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Visser C, Yousefi A, Nierman MC, Huisman MV, Gulpen AJW, van Ommen CH, Kruip MJHA. The effect of COVID-19 vaccination on anticoagulation stability in adolescents and young adults using vitamin K antagonists. Thromb Res 2023; 228:121-127. [PMID: 37321159 PMCID: PMC10258126 DOI: 10.1016/j.thromres.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/21/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The European Medicine Agency has authorized COVID-19 vaccination in adolescents and young adults (AYAs) from 12 years onwards. In elderly vitamin K antagonist (VKA) users, COVID-19 vaccination has been associated with an increased risk of supra- and subtherapeutic INRs. Whether this association is also observed in AYAs using VKA is unknown. Our aim was to describe the stability of anticoagulation after COVID-19 vaccination in AYA VKA users. MATERIALS AND METHODS A case-crossover study was performed in a cohort of AYAs (12-30 years) using VKAs. The most recent INR results before vaccination, the reference period, were compared with the most recent INR after the first and, if applicable, second vaccination. Several sensitivity analyses were performed in which we restricted our analysis to stable patients and patients without interacting events. RESULTS 101 AYAs were included, with a median age [IQR] of 25 [7] years, of whom 51.5 % were male and 68.3 % used acenocoumarol. We observed a decrease of 20.8 % in INRs within range after the first vaccination, due to an increase of 16.8 % in supratherapeutic INRs. These results were verified in our sensitivity analyses. No differences were observed after the second vaccination compared to before and after the first vaccination. Complications after vaccination occurred less often than before vaccination (9.0 vs 3.0 bleedings) and were non-severe. CONCLUSIONS the stability of anticoagulation after COVID-19 vaccination was decreased in AYA VKA users. However, the decrease might not be clinically relevant as no increase of complications nor significant dose adjustments were observed.
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Affiliation(s)
- Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Arjen Yousefi
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Anouk J W Gulpen
- Department of Internal Medicine, The Elkerliek Hospital, Helmond, the Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands; Thrombosis Service Star-shl, Rotterdam, the Netherlands.
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Gulpen AJW, Braeken DCW, Schalla S, Ten Cate H, Crijns HJ, Ten Cate-Hoek AJ. Long-term adherence to direct oral anticoagulants in patients with atrial fibrillation; a comparative cross-sectional study. Acta Haematol 2022; 145:476-483. [PMID: 35306490 DOI: 10.1159/000524094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Long-term treatment with direct oral anticoagulants (DOAC) is required for the majority of patients with non-valvular atrial fibrillation (AF) to prevent ischemic stroke and systemic embolism. Adherence to therapy may impact clinical outcomes. Therefore, the purpose of this study was to assess the potential impact of structured follow-up on long-term adherence to DOAC therapy compared to standard care. METHODS This is a cross sectional study on the implementation phase of medication adherence to DOACs, comparing patients with AF following completion of structured follow-up of minimally 1 year with those who received standard care. All patients used DOACs for more than two years and completed a questionnaire on adherence. Adherence was measured with the MMAS-8 score and assessed via an online webportal. RESULTS A total of 212 patients were included. The mean MMAS-8 score was 7.55(SD 0.93) after structured follow-up and 7.25(SD 1.01) for standard care; p=0.045. Following structured follow-up 64.1% of patients had a high adherence (MMAS score of 8) compared to 50% receiving standard care; p=0.05. Patients following structured follow-up on a once daily DOAC regime had higher MMAS-8 scores compared to those on a twice daily regime; 7.74(SD 0.74) vs. 7.00(SD 1.22); p<0.001. The rates of minor bleedings were 10.6% versus 21.4% respectively, p=0.038. CONCLUSION In patients on long-term DOAC treatment, adherence to therapy was significantly increased after receiving an initial period of structured follow-up compared to standard care. Additionally, adherence to DOAC therapy was higher with once-daily treatment regimen. Significant more minor bleedings were reported in the standard care group. . These results indicate that implementation of structured follow-up of patients with AF using DOACs merits further evaluation.
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Affiliation(s)
- Anouk J W Gulpen
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dionne C W Braeken
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
| | - Simon Schalla
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology and Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Harry J Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology and Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arina J Ten Cate-Hoek
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Visser C, Biedermann JS, Nierman MC, van der Meer FJM, Gulpen AJW, Moors YCF, Cannegieter SC, Lijfering WM, Kruip MJHA. The Immediate Effect of COVID-19 Vaccination on Anticoagulation Control in Patients Using Vitamin K Antagonists. Thromb Haemost 2022; 122:377-385. [PMID: 35245945 PMCID: PMC8899332 DOI: 10.1055/s-0042-1742628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background
In January 2021, the Dutch vaccination program against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was started. Clinical studies have shown that systemic reactions occur in up to 50% of vaccine recipients. Therefore, COVID-19 vaccination could affect anticoagulation control, potentially leading to an increased risk of thrombotic events and bleeding complications.
Aims
This article investigates whether the BNT162b2 vaccine affects anticoagulation control in outpatients using vitamin K antagonists (VKAs).
Methods
A case-crossover study was performed in a cohort of outpatient VKA users from four Dutch anticoagulation clinics who received a BNT162b2 vaccine. International normalized ratio (INR) results and VKA dosages before the first vaccination, the reference period, were compared with those after the first and second vaccination.
Results
A total of 3,148 outpatient VKA users were included, with a mean age (standard deviation) of 86.7 (8.7) years, of whom 43.8% were male, 67.0% used acenocoumarol, and 33.0% phenprocoumon. We observed a decrease of 8.9% of INRs within range in the standard intensity group (target INR 2.0–3.0). There was both an increased risk of supratherapeutic (odds ratio [OR] = 1.34 [95% confidence interval [CI] 1.08–1.67]) and subtherapeutic levels (OR = 1.40 [95% CI 1.08–1.83]) after first vaccination. In the high-intensity group (target INR 2.5–3.5), the risk of a supratherapeutic INR was 2.3 times higher after first vaccination (OR = 2.29 [95% CI 1.22–4.28]) and 3.3 times higher after second vaccination (OR = 3.25 [95% CI 1.06–9.97]).
Conclusion
BNT162b2 was associated with an immediate negative effect on anticoagulation control in patients treated with VKAs, so it is advisable to monitor the INR shortly after vaccination, even in stable patients.
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Affiliation(s)
- Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joseph S Biedermann
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, The Netherlands
| | - Felix J M van der Meer
- Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anouk J W Gulpen
- Department of Internal Medicine, Elkerliek Hospital, Helmond, The Netherlands
| | - Yvonne C F Moors
- Department of Internal Medicine, Elkerliek Hospital, Helmond, The Netherlands
| | - Suzanne C Cannegieter
- Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Kennisinstituut van de Federatie Medisch Specialisten, Utrecht, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.,Thrombosis Service Star-shl, Rotterdam, The Netherlands
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Gulpen AJW, Teijink JAW. Pectoralis minor muscle causes venous thoracic outlet syndrome: visualised using venography. Lancet 2022; 399:e1. [PMID: 34998504 DOI: 10.1016/s0140-6736(21)02647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/04/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Anouk J W Gulpen
- Department of Internal Medicine, Elkerliek Hospital, Helmond, Netherlands.
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, Netherlands
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Strauven L, van der Wolk S, Gulpen AJW. [A man with Covid-19 and abdominal pain]. Ned Tijdschr Geneeskd 2022; 166:D6381. [PMID: 35138740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A 53-year-old man, diagnosed with Covid19, experienced pain in the left flank. Imaging results showed multiple spleen infarction. While thrombotic events are common complications in Covid19, diagnosing and imaging a spleen infarction is rather rare. There is no clear loss of contrast in the picture, which suggests local inflammation and coagulation in capillary vessels as physiological mechanism. Conflict of interest and financial support: none declared.
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Affiliation(s)
- Lisa Strauven
- Elkerliek ziekenhuis, afd Interne Geneeskunde, Helmond
- Contact: Lisa Strauven
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Giesen PLA, Gulpen AJW, van Oerle R, Ten Cate H, Nagy M, Spronk HMH. Calibrated automated thrombogram II: removing barriers for thrombin generation measurements. Thromb J 2021; 19:60. [PMID: 34454531 PMCID: PMC8399793 DOI: 10.1186/s12959-021-00312-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/13/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Thrombin generation (TG) assessed by Calibrated Automated Thrombogram (CAT-I) reflects the overall capacity of plasma to generate thrombin, thus evaluating the balance between the anti- and procoagulant processes. However, with this method the calibrator curve is usually not measured until completion which has a severe impact on the calculation of the TG parameters, especially under conditions where almost all substrate is consumed. In addition, direct thrombin inhibitor (DTI) cannot be present in the calibration sample due to inhibition of the calibrator. We have developed a modified TG assay (CAT-II) and performed head-to-head comparison with the CAT-I method using the same fluorometer. Furthermore, we have compared our CAT-II method to a new automated TG instrument (ST®-Genesia) using the same calibration method. METHODS TG was assessed with CAT-I and CAT-II using the same fulorometer and with ST®-Genesia in control plasma and plasma containing different anticoagulants (dabigatran, rivaroxaban, apixaban) and plasmas to which common interfering substances, bilirubin, hemoglobin and lipids were added. In CAT-I, calibration was against the same plasma containing calibrator in the presence of fluorogenic substrate (Z-GGR-AMC). In contrast, CAT-II method and ST®-Genesia used a standard concentration of thrombin in buffer and 7-amino-4-methylcoumarin (AMC) in a separate plasma sample for calibration. RESULTS TG obtained from CAT-I using anticoagulant-free plasmas was lower compared with TG from CAT-II but both methods demonstrated an intra-assay variation less than 5% on all measured parameters. When comparing the two different calibration methods in the presence of different anticoagulants, a high correlation was seen in the presence of rivaroxaban and apixaban (R2 > 0.97), but not with dabigatran, a direct thrombin inhibitor. CAT-II method showed dose-dependent inhibition of TG in the presence of dabigatran, while CAT-I was not able to detect it. Both methods were able to correct for the interfering substances. CONCLUSIONS Our results showed high similarity between the results of CAT-I and CAT-II method when it is applied in control plasmas and plasmas not inhibited with a direct thrombin inhibitor. Furthermore, both the CAT-II method and ST-Genesia using the same calibration method were able to detect the effect of all oral anticoagulants. Taken together, applying a new calibration method is a significant improvement for monitoring patients on direct thrombin inhibitors while not introducing any bias to results obtained on other types of samples.
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Affiliation(s)
| | - A J W Gulpen
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - R van Oerle
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - H Ten Cate
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Nagy
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - H M H Spronk
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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Abstract
Direct oral anticoagulants (DOACs) are recommended by several scientific societies as first-line therapy for the prevention of stroke and systemic embolism in patients with atrial fibrillation. However, there is uncertainty regarding the organisation of anticoagulation care, with various caregivers being involved. Patients and caregivers are often confronted by uncertainty about the coordination of treatment. With the functional resonance analysis method we visualised the process of anticoagulation care in daily practice in the Maastricht region. This resulted in recommendations on how to improve the organisation of anticoagulation care for DOAC patients.
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Affiliation(s)
- A J W Gulpen
- Thrombosis Expertise Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | - N L Damen
- Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - H Ten Cate
- Thrombosis Expertise Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S Schalla
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - A J Ten Cate-Hoek
- Thrombosis Expertise Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Gulpen AJW, Claessen RJM, Vanmolkot FHM. [PCSK9 inhibitors; who benefits from these new cholesterol-lowering drugs?]. Ned Tijdschr Geneeskd 2020; 164:D4325. [PMID: 32186821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PCSK9 inhibitors are monoclonal antibodies that target the protein PCSK9. These drugs (alirocumab and evolcumab) are a new generation of cholesterol-lowering agents for patients with a very high risk of cardiovascular disease. They lower the LDL cholesterol concentration by approximately 50% in comparison with placebo, thereby lowering the risk of myocardial infarction, stroke and cardiovascular death in high-risk patients. Due to their high cost and the cost-effectiveness, there are strict conditions for reimbursement for these agents in the Netherlands. PCSK9 inhibitors can be given to high-risk patients in whom, despite maximal medicinal therapy with statins and ezetimibe, the target level of LDL cholesterol cannot be reached. This article gives an overview of the efficacy and the safety of PCSK9 inhibitors, and of their use in the Netherlands.
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Affiliation(s)
- Anouk J W Gulpen
- Maastricht Universitair Medisch Centrum (MUMC+), afd. Interne Geneeskunde, Maastricht
- Contact: Anouk J.W. Gulpen (A.J.W. Gulpen )
| | - Roy J M Claessen
- Maastricht Universitair Medisch Centrum (MUMC+), afd. Interne Geneeskunde, Maastricht
| | - Floris H M Vanmolkot
- Maastricht Universitair Medisch Centrum (MUMC+), afd. Interne Geneeskunde, Maastricht
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Henskens YMC, Gulpen AJW, van Oerle R, Wetzels R, Verhezen P, Spronk H, Schalla S, Crijns HJ, ten Cate H, ten Cate-Hoek A. Detecting clinically relevant rivaroxaban or dabigatran levels by routine coagulation tests or thromboelastography in a cohort of patients with atrial fibrillation. Thromb J 2018; 16:3. [PMID: 29434525 PMCID: PMC5793444 DOI: 10.1186/s12959-017-0160-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/29/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Traditional coagulation tests are included in emergency guidelines for management of patients on direct oral anticoagulants (DOACs) who experience acute bleeding or require surgery. We determined the ability of traditional coagulation tests and fast whole blood thromboelastography (ROTEM®) to screen for anticoagulation activity of dabigatran and rivaroxaban as low as 30 ng/mL. METHODS One hundred eighty-four citrated blood samples (75 dabigatran, 109 rivaroxaban) were collected from patients with non-valvular atrial fibrillation (NVAF), to perform screening tests from different manufacturers, (diluted, D) PT, aPTT, TT and ROTEM®. The activity of DOACs was quantitatively determined by clot detection assays: Hemoclot DTT and DiXaI test (Biophen), on CS2100 (Siemens). The clotting time (CT) of INTEM and EXTEM ROTEM® (Werfen) were used as test parameters. RESULTS Dabigatran, ≥ 30 ng/mL, was accurately detected by five coagulation tests: APTT Actin FSL (93%), PT Neoplastin (93%), APTT Cephascreen, Thromboclotin, and Thrombin (all 100%), but not by PT Innovin (49%). CT-EXTEM (91%) was sufficiently sensitive, but not CT-INTEM (52%). APTT Cephascreen and Thrombin showed good linearity (R2 = 0.71,R2 = 0.72). For the other tests linearity was moderate to poor. Rivaroxaban was accurately detected by PT Neoplastin (98%) and less so by APTT Cephascreen (85%). In addition, rivaroxaban was also accurately detected by CT-INTEM (96%). PT Neoplastin showed good linearity (R2 = 0.81), all other tests had moderate to poor linearity. CONCLUSION In patients with NVAF, the ability of routine coagulation tests to detect the presence of significant levels of DOACs is test and reagent dependent. CT-INTEM and CT-EXTEM may be fast whole blood alternatives. TRIAL REGISTRATION The Institutional Review Board of the MUMC approved this study (December 2011, project number 114069).
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Affiliation(s)
- Yvonne M. C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Anouk J. W. Gulpen
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
- Internal medicine, MUMC+, Maastricht, The Netherlands
| | - René van Oerle
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
| | - Rick Wetzels
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Paul Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Henri Spronk
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
| | - Simon Schalla
- Department of Cardiology, Cardiovascular center MUMC+, Maastricht, The Netherlands
| | - Harry J. Crijns
- Department of Cardiology, Cardiovascular center MUMC+, Maastricht, The Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
- Internal medicine, MUMC+, Maastricht, The Netherlands
| | - Arina ten Cate-Hoek
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Thrombosis Expertise Centre, Vascular medicine, Cardiovascular Centre MUMC+, Maastricht, The Netherlands
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