient related outcomes.
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Affiliation(s)
- Annemie Stege Bojer
- Department of Cardiology and Endocrinology, Slagelse Hospital, 4200 Slagelse, Denmark; (M.H.S.); (P.G.)
- Institute of Regional Health Research, University of Sothern Denmark, 5230 Odense, Denmark
- Correspondence:
| | - Martin Heyn Soerensen
- Department of Cardiology and Endocrinology, Slagelse Hospital, 4200 Slagelse, Denmark; (M.H.S.); (P.G.)
| | - Peter Gaede
- Department of Cardiology and Endocrinology, Slagelse Hospital, 4200 Slagelse, Denmark; (M.H.S.); (P.G.)
- Institute of Regional Health Research, University of Sothern Denmark, 5230 Odense, Denmark
| | - Saul Myerson
- Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford OX1 2JD, UK;
| | - Per Lav Madsen
- Department of Cardiology, Copenhagen University Hospital, 2730 Herlev, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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Kusy K, Błażejewski J, Gilewski W, Karasek D, Banach J, Bujak R, Zieliński J, Sinkiewicz W, Grześk G. Aging Athlete's Heart: An Echocardiographic Evaluation of Competitive Sprint- versus Endurance-Trained Master Athletes. J Am Soc Echocardiogr 2021; 34:1160-1169. [PMID: 34175421 DOI: 10.1016/j.echo.2021.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sports training triggers exercise-induced cardiac remodeling (EICR). Sprint- and endurance-trained master athletes are exposed to different hemodynamic stimuli accompanied by aging. The aim of this study was to compare EICR types in light of the Morganroth hypothesis, frequency of abnormalities, and relationships between cardiac traits and age. METHODS In this observational cross-sectional study, echocardiographic examinations were conducted in 143 sprint-trained (age range, 36-83 years) and 114 endurance-trained (age range, 38-85 years) competitive master athletes. Structural and functional characteristics were compared with population reference values, and EICR types were identified. Athletic groups were compared using t tests and χ2 tests. Relationships with age were assessed using linear regression. RESULTS In the sprint group, 51.0% of athletes had normal cardiac geometry (nonhypertrophic heart), 4.2% had eccentric hypertrophy, 36.4% had concentric remodeling, and 8.4% had concentric hypertrophy. In their endurance-trained peers, these proportions were 22.8%, 16.7%, 36.8%, and 23.7%, respectively. Many athletes in both groups had structural abnormalities, as assessed using population norms (up to ~81% for septal thickness) but their resting cardiac function was normal. The relationships of structural and functional cardiac characteristics with age were mostly weak to moderate and did not differ between training modalities. CONCLUSIONS Even though many endurance- and sprint-oriented master athletes exceed population norms for cardiac structure, they do not go beyond the "gray zone" and preserve normal cardiac function. Therefore, physiologic adaptations, rather than pathologic abnormalities, are expected in aging but still active athletes. Inconsistent with the Morganroth hypothesis, EICR is shifted toward normal geometry in sprinters and toward concentric remodeling and hypertrophy in endurance runners. A better understanding of the mechanisms behind cardiac remodeling during aging is needed to adequately predict EICR types in master athletes.
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Affiliation(s)
- Krzysztof Kusy
- Department of Athletics, Strength and Conditioning, Faculty of Sport Sciences, Poznan University of Physical Education, Poznań, Poland.
| | - Jan Błażejewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Wojciech Gilewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Danuta Karasek
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Joanna Banach
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Robert Bujak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Jacek Zieliński
- Department of Athletics, Strength and Conditioning, Faculty of Sport Sciences, Poznan University of Physical Education, Poznań, Poland
| | - Władysław Sinkiewicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
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Grobbel MR, Lee LC, Watts SW, Fink GD, Roccabianca S. Left ventricular geometry, tissue composition, and residual stress in High Fat Diet Dahl-Salt sensitive rats. EXPERIMENTAL MECHANICS 2021; 61:191-201. [PMID: 33776071 PMCID: PMC7990029 DOI: 10.1007/s11340-020-00664-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/02/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Hypertension drives myocardial remodeling, leading to changes in structure, composition and mechanical behavior, including residual stress, which are linked to heart disease progression in a gender-specific manner. Emerging therapies are also targeting constituent-specific pathological features. All previous studies, however, have characterized remodeling in the intact tissue, rather than isolated tissue constituents, and did not include sex as a biological variable. OBJECTIVE In this study we first identified the contribution of collagen fiber network and myocytes to the myocardial residual stress/strain in Dahl-Salt sensitive rats fed with high fat diet. Then, we quantified the effect of hypertension on the remodeling of the left ventricle (LV), as well as the existence of sex-specific remodeling features. METHODS We performed mechanical tests (opening angle, ring-test) and histological analysis on isolated constituents and intact tissue of the LV. Based on the measurements from the tests, we performed a stress analysis to evaluate the residual stress distribution. Statistical analysis was performed to identify the effects of constituent isolation, elevated blood pressure, and sex of the animal on the output of both experimental measures and modeling results. RESULTS Hypertension leads to reduced residual stress/strain intact tissue, isolated collagen fibers, and isolated myocytes in male and female rats. Collagen remains the largest contributor to myocardial residual stress in both normotensive and hypertensive animals. We identified sex-differences in both hypertensive and normotensive animals. CONCLUSIONS We observed both constituent- and sex-specific remodeling features in the LV of an animal model of hypertension.
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Affiliation(s)
- M. R. Grobbel
- Michigan State University, Mechanical Engineering Department
| | - L. C. Lee
- Michigan State University, Mechanical Engineering Department
| | - S. W. Watts
- Michigan State University, Pharmacology & Toxicology Department
| | - G. D. Fink
- Michigan State University, Pharmacology & Toxicology Department
| | - S. Roccabianca
- Michigan State University, Mechanical Engineering Department
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Alem MM, Alshehri AM. Inter-relationships between left ventricular mass, geometry and arterial stiffness. J Int Med Res 2020; 48:300060520903623. [PMID: 32237948 PMCID: PMC7132812 DOI: 10.1177/0300060520903623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To investigate the inter-relationships between left ventricular mass (LVM), left ventricular (LV) geometry and arterial stiffness parameters (aortic pulse wave velocity [Ao-PWV] and heart rate-corrected augmentation index [c-AIx]) in patients with chronic heart failure (CHF). Methods This study was a secondary analysis of existing data that were collected from patients with CHF New York Heart Association class I–III with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Transthoracic echocardiography was performed on all patients, along with measurement of arterial stiffness parameters (Ao-PWV and c-AIx) using sphygmocardiography. Results A total of 73 patients (58 males) with a mean ± SD age of 55.9 ± 11.6 years were enrolled in this study. Of these, 20 patients (27.4%) had systemic hypertension, 46 (63.0%) had type 2 diabetes mellitus. Ischaemic heart disease was the main aetiology of CHF (63 of 73 patients; 86.3%). In multiple linear regression, the left ventricular mass index (LVMI) was significantly associated with c-AIx (β = –1.59) and EF (β = –1.51). Comparison of Ao-PWV among the four LV geometric patterns revealed significant differences. Conclusion In this cohort of CHF patients, LVMI was predicted by c-AIx and EF. The corresponding values of Ao-PWV were parallel in different LV geometric patterns and confirmed their adverse prognostic values.
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Affiliation(s)
- Manal M. Alem
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Manal M. Alem, Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, PO Box 1982, Building A76 King Faisal Road, Dammam 31441, Saudi Arabia.
| | - Abdullah M. Alshehri
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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MacGowan GA, Jakovljevic DG. Exercise Hemodynamics to Evaluate the Breathless Patient: Defining the Normal Pulmonary Arterial Wedge Pressure. J Card Fail 2018; 25:123-124. [PMID: 30528706 DOI: 10.1016/j.cardfail.2018.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Guy A MacGowan
- Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom; Institutes of Genetic Medicine and Cellular Medicine, Cardiovascular Research Centre, Newcastle University, Newcastle Upon Tyne, United Kingdom.
| | - Djordje G Jakovljevic
- Institutes of Genetic Medicine and Cellular Medicine, Cardiovascular Research Centre, Newcastle University, Newcastle Upon Tyne, United Kingdom
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