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Miceli G, Basso MG, Pintus C, Pennacchio AR, Cocciola E, Cuffaro M, Profita M, Rizzo G, Tuttolomondo A. Molecular Pathways of Vulnerable Carotid Plaques at Risk of Ischemic Stroke: A Narrative Review. Int J Mol Sci 2024; 25:4351. [PMID: 38673936 PMCID: PMC11050267 DOI: 10.3390/ijms25084351] [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: 02/26/2024] [Revised: 04/05/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
The concept of vulnerable carotid plaques is pivotal in understanding the pathophysiology of ischemic stroke secondary to large-artery atherosclerosis. In macroscopic evaluation, vulnerable plaques are characterized by one or more of the following features: microcalcification; neovascularization; lipid-rich necrotic cores (LRNCs); intraplaque hemorrhage (IPH); thin fibrous caps; plaque surface ulceration; huge dimensions, suggesting stenosis; and plaque rupture. Recognizing these macroscopic characteristics is crucial for estimating the risk of cerebrovascular events, also in the case of non-significant (less than 50%) stenosis. Inflammatory biomarkers, such as cytokines and adhesion molecules, lipid-related markers like oxidized low-density lipoprotein (LDL), and proteolytic enzymes capable of degrading extracellular matrix components are among the key molecules that are scrutinized for their associative roles in plaque instability. Through their quantification and evaluation, these biomarkers reveal intricate molecular cross-talk governing plaque inflammation, rupture potential, and thrombogenicity. The current evidence demonstrates that plaque vulnerability phenotypes are multiple and heterogeneous and are associated with many highly complex molecular pathways that determine the activation of an immune-mediated cascade that culminates in thromboinflammation. This narrative review provides a comprehensive analysis of the current knowledge on molecular biomarkers expressed by symptomatic carotid plaques. It explores the association of these biomarkers with the structural and compositional attributes that characterize vulnerable plaques.
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Affiliation(s)
- Giuseppe Miceli
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Maria Grazia Basso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Chiara Pintus
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Andrea Roberta Pennacchio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Elena Cocciola
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Mariagiovanna Cuffaro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Martina Profita
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Giuliana Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; (G.M.); (M.G.B.); (C.P.); (A.R.P.); (E.C.); (M.C.); (M.P.); (G.R.)
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone”, 90127 Palermo, Italy
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Breitenstein A, Gay A, Vogtländer K, Fox KAA, Steffel J. The Net Clinical Outcome of Dual-Pathway Inhibition in Clinical Practice: The "Xarelto plus Acetylsalicylic Acid: Treatment Patterns and Outcomes in Patients with Atherosclerosis" Registry. J Clin Med 2024; 13:1956. [PMID: 38610724 PMCID: PMC11012443 DOI: 10.3390/jcm13071956] [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: 02/22/2024] [Revised: 03/17/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: In the COMPASS trial, the combination of acetylsalicylic acid (ASA) plus 2.5 mg rivaroxaban twice daily (dual-pathway inhibition, DPI) has been shown to be superior to ASA monotherapy for the reduction in ischemic major adverse cardiovascular events (MACEs, i.e., cardiovascular death, stroke, or myocardial infarction). Methods: The international XATOA registry (Xarelto plus Acetylsalicylic acid: Treatment patterns and Outcomes in patients with Atherosclerosis) is a prospective post-approval registry that investigates the cardiovascular outcomes of patients taking ASA plus 2.5 mg rivaroxaban. The aim of this pre-specified analysis was to determine the net clinical outcome (NCO), i.e., a combination of MACEs and bleeding events, of DPI in patients from daily clinical practice. Results: Among the 5615 patients, the presence of multiple risk factors resulted in an increase in the total risk of experiencing an NCO event, e.g., from 1.27% (one risk factor) to 2.18% (two risk factors) and 4.07% (three or more risk factors), respectively, with ischemic MACE representing the primary driver of bleeding complications. Conclusions: In the real-world XATOA registry, the annual rate of NCO events was low and numerically similar to those seen in the treatment group in the randomized COMPASS trial.
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Affiliation(s)
- Alexander Breitenstein
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland;
- University of Zurich, 8006 Zurich, Switzerland
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK;
| | - Jan Steffel
- University of Zurich, 8006 Zurich, Switzerland
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Potashnikova D, Maryukhnich E, Vorobyeva D, Rusakovich G, Komissarov A, Tvorogova A, Gontarenko V, Vasilieva E. Cytokine Profiling of Plasma and Atherosclerotic Plaques in Patients Undergoing Carotid Endarterectomy. Int J Mol Sci 2024; 25:1030. [PMID: 38256102 PMCID: PMC10816498 DOI: 10.3390/ijms25021030] [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: 10/11/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Atherosclerotic plaques are sites of chronic inflammation with diverse cell contents and complex immune signaling. Plaque progression and destabilization are driven by the infiltration of immune cells and the cytokines that mediate their interactions. Here, we attempted to compare the systemic cytokine profiles in the blood plasma of patients with atherosclerosis and the local cytokine production, using ex vivo plaque explants from the same patients. The developed method of 41-plex xMAP data normalization allowed us to differentiate twenty-two cytokines produced by the plaque that were not readily detectable in free circulation and six cytokines elevated in blood plasma that may have other sources than atherosclerotic plaque. To verify the xMAP data on the putative atherogenesis-driving chemokines MCP-1 (CCL2), MIP-1α (CCL3), MIP-1β (CCL4), RANTES (CCL5), and fractalkine (CX3CL1), qPCR was performed. The MIP1A (CCL3), MIP1B (CCL4), FKN (CX3CL1), and MCP1 (CCL2) genes were expressed at high levels in the plaques, whereas RANTES (CCL5) was almost absent. The expression patterns of the chemokines were restricted to the plaque cell types: the MCP1 (CCL2) gene was predominantly expressed in endothelial cells and monocytes/macrophages, MIP1A (CCL3) in monocytes/macrophages, and MIP1B (CCL4) in monocytes/macrophages and T cells. RANTES (CCL5) was restricted to T cells, while FKN (CX3CL1) was not differentially expressed. Taken together, our data indicate a plaque-specific cytokine production profile that may be a useful tool in atherosclerosis studies.
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Affiliation(s)
- Daria Potashnikova
- Laboratory of Atherothrombosis, Cardiology Department, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127006 Moscow, Russia
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
| | - Elena Maryukhnich
- Laboratory of Atherothrombosis, Cardiology Department, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127006 Moscow, Russia
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
| | - Daria Vorobyeva
- Laboratory of Atherothrombosis, Cardiology Department, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127006 Moscow, Russia
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
| | - George Rusakovich
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
| | - Alexey Komissarov
- Laboratory of Atherothrombosis, Cardiology Department, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127006 Moscow, Russia
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
- National Research Center “Kurchatov Institute”, 123182 Moscow, Russia
| | - Anna Tvorogova
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
| | - Vladimir Gontarenko
- Department of Vascular Surgery, National Medical Research Centre of Surgery Named after A.V. Vishnevsky under the RF Public Health Ministry, 117997 Moscow, Russia
| | - Elena Vasilieva
- Laboratory of Atherothrombosis, Cardiology Department, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127006 Moscow, Russia
- City Clinical Hospital Named after I.V. Davydovsky, Moscow Department of Healthcare, 109240 Moscow, Russia; (G.R.)
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Cartland SP, Stanley CP, Bursill C, Passam F, Figtree GA, Patel S, Loa J, Golledge J, Robinson DA, Aitken SJ, Kavurma MM. Sex, Endothelial Cell Functions, and Peripheral Artery Disease. Int J Mol Sci 2023; 24:17439. [PMID: 38139267 PMCID: PMC10744086 DOI: 10.3390/ijms242417439] [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: 10/03/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/24/2023] Open
Abstract
Peripheral artery disease (PAD) is caused by blocked arteries due to atherosclerosis and/or thrombosis which reduce blood flow to the lower limbs. It results in major morbidity, including ischemic limb, claudication, and amputation, with patients also suffering a heightened risk of heart attack, stroke, and death. Recent studies suggest women have a higher prevalence of PAD than men, and with worse outcomes after intervention. In addition to a potential unconscious bias faced by women with PAD in the health system, with underdiagnosis, and lower rates of guideline-based therapy, fundamental biological differences between men and women may be important. In this review, we highlight sexual dimorphisms in endothelial cell functions and how they may impact PAD pathophysiology in women. Understanding sex-specific mechanisms in PAD is essential for the development of new therapies and personalized care for patients with PAD.
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Affiliation(s)
- Siân P. Cartland
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
| | - Christopher P. Stanley
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
| | - Christina Bursill
- South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia;
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
| | - Freda Passam
- Faculty of Health and Medicine, The University of Sydney, Sydney, NSW 2050, Australia; (F.P.); (G.A.F.); (S.J.A.)
| | - Gemma A. Figtree
- Faculty of Health and Medicine, The University of Sydney, Sydney, NSW 2050, Australia; (F.P.); (G.A.F.); (S.J.A.)
- Kolling Institute of Medical Research, Sydney, NSW 2064, Australia
| | - Sanjay Patel
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
- Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia (D.A.R.)
| | - Jacky Loa
- Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia (D.A.R.)
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia;
- Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, QLD 4814, Australia
| | | | - Sarah J. Aitken
- Faculty of Health and Medicine, The University of Sydney, Sydney, NSW 2050, Australia; (F.P.); (G.A.F.); (S.J.A.)
- Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Mary M. Kavurma
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
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Das D, Shruthi NR, Banerjee A, Jothimani G, Duttaroy AK, Pathak S. Endothelial dysfunction, platelet hyperactivity, hypertension, and the metabolic syndrome: molecular insights and combating strategies. Front Nutr 2023; 10:1221438. [PMID: 37614749 PMCID: PMC10442661 DOI: 10.3389/fnut.2023.1221438] [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: 05/12/2023] [Accepted: 07/25/2023] [Indexed: 08/25/2023] Open
Abstract
Metabolic syndrome (MetS) is a multifaceted condition that increases the possibility of developing atherosclerotic cardiovascular disease. MetS includes obesity, hypertension, dyslipidemia, hyperglycemia, endothelial dysfunction, and platelet hyperactivity. There is a concerning rise in the occurrence and frequency of MetS globally. The rising incidence and severity of MetS need a proactive, multipronged strategy for identifying and treating those affected. For many MetS patients, achieving recommended goals for healthy fat intake, blood pressure control, and blood glucose management may require a combination of medicine therapy, lifestyles, nutraceuticals, and others. However, it is essential to note that lifestyle modification should be the first-line therapy for MetS. In addition, MetS requires pharmacological, nutraceutical, or other interventions. This review aimed to bring together the etiology, molecular mechanisms, and dietary strategies to combat hypertension, endothelial dysfunction, and platelet dysfunction in individuals with MetS.
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Affiliation(s)
- Diptimayee Das
- Faculty of Allied Health Sciences, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
| | - Nagainallur Ravichandran Shruthi
- Faculty of Allied Health Sciences, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
| | - Antara Banerjee
- Faculty of Allied Health Sciences, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
| | - Ganesan Jothimani
- Faculty of Allied Health Sciences, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
| | - Asim K. Duttaroy
- Faculty of Medicine, Department of Nutrition, Institute of Medical Sciences, University of Oslo, Oslo, Norway
| | - Surajit Pathak
- Faculty of Allied Health Sciences, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
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Wei JH, Lee WJ, Luo JL, Huang HL, Wang SC, Chou RH, Huang PH, Lin SJ. Vertical Sleeve Gastrectomy Offers Protection against Disturbed Flow-Induced Atherosclerosis in High-Fat Diet-Fed Mice. Int J Mol Sci 2023; 24:ijms24065669. [PMID: 36982743 PMCID: PMC10051344 DOI: 10.3390/ijms24065669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Bariatric surgery reduces body weight, enhances metabolic and diabetic control, and improves outcomes on obesity-related comorbidities. However, the mechanisms mediating this protection against cardiovascular diseases remain unclear. We investigated the effect of sleeve gastrectomy (SG) on vascular protection in response to shear stress-induced atherosclerosis using an overweighted and carotid artery ligation mouse model. Eight-week-old male wild-type mice (C57BL/6J) were fed a high-fat diet (HFD) for two weeks to induce weight gain and dysmetabolism. SG was performed in HFD-fed mice. Two weeks after the SG procedure, partial carotid-artery ligation was performed to promote disturbed flow-induced atherosclerosis. Compared with the control mice, HFD-fed wild-type mice exhibited increased body weight, total cholesterol level, hemoglobin A1c, and enhanced insulin resistance; SG significantly reversed these adverse effects. As expected, HFD-fed mice exhibited greater neointimal hyperplasia and atherosclerotic plaques than the control group, and the SG procedure attenuated HFD-promoted ligation-induced neointimal hyperplasia and arterial elastin fragmentation. Besides, HFD promoted ligation-induced macrophage infiltration, matrix metalloproteinase-9 expression, upregulation of inflammatory cytokines, and increased vascular endothelial growth factor secretion. SG significantly reduced the above-mentioned effects. Moreover, HFD restriction partially reversed the intimal hyperplasia caused by carotid artery ligation; however, this protective effect was significantly lower than that observed in SG-operated mice. Our study demonstrated that HFD deteriorates shear stress-induced atherosclerosis and SG mitigates vascular remodeling, and this protective effect was not comparable in HFD restriction group. These findings provide a rationale for using bariatric surgery to counter atherosclerosis in morbid obesity.
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Affiliation(s)
- Jih-Hua Wei
- Division of Cardiology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan 330, Taiwan; (J.-H.W.)
- School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, Taoyuan 330, Taiwan
| | - Jing-Lin Luo
- Division of Cardiology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan 330, Taiwan; (J.-H.W.)
| | - Hsin-Lei Huang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei 112, Taiwan
| | - Shen-Chih Wang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Ruey-Hsing Chou
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Department of Anesthesiology, Taipei Veteran General Hospital, Taipei 112, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 112, Taiwan
| | - Po-Hsun Huang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Department of Anesthesiology, Taipei Veteran General Hospital, Taipei 112, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 112, Taiwan
- Correspondence: ; Tel.: +886-2-2875-7374; Fax: +886-2-2875-7375
| | - Shing-Jong Lin
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Anesthesiology, Taipei Veteran General Hospital, Taipei 112, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei 112, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei 110, Taiwan
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