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Møller JE, Engstrøm T, Jensen LO, Eiskjær H, Mangner N, Polzin A, Schulze PC, Skurk C, Nordbeck P, Clemmensen P, Panoulas V, Zimmer S, Schäfer A, Werner N, Frydland M, Holmvang L, Kjærgaard J, Sørensen R, Lønborg J, Lindholm MG, Udesen NLJ, Junker A, Schmidt H, Terkelsen CJ, Christensen S, Christiansen EH, Linke A, Woitek FJ, Westenfeld R, Möbius-Winkler S, Wachtell K, Ravn HB, Lassen JF, Boesgaard S, Gerke O, Hassager C. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med 2024; 390:1382-1393. [PMID: 38587239 DOI: 10.1056/nejmoa2312572] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND The effects of temporary mechanical circulatory support with a microaxial flow pump on mortality among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock remains unclear. METHODS In an international, multicenter, randomized trial, we assigned patients with STEMI and cardiogenic shock to receive a microaxial flow pump (Impella CP) plus standard care or standard care alone. The primary end point was death from any cause at 180 days. A composite safety end point was severe bleeding, limb ischemia, hemolysis, device failure, or worsening aortic regurgitation. RESULTS A total of 360 patients underwent randomization, of whom 355 were included in the final analysis (179 in the microaxial-flow-pump group and 176 in the standard-care group). The median age of the patients was 67 years, and 79.2% were men. Death from any cause occurred in 82 of 179 patients (45.8%) in the microaxial-flow-pump group and in 103 of 176 patients (58.5%) in the standard-care group (hazard ratio, 0.74; 95% confidence interval [CI], 0.55 to 0.99; P = 0.04). A composite safety end-point event occurred in 43 patients (24.0%) in the microaxial-flow-pump group and in 11 (6.2%) in the standard-care group (relative risk, 4.74; 95% CI, 2.36 to 9.55). Renal-replacement therapy was administered to 75 patients (41.9%) in the microaxial-flow-pump group and to 47 patients (26.7%) in the standard-care group (relative risk, 1.98; 95% CI, 1.27 to 3.09). CONCLUSIONS The routine use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. The incidence of a composite of adverse events was higher with the use of the microaxial flow pump. (Funded by the Danish Heart Foundation and Abiomed; DanGer Shock ClinicalTrials.gov number, NCT01633502.).
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Affiliation(s)
- Jacob E Møller
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Thomas Engstrøm
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Lisette O Jensen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Hans Eiskjær
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Norman Mangner
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Amin Polzin
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - P Christian Schulze
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Carsten Skurk
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Peter Nordbeck
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Peter Clemmensen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Vasileios Panoulas
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Sebastian Zimmer
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Andreas Schäfer
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Nikos Werner
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Martin Frydland
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Lene Holmvang
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Jesper Kjærgaard
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Rikke Sørensen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Jacob Lønborg
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Matias G Lindholm
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Nanna L J Udesen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Anders Junker
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Henrik Schmidt
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Christian J Terkelsen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Steffen Christensen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Evald H Christiansen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Axel Linke
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Felix J Woitek
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Ralf Westenfeld
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Sven Möbius-Winkler
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Kristian Wachtell
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Hanne B Ravn
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Jens F Lassen
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Søren Boesgaard
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Oke Gerke
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
| | - Christian Hassager
- From the Department of Cardiology, Copenhagen University Hospital-Rigshospitalet (J.E.M., T.E., M.F., L.H., J.K., R.S., J.L., S.B., C.H.), and the Department of Clinical Medicine, University of Copenhagen (T.E., L.H., C.H.), Copenhagen, the Departments of Cardiology (J.E.M., L.O.J., N.L.J.U., A.J., J.F.L.), Anesthesiology and Intensive Care (H.S., H.B.R.), and Nuclear Medicine (O.G.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (J.E.M., L.O.J., H.B.R., J.F.L.), Odense, the Departments of Cardiology (H.E., C.J.T., E.H.C.) and Anesthesiology and Intensive Care Medicine (S.C.), Aarhus University Hospital, Aarhus, and the Department of Cardiology, Zealand University Hospital, Roskilde (P.C., M.G.L.) - all in Denmark; the Department of Internal Medicine and Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden (N.M., A.L., F.J.W.), the Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, and the Cardiovascular Research Institute Düsseldorf, Düsseldorf (A.P., R.W.), the Department of Internal Medicine I, Cardiology, Angiology, and Intensive Medical Care, University Hospital Jena, Jena (P.C.S., S.M.-W.), the Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, and Deutsches Zentrum für Herz Kreislauf Forschung, Berlin (C.S.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology, University Heart and Vascular Center, University Clinic Hamburg-Eppendorf, Hamburg (P.C.), the Department of Cardiology, University Hospital Bonn, Bonn (S.Z.), the Department of Cardiology and Angiology, Hannover Medical School, Hannover (A.S.), and the Department of Internal Medicine III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier (N.W.) - all in Germany; the Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom (V.P.); and the Greenberg Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York (K.W.)
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2
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Klein F, Dinesh S, Fiedler D, Grün K, Schrepper A, Bogoviku J, Bäz L, Pfeil A, Kretzschmar D, Schulze PC, Möbius-Winkler S, Franz M. Identification of Serum Interleukin-22 as Novel Biomarker in Pulmonary Hypertension: A Translational Study. Int J Mol Sci 2024; 25:3985. [PMID: 38612795 PMCID: PMC11012889 DOI: 10.3390/ijms25073985] [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: 03/03/2024] [Revised: 03/30/2024] [Accepted: 03/31/2024] [Indexed: 04/14/2024] Open
Abstract
Growing evidence suggests the crucial involvement of inflammation in the pathogenesis of pulmonary hypertension (PH). The current study analyzed the expression of interleukin (IL)-17a and IL-22 as potential biomarkers for PH in a preclinical rat model of PH as well as the serum levels in a PH patient collective. PH was induced by monocrotalin (60 mg/kg body weight s.c.) in 10 Sprague Dawley rats (PH) and compared to 6 sham-treated controls (CON) as well as 10 monocrotalin-induced, macitentan-treated rats (PH_MAC). Lung and cardiac tissues were subjected to histological and immunohistochemical analysis for the ILs, and their serum levels were quantified using ELISA. Serum IL levels were also measured in a PH patient cohort. IL-22 expression was significantly increased in the lungs of the PH and PH_MAC groups (p = 0.002), whereas increased IL17a expression was demonstrated only in the lungs and RV of the PH (p < 0.05) but not the PH_MAC group (p = n.s.). The PH group showed elevated serum concentrations for IL-22 (p = 0.04) and IL-17a (p = 0.008). Compared to the PH group, the PH_MAC group demonstrated a decrease in IL-22 (p = 0.021) but not IL17a (p = n.s.). In the PH patient collective (n = 92), increased serum levels of IL-22 but not IL-17a could be shown (p < 0.0001). This elevation remained significant across the different etiological groups (p < 0.05). Correlation analysis revealed multiple significant relations between IL-22 and various clinical, laboratory, functional and hemodynamic parameters. IL-22 could serve as a promising inflammatory biomarker of PH with potential value for initial diagnosis, functional classification or even prognosis estimation. Its validation in larger patients' cohorts regarding outcome and survival data, as well as the probability of promising therapeutic target structures, remains the object of further studies.
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Affiliation(s)
- Friederike Klein
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Sandesh Dinesh
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Desiree Fiedler
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Katja Grün
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Andrea Schrepper
- Department of Cardiothoracic Surgery, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Jürgen Bogoviku
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Laura Bäz
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Alexander Pfeil
- Department of Internal Medicine III, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Daniel Kretzschmar
- Herz-und Gefäßmedizin Goslar (HUGG), Goslar, Fleischscharren 4, 38640 Goslar, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
| | - Marcus Franz
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (F.K.)
- Department of Cardiology, Angiology and Intensive Care Medicine, Cardiovascular Center Rotenburg Klinikum Hersfeld-Rotenburg, Heinz-Meise-Straße 100, 36199 Rotenburg an der Fulda, Germany
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3
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Banz M, Stallmach A, Gaßler N, Schulze PC, Fritzenwanger M, Cornely O, Kurzai O, Pletz MW. Fatal pulmonary hemorrhage, pneumothorax and skin necrosis caused by IRIS to an Aspergillus flavus infection in a young patient with metamizole associated agranulocytosis. Infection 2024; 52:685-690. [PMID: 38133714 PMCID: PMC10955021 DOI: 10.1007/s15010-023-02149-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
We report the case of a young female with steroid-dependent ulcerative colitis (UC) who developed a complex systemic infection with Aspergillus flavus. This occurred following a UC relapse while vacationing in the Middle East, leading to extended use of metamizole and subsequent agranulocytosis. On her return to Germany, she was hospitalized for neutropenic sepsis and later transferred to our hospital due to persistent cytopenia and suspected Hemophagocytic Lymphohistiocytosis (HLH). Despite initial stabilization with targeted treatment for pulmonary Aspergillus flavus infection, her condition rapidly deteriorated following the onset of an Immune Reconstitution Inflammatory Syndrome (IRIS), which manifested as skin necrosis and pneumothorax after the replenishment of neutrophil granulocytes. The patient eventually died from an unmanageable pulmonary hemorrhage. Microscopy of skin necroses showed a massive presence of Aspergillus flavus, but tissue culture remained negative, suggesting effective antifungal treatment yet delayed phagocytosis due to agranulocytosis. This case underscores the need to consider IRIS in immunosuppressed patients who worsen despite aggressive and appropriately targeted treatment, highlighting its potential beyond the commonly recognized context in HIV-positive patients.
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Affiliation(s)
- Micha Banz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany.
| | - Andreas Stallmach
- Department of Gastroenterology, Hepatology and Infectology, Jena University Hospital, Jena, Germany
| | - Nikolaus Gaßler
- Institute of Pathology, Jena University Hospital, Jena, Germany
| | - P Christian Schulze
- Department of Cardiology, Angiology, and Pulmonology, Jena University Hospital, Jena, Germany
| | - Michael Fritzenwanger
- Department of Cardiology, Angiology, and Pulmonology, Jena University Hospital, Jena, Germany
| | - Oliver Cornely
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Excellence Center for Medical Mycology, Cologne, Germany
| | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
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4
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Haertel F, Kaluza M, Bogoviku J, Westphal J, Fritzenwanger M, Pfeifer R, Kretzschmar D, Doenst T, Moebius-Winkler S, Schulze PC. The Jena Method: Perfusionist Independent, Standby Wet-Primed Extracorporeal Membrane Oxygenation (ECMO) Circuit for Immediate Catheterization Laboratory and/or Hybrid Operating Room Deployment. J Clin Med 2024; 13:1292. [PMID: 38592110 PMCID: PMC10932279 DOI: 10.3390/jcm13051292] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The timely initiation of extracorporeal membrane oxygenation (ECMO) is crucial for providing life support. However, delays can occur when perfusionists are not readily available. The Jena Method aims to address this issue by offering a wet-primed ECMO system that can be rapidly established without the perfusionist's presence. Methods: The goal was to ensure prompt ECMO initiation while maintaining patient safety. The method focuses on meeting hygienic standards, safe primed storage of the circuit, staff training, and providing clear step-by-step instructions for the ECMO unit. Results: Since implementing the Jena Method in 2015, 306 patients received VA-ECMO treatment. Bacterial tests confirmed the sterility of the primed ECMO circuits during a 14-day period. The functionality of all the components of the primed ECMO circuit after 14 days, especially the pump and oxygenator, were thoroughly checked and no malfunction was found to this day. To train staff for independent ECMO initiation, a step-by-step system involves safely bringing the ECMO unit to the intervention site and establishing all connections. This includes powering up, managing recirculation, de-airing the system, and preparing it for cannula connection. A self-developed picture-based guide assists in this process. New staff members learn from colleagues and receive quarterly training sessions by perfusionists. After ECMO deployment, the perfusionist provides a new primed system for a potential next patient. Conclusions: Establishing a permanently wet-primed on-demand extracorporeal life support circuit without direct perfusionist support is feasible and safe. The Jena Method enables rapid ECMO deployment and has the potential to be adopted in emergency departments as well.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Mirko Kaluza
- Department of Cardiothoracic Surgery, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Jurgen Bogoviku
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Julian Westphal
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Michael Fritzenwanger
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ruediger Pfeifer
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Daniel Kretzschmar
- Heart and Vascular Medicine (HUGG), Fleischscharren 4, 38642 Goslar, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sven Moebius-Winkler
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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5
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Beer BN, Kellner C, Goßling A, Sundermeyer J, Besch L, Dettling A, Kirchhof P, Blankenberg S, Bernhardt AM, Brunner S, Colson P, Eckner D, Frank D, Eitel I, Frey N, Eden M, Graf T, Kupka D, Landmesser U, Majunke N, Maniuc O, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Reichenspurner H, Schulze PC, Schwinger RHG, Wechsler A, Skurk C, Thiele H, Varshney AS, Sag CM, Krais J, Westermann D, Schrage B. Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study. Eur Heart J Acute Cardiovasc Care 2024; 13:203-212. [PMID: 37875127 DOI: 10.1093/ehjacc/zuad129] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). METHODS AND RESULTS All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. CONCLUSION Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.
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Affiliation(s)
- Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Alexander M Bernhardt
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Brunner
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Derk Frank
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ingo Eitel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Eden
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Danny Kupka
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | | | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Curt Noel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | - Martin Orban
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St.Rita's Medical Center, Lima, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Hermann Reichenspurner
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Antonia Wechsler
- Department of Internal Medicine II, Klinikum Weiden, Weiden, Germany
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, USA
| | - Can Martin Sag
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jannis Krais
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
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Diab M, Moschovas A, Franz M, Hamadanchi A, Faerber G, Caldonazo T, Kirov H, Lehmann T, Schulze PC, Doenst T. Improving Preoperative Abscess Detection in Infective Endocarditis by Adding Troponin I: A REMOVE Trial Analysis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00035-4. [PMID: 38430098 DOI: 10.1016/j.jcmg.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 03/03/2024]
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Haertel F, Nuding S, Reisberg D, Peters M, Werdan K, Schulze PC, Ebelt H. The Prognostic Value of a Liver Function Test Using Indocyanine Green (ICG) Clearance in Patients with Multiple Organ Dysfunction Syndrome (MODS). J Clin Med 2024; 13:1039. [PMID: 38398351 PMCID: PMC10888702 DOI: 10.3390/jcm13041039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/22/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is common in intensive care units (ICUs) and is associated with high mortality. Although there have been multiple investigations into a multitude of organ dysfunctions, little is known about the role of liver dysfunction. In addition, clinical and laboratory findings of liver dysfunction may occur with a significant delay. Therefore, the aim of this study was to investigate whether a liver function test, based on indocyanine green (ICG)-clearance, contains prognostic information for patients in the early phase of MODS. METHODS The data of this analysis were based on the MODIFY study, which included 70 critically ill patients of a tertiary medical ICU in the early phase of MODS (≤24 h after diagnosis by an APACHE II score ≥ 20 and a sinus rhythm ≥ 90 beats per minute, with the following subgroups: cardiogenic (cMODS) and septic MODS (sMODS)) over a period of 18 months. ICG clearance was characterized by plasma disappearance rate = PDR (%/min); it was measured non-invasively by using the LiMON system (PULSION Medical Systems, Feldkirchen, Germany). The PDR was determined on the day of study inclusion (baseline) and after 96 h. The primary endpoint of this analysis was 28-day mortality. RESULTS ICG clearance was measured in 44 patients of the MODIFY trial cohort, of which 9 patients had cMODS (20%) and 35 patients had sMODS (80%). Mean age: 59.7 ± 16.5 years; 31 patients were men; mean APACHE II score: 33.6 ± 6.3; 28-day mortality was 47.7%. Liver function was reduced in the total cohort as measured by a PDR of 13.4 ± 6.3%/min At baseline, there were no relevant differences between survivors and non-survivors regarding ICG clearance (PDR: 14.6 ± 6.1%/min vs. 12.1 ± 6.5%/min; p = 0.21). However, survivors showed better liver function than non-survivors after 96 h (PDR: 21.9 ± 6.3%/min vs. 9.2 ± 6.3%/min, p < 0.05). Consistent with these findings, survivors but not non-survivors show a significant improvement in the PDR (7.3 ± 6.3%/min vs. -2.9 ± 2.6%/min; p < 0.01) within 96 h. In accordance, receiver-operating characteristic curves (ROCs) at 96 h but not at baseline show a link between the PDR and 28-day mortality (PDR at 96 h: AUC: 0.87, 95% CI: 0.76-0.98; p < 0.01. CONCLUSIONS In our study, we found that ICG clearance at baseline did not provide prognostic information in patients in the early stages of MODS despite being reduced in the total cohort. However, improvement of ICG clearance 96 h after ICU admission is associated with reduced 28-day mortality.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sebastian Nuding
- Department of Internal Medicine III, Cardiology University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle, Germany
- Department of Internal Medicine II, Cardiology, Hospital St. Elisabeth and St. Barbara Halle (Saale), Mauerstraße 5, 06110 Halle (Saale), Germany
| | - Diana Reisberg
- Department of pediatrics, Ameos Hospital Aschersleben, Eislebener Str. 7A, 06449 Aschersleben, Germany
| | - Martin Peters
- Department of Internal Medicine, Helios Hospital Jerichower Land, August-Bebel-Str. 55a, 39288 Burg, Germany
| | - Karl Werdan
- Department of Internal Medicine III, Cardiology University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Henning Ebelt
- Department of Internal Medicine III, Cardiology University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle, Germany
- Department of Internal Medicine II, Cardiology, Catholic Hospital “St. Johann Nepomuk”, Haarbergstr. 72, 99097 Erfurt, Germany
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Günther A, Werner A, Fritzenwanger M, Brauer M, Freesmeyer M, Schulze PC, Salih F, Drescher R. Determination of brain death using 99mTc-HMPAO scintigraphy and transcranial duplex sonography in a patient on veno-arterial ECMO. Neurol Res Pract 2024; 6:6. [PMID: 38268033 PMCID: PMC10809543 DOI: 10.1186/s42466-023-00298-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/15/2023] [Indexed: 01/26/2024] Open
Affiliation(s)
- Albrecht Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Anke Werner
- Klinik für Nuklearmedizin, Universitätsklinikum Jena, Jena, Germany
| | | | - Martin Brauer
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Jena, Germany
| | | | | | - Farid Salih
- Klinik für Neurologie mit Experimenteller Neurologie, Charitè Universitätsmedizin, Berlin, Germany
| | - Robert Drescher
- Klinik für Nuklearmedizin, Universitätsklinikum Jena, Jena, Germany
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Heiss J, Grün K, Singerer I, Tempel L, Matasci M, Jung C, Pfeil A, Schulze PC, Neri D, Franz M. Expression of Inflammatory Genes in Murine Lungs in a Model of Experimental Pulmonary Hypertension: Effects of an Antibody-Based Targeted Delivery of Interleukin-9. Adv Respir Med 2024; 92:27-35. [PMID: 38247549 PMCID: PMC10801467 DOI: 10.3390/arm92010005] [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: 11/11/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Pathogenesis of pulmonary hypertension (PH) is a multifactorial process driven by inflammation and pulmonary vascular remodeling. To target these two aspects of PH, we recently tested a novel treatment: Interleukin-9 (IL9) fused to F8, an antibody that binds to the extra-domain A of fibronectin (EDA+ Fn). As EDA+ Fn is not found in healthy adult tissue but is expressed during PH, IL9 is delivered specifically to the tissue affected by PH. We found that F8IL9 reduced pulmonary vascular remodeling and attenuated PH compared with sham-treated mice. PURPOSE To evaluate possible F8IL9 effects on PH-associated inflammatory processes, we analysed the expression of genes involved in pulmonary immune responses. METHODS We applied the monocrotaline (MCT) model of PH in mice (n = 44). Animals were divided into five experimental groups: sham-induced animals without PH (control, n = 4), MCT-induced PH without treatment (PH, n = 8), dual endothelin receptor antagonist treatment (dual ERA, n = 8), F8IL9 treatment (n = 12, 2 formats with n = 6 each), or with KSFIL9 treatment (KSFIL9, n = 12, 2 formats with n = 6 each, KSF: control antibody with irrelevant antigen specificity). After 28 days, a RT-PCR gene expression analysis of inflammatory response (84 genes) was performed in the lung. RESULTS Compared with the controls, 19 genes exhibited relevant (+2.5-fold) upregulation in the PH group without treatment. Gene expression levels in F8IL9-treated lung tissue were reduced compared to the PH group without treatment. This was the case especially for CCL20, CXCL5, C-reactive protein, pentraxin related (CRPPR), and Kininogen-1 (KNG1). CONCLUSION In accordance with the hypothesis stated above, F8IL9 treatment diminished the upregulation of some genes associated with inflammation in a PH animal model. Therefore, we hypothesize that IL9-based immunocytokine treatment will likely modulate various inflammatory pathways.
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Affiliation(s)
- Judith Heiss
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (J.H.); (K.G.); (I.S.); (L.T.); (P.C.S.)
- Else Kröner Graduate School for Medical Students “JSAM”, Jena University Hospital, 07747 Jena, Germany
| | - Katja Grün
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (J.H.); (K.G.); (I.S.); (L.T.); (P.C.S.)
| | - Isabell Singerer
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (J.H.); (K.G.); (I.S.); (L.T.); (P.C.S.)
| | - Laura Tempel
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (J.H.); (K.G.); (I.S.); (L.T.); (P.C.S.)
| | | | - Christian Jung
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Alexander Pfeil
- Department of Internal Medicine III, University Hospital Jena, 07747 Jena, Germany;
| | - P. Christian Schulze
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (J.H.); (K.G.); (I.S.); (L.T.); (P.C.S.)
| | - Dario Neri
- Philochem AG, 8112 Otelfingen, Switzerland; (M.M.)
| | - Marcus Franz
- Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany; (J.H.); (K.G.); (I.S.); (L.T.); (P.C.S.)
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Kretzschmar T, Westphal J, Neugebauer S, Wu JM, Zeller M, Bogoviku J, Bekhite MM, Bekfani T, Schlattmann P, Kiehntopf M, Franz M, Schulze PC. Metabolic Profiling Identifies 1-MetHis and 3-IPA as Potential Diagnostic Biomarkers for Patients With Acute and Chronic Heart Failure With Reduced Ejection Fraction. Circ Heart Fail 2024; 17:e010813. [PMID: 38179791 PMCID: PMC10782933 DOI: 10.1161/circheartfailure.123.010813] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/30/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Metabolomics has become a valuable tool for identifying potential new biomarkers and metabolic profiles. It has the potential to improve the diagnosis and prognosis of different phenotypes of heart failure. To generate a distinctive metabolic profile, we assessed and compared the metabolic phenotypes of patients with acute decompensated heart failure (ADHF), patients with chronic heart failure (CHF), and healthy controls. METHODS Plasma metabolites were analyzed by liquid-chromatography mass spectrometry/mass spectrometry and the MxP Quant 500 kit in 15 patients with ADHF, 50 patients with CHF (25 with dilated cardiomyopathy, 25 with ischemic cardiomyopathy), and 13 controls. RESULTS Of all metabolites identified to be significantly altered, 3-indolepropionic acid and 1-methyl histidine showed the highest concentration differences in ADHF and CHF compared with control. Area under the curve-receiver operating characteristic analysis showed an area under the curve ≥0.8 for 3-indolepropionic acid and 1-methyl histidine, displaying good discrimination capabilities between control and patient cohorts. Additionally, symmetrical dimethylarginine (mean, 1.97±0.61 [SD]; P=0.01) was identified as a suitable biomarker candidate for ADHF and kynurenine (mean, 1.69±0.39 [SD]; P=0.009) for CHF when compared with control, both demonstrating an area under the curve ≥0.85. CONCLUSIONS Our study provides novel insights into the metabolic differences between ADHF and CHF and healthy controls. We here identify new metabolites for potential diagnostic and prognostic purposes.
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Affiliation(s)
- Tom Kretzschmar
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - Julian Westphal
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - Sophie Neugebauer
- Institute of Clinical Chemistry and Laboratory Diagnostics (S.N., M.K.), University Hospital Jena, Germany
| | - Jasmine M.F. Wu
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - Max Zeller
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - Jurgen Bogoviku
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - Mohamed M. Bekhite
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - Tarek Bekfani
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Magdeburg, Germany (T.B.)
| | - Peter Schlattmann
- Department of Medical Statistics, Computer Sciences and Data Science, Centre for Sepsis Control and Care, Jena University Hospital, Germany (P.S.)
| | - Michael Kiehntopf
- Institute of Clinical Chemistry and Laboratory Diagnostics (S.N., M.K.), University Hospital Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Division of Cardiology (T.K., J.W., J.M.F.W., M.Z., J.B., M.M.B., M.F., P.C.S.), University Hospital Jena, Germany
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Jung C, Boeken U, Schulze PC, Frantz S, Hermes C, Kill C, Marohl R, Voigt I, Wolfrum S, Bernhard M, Michels G. [Monitoring of emergency cardiovascular patients in the emergency department : Consensus paper of the DGK, DGINA and DGIIN]. Med Klin Intensivmed Notfmed 2023; 118:47-58. [PMID: 37712970 DOI: 10.1007/s00063-023-01069-w] [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] [Accepted: 06/26/2023] [Indexed: 09/16/2023]
Abstract
Patients with potential or proven cardiovascular diseases represent a relevant proportion of the total spectrum in the emergency department. Their monitoring for cardiovascular surveillance until the diagnostics and acute treatment are initiated, often poses an interdisciplinary and interprofessional challenge, because resources are limited, nevertheless a high level of patient safety has to be ensured and the correct procedure has a major prognostic significance. This consensus paper provides an overview of the practical implementation, the modalities of monitoring and the application in a selection of cardiovascular diagnoses. The article provides specific comments on the clinical presentations of acute coronary syndrome, acute heart failure, cardiogenic shock, hypertensive emergency events, syncope, acute pulmonary embolism and cardiac arrhythmia. The level of evidence is generally low as no randomized trials are available on this topic. The recommendations are intended to supplement or establish local standards and to assist all physicians, nursing personnel and the patients to be treated in making decisions about monitoring in the emergency department.
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Affiliation(s)
- Christian Jung
- Klinik für Kardiologie, Pneumologie und Angiologie des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Udo Boeken
- Klinik für Herzchirurgie des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - P Christian Schulze
- Klinik für Innere Medizin I des Universitätsklinikums Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - Stefan Frantz
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
- Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Deutschland
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Deutschland
| | - Clemens Kill
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Ranka Marohl
- Klinik für Notfall- und Akutmedizin/Interdisziplinäre Notfallambulanz, Krankenhaus Porz am Rhein, Köln, Deutschland
| | - Ingo Voigt
- Klinik für Akut- und Notfallmedizin, Elisabeth-Krankenhaus Essen, Essen, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Schleswig-Holstein am Campus Lübeck, Lübeck, Deutschland
| | - Michael Bernhard
- Zentrale Notaufnahme des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus Trier der Universitätsmedizin Mainz, Trier, Deutschland
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12
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De Filippo O, Cammann VL, Pancotti C, Di Vece D, Silverio A, Schweiger V, Niederseer D, Szawan KA, Würdinger M, Koleva I, Dusi V, Bellino M, Vecchione C, Parodi G, Bossone E, Gili S, Neuhaus M, Franke J, Meder B, Jaguszewski M, Noutsias M, Knorr M, Jansen T, Dichtl W, von Lewinski D, Burgdorf C, Kherad B, Tschöpe C, Sarcon A, Shinbane J, Rajan L, Michels G, Pfister R, Cuneo A, Jacobshagen C, Karakas M, Koenig W, Pott A, Meyer P, Roffi M, Banning A, Wolfrum M, Cuculi F, Kobza R, Fischer TA, Vasankari T, Airaksinen KEJ, Napp LC, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Chan C, Bridgman P, Beug D, Delmas C, Lairez O, Gilyarova E, Shilova A, Gilyarov M, El-Battrawy I, Akin I, Poledniková K, Toušek P, Winchester DE, Massoomi M, Galuszka J, Ukena C, Poglajen G, Carrilho-Ferreira P, Hauck C, Paolini C, Bilato C, Kobayashi Y, Kato K, Ishibashi I, Himi T, Din J, Al-Shammari A, Prasad A, Rihal CS, Liu K, Schulze PC, Bianco M, Jörg L, Rickli H, Pestana G, Nguyen TH, Böhm M, Maier LS, Pinto FJ, Widimský P, Felix SB, Braun-Dullaeus RC, Rottbauer W, Hasenfuß G, Pieske BM, Schunkert H, Budnik M, Opolski G, Thiele H, Bauersachs J, Horowitz JD, Di Mario C, Bruno F, Kong W, Dalakoti M, Imori Y, Münzel T, Crea F, Lüscher TF, Bax JJ, Ruschitzka F, De Ferrari GM, Fariselli P, Ghadri JR, Citro R, D'Ascenzo F, Templin C. Machine learning-based prediction of in-hospital death for patients with takotsubo syndrome: The InterTAK-ML model. Eur J Heart Fail 2023; 25:2299-2311. [PMID: 37522520 DOI: 10.1002/ejhf.2983] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/01/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS Takotsubo syndrome (TTS) is associated with a substantial rate of adverse events. We sought to design a machine learning (ML)-based model to predict the risk of in-hospital death and to perform a clustering of TTS patients to identify different risk profiles. METHODS AND RESULTS A ridge logistic regression-based ML model for predicting in-hospital death was developed on 3482 TTS patients from the International Takotsubo (InterTAK) Registry, randomly split in a train and an internal validation cohort (75% and 25% of the sample size, respectively) and evaluated in an external validation cohort (1037 patients). Thirty-one clinically relevant variables were included in the prediction model. Model performance represented the primary endpoint and was assessed according to area under the curve (AUC), sensitivity and specificity. As secondary endpoint, a K-medoids clustering algorithm was designed to stratify patients into phenotypic groups based on the 10 most relevant features emerging from the main model. The overall incidence of in-hospital death was 5.2%. The InterTAK-ML model showed an AUC of 0.89 (0.85-0.92), a sensitivity of 0.85 (0.78-0.95) and a specificity of 0.76 (0.74-0.79) in the internal validation cohort and an AUC of 0.82 (0.73-0.91), a sensitivity of 0.74 (0.61-0.87) and a specificity of 0.79 (0.77-0.81) in the external cohort for in-hospital death prediction. By exploiting the 10 variables showing the highest feature importance, TTS patients were clustered into six groups associated with different risks of in-hospital death (28.8% vs. 15.5% vs. 5.4% vs. 1.0.8% vs. 0.5%) which were consistent also in the external cohort. CONCLUSION A ML-based approach for the identification of TTS patients at risk of adverse short-term prognosis is feasible and effective. The InterTAK-ML model showed unprecedented discriminative capability for the prediction of in-hospital death.
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Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Victoria L Cammann
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Corrado Pancotti
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Davide Di Vece
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | - Victor Schweiger
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Konrad A Szawan
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Michael Würdinger
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Iva Koleva
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
- Department of Vascular Physiopathology, IRCCS Neuromed, Pozzilli, Italy
| | - Guido Parodi
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Eduardo Bossone
- Division of Cardiology, 'Antonio Cardarelli' Hospital, Naples, Italy
| | | | - Michael Neuhaus
- Department of Cardiology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | - Jennifer Franke
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Meder
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Miłosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michel Noutsias
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine III, Mid-German Heart Center, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Maike Knorr
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Thomas Jansen
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Wolfgang Dichtl
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Behrouz Kherad
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Annahita Sarcon
- Section of Cardiac Electrophysiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jerold Shinbane
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Eschweiler, Germany
| | - Roman Pfister
- Department of Internal Medicine III, Heart Center University of Cologne, Cologne, Germany
| | - Alessandro Cuneo
- Krankenhaus 'Maria Hilf' Medizinische Klinik, Stadtlohn, Germany
| | - Claudius Jacobshagen
- Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany
- Vincentius-Diakonissen Hospital, Karlsruhe, Germany
| | - Mahir Karakas
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Alexander Pott
- Department of Internal Medicine II-Cardiology, Medical Center, University of Ulm, Ulm, Germany
| | - Philippe Meyer
- Service de Cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Marco Roffi
- Service de Cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Adrian Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Mathias Wolfrum
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Florim Cuculi
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Richard Kobza
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Thomas A Fischer
- Department of Cardiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | | | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | | | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Leonarda Galiuto
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Christina Chan
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Paul Bridgman
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Daniel Beug
- Department of Cardiology and Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Clément Delmas
- Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Olivier Lairez
- Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Ekaterina Gilyarova
- Intensive Coronary Care Unit, Moscow City Hospital No 1 named after N. Pirogov, Moscow, Russia
| | - Alexandra Shilova
- Intensive Coronary Care Unit, Moscow City Hospital No 1 named after N. Pirogov, Moscow, Russia
| | - Mikhail Gilyarov
- Intensive Coronary Care Unit, Moscow City Hospital No 1 named after N. Pirogov, Moscow, Russia
| | - Ibrahim El-Battrawy
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Karolina Poledniková
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Petr Toušek
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael Massoomi
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Galuszka
- Department of Internal Medicine I-Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Christian Ukena
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Gregor Poglajen
- Advanced Heart Failure and Transplantation Center, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Pedro Carrilho-Ferreira
- CHULN, Center of Cardiology of the University of Lisbon, Lisbon School of Medicine, Lisbon Academic Medical Center, Santa Maria University Hospital, Lisbon, Portugal
| | - Christian Hauck
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Carla Paolini
- Local Health Unit n. 8, Cardiology Unit, Vicenza, Italy
| | | | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ken Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Iwao Ishibashi
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Toshiharu Himi
- Division of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Jehangir Din
- Dorset Heart Centre, Royal Bournemouth Hospital, Bournemouth, UK
| | - Ali Al-Shammari
- Dorset Heart Centre, Royal Bournemouth Hospital, Bournemouth, UK
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Kan Liu
- Division of Cardiology, Heart and Vascular Center, University of Iowa, Iowa City, IA, USA
| | - P Christian Schulze
- Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Matteo Bianco
- Division of Cardiology, A.O.U. San Luigi Gonzaga, Turin, Italy
| | - Lucas Jörg
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Gonçalo Pestana
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Thanh H Nguyen
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Lars S Maier
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Fausto J Pinto
- CHULN, Center of Cardiology of the University of Lisbon, Lisbon School of Medicine, Lisbon Academic Medical Center, Santa Maria University Hospital, Lisbon, Portugal
| | - Petr Widimský
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Stephan B Felix
- Department of Cardiology and Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | | | - Wolfgang Rottbauer
- Department of Internal Medicine II-Cardiology, Medical Center, University of Ulm, Ulm, Germany
| | - Gerd Hasenfuß
- Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany
| | - Burkert M Pieske
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Monika Budnik
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University Hospital, Leipzig, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - John D Horowitz
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Francesco Bruno
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - William Kong
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Mayank Dalakoti
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Yoichi Imori
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Thomas Münzel
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland
- Royal Brompton and Harefield Hospitals Trust and Imperial College and Kings College, London, UK
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Piero Fariselli
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Jelena R Ghadri
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
| | - Rodolfo Citro
- Department of Vascular Physiopathology, IRCCS Neuromed, Pozzilli, Italy
- Department of Cardio-Thoracic-Vascular, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, and University of Zurich, Zurich, Switzerland
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Haertel F, Lustermann P, Hamadanchi A, Gruen K, Bogoviku J, Aftanski P, Westphal J, Baez L, Franz M, Schulze PC, Moebius-Winkler S. Prognostic Value of Galectin-3 after Left Atrial Appendage Occlusion for Predicting Peri-Device Leakage. Int J Mol Sci 2023; 24:16802. [PMID: 38069127 PMCID: PMC10705923 DOI: 10.3390/ijms242316802] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Echocardiographic detection of residual peri-device leakage (PDL) after percutaneous left atrial appendage occlusion (LAAO) is crucial for managing anticoagulation. Galectin-3, a protein involved in tissue-foreign body interactions, may hold significance in understanding PDL and cardiac tissue remodeling after LAAO. This study aimed to analyze galectin-3 serum levels in relation to PDL using a novel echo-morphological classification. LAAO eligible patients were included in the study. Galectin-3 serum levels were measured before LAAO, at 45 days (45D), and at 6 months (6M) after the procedure. Transesophageal echocardiography was used to assess LAAO success. A new echo-morphological classification categorized the degree of LAAO into three different types (A: homogenous echodensity, indicating completely thrombosed device; B: inhomogeneous echolucencies (<50% of device); and C: partially thrombosed device with echolucencies > 50%). Among 47 patients, complete LAAO was achieved in 60% after 45D and in 74% after 6M. We observed a significant increase and distribution of serum levels of galectin-3 [ng/mL] after 45D among the three types (baseline: 13.1 ± 5.8 ng/mL; 45D: 16.3 ± 7.2 ng/mL (Type A) vs. 19.2 ± 8.6 ng/mL (Type B) vs. 25.8 ± 9.4 ng/mL (Type C); p = 0.031), followed by a drop in galectin-3 for Types A and B after 6M toward and below the baseline levels (6M: 8.9 ± 3.1 ng/mL (Type A) vs. 12.4 ± 5.5 ng/mL (Type B)), whereas Type C persisted in showing elevated galectin-3 levels compared to all other types (6M: 17.5 ± 4.5 ng/mL (Type C); p < 0.01). Increased galectin-3 serum levels after LAAO likely reflect the transition from thrombus formation to fibrotic scar development in the LAA lumen. Successful occlusion is associated with a time-restricted decrease in galectin-3 levels after 6 months, while relevant PDL leads to persistently elevated levels, making galectin-3 a potential predictor of occlusion success.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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14
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Wayda B, Angleitner P, Smits JM, van Kins A, Berchtold-Herz M, De Pauw M, Erasmus ME, Gummert J, Hartyanszky I, Knezevic I, Laufer G, Milicic D, Rega F, Schulze PC, van Caeneghem O, Khush KK, Zuckermann AO. Disparities in donor heart acceptance between the USA and Europe: clinical implications. Eur Heart J 2023; 44:4665-4674. [PMID: 37936176 PMCID: PMC10659950 DOI: 10.1093/eurheartj/ehad684] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND AND AIMS Given limited evidence and lack of consensus on donor acceptance for heart transplant (HT), selection practices vary widely across HT centres in the USA. Similar variation likely exists on a broader scale-across countries and HT systems-but remains largely unexplored. This study characterized differences in heart donor populations and selection practices between the USA and Eurotransplant-a consortium of eight European countries-and their implications for system-wide outcomes. METHODS Characteristics of adult reported heart donors and their utilization (the percentage of reported donors accepted for HT) were compared between Eurotransplant (n = 8714) and the USA (n = 60 882) from 2010 to 2020. Predictors of donor acceptance were identified using multivariable logistic regression. Additional analyses estimated the impact of achieving Eurotransplant-level utilization in the USA amongst donors of matched quality, using probability of acceptance as a marker of quality. RESULTS Eurotransplant reported donors were older with more cardiovascular risk factors but with higher utilization than in the USA (70% vs. 44%). Donor age, smoking history, and diabetes mellitus predicted non-acceptance in the USA and, by a lesser magnitude, in Eurotransplant; donor obesity and hypertension predicted non-acceptance in the USA only. Achieving Eurotransplant-level utilization amongst the top 30%-50% of donors (by quality) would produce an additional 506-930 US HTs annually. CONCLUSIONS Eurotransplant countries exhibit more liberal donor heart acceptance practices than the USA. Adopting similar acceptance practices could help alleviate the scarcity of donor hearts and reduce waitlist morbidity in the USA.
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Affiliation(s)
- Brian Wayda
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, CA
| | - Philipp Angleitner
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria
| | | | | | | | - Michel De Pauw
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Gummert
- Department of Cardiovascular and Thoracic Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | | | - Ivan Knezevic
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria
| | - Davor Milicic
- Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - P Christian Schulze
- Department of Internal Medicine I, Jena University Hospital—Friedrich Schiller University Jena, Am Klinikum 1, Jena, Germany
| | - Olivier van Caeneghem
- Department of Cardiac Research, Université Catholique de Louvain Clinique Saint-Luc, Brussels, Belgium
| | - Kiran K Khush
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, CA
| | - Andreas O Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria
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Makhmudova U, Schatz U, Perakakis N, Kassner U, Schumann F, Axthelm C, Stürzebecher P, Sinning DL, Doevelaar A, Rohn B, Westhoff T, Vogt A, Scholl M, Kästner U, Geiling JA, Stach K, Mensch J, Lorenz E, Paitazoglou C, Eitel I, Baessler A, Steinhagen-Thiessen E, Koenig W, Schulze PC, Landmesser U, Laufs U, Weingärtner O. High interindividual variability in LDL-cholesterol reductions after inclisiran administration in a real-world multicenter setting in Germany. Clin Res Cardiol 2023; 112:1639-1649. [PMID: 37422840 PMCID: PMC10584696 DOI: 10.1007/s00392-023-02247-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND AND AIMS Low-density lipoprotein cholesterol (LDL-C) is the main therapeutic target in the treatment of hypercholesterolemia. Small interfering RNA (siRNA) inclisiran is a new drug, which targets PCSK9 mRNA in the liver, reducing concentrations of circulating LDL-C. In randomized trials, inclisiran demonstrated a substantial reduction in LDL-C. The German Inclisiran Network (GIN) aims to evaluate LDL-C reductions in a real-world cohort of patients treated with inclisiran in Germany. METHODS Patients who received inclisiran in 14 lipid clinics in Germany for elevated LDL-C levels between February 2021 and July 2022 were included in this analysis. We described baseline characteristics, individual LDL-C changes (%) and side effects in 153 patients 3 months (n = 153) and 9 months (n = 79) after inclisiran administration. RESULTS Since all patients were referred to specialized lipid clinics, only one-third were on statin therapy due to statin intolerance. The median LDL-C reduction was 35.5% at 3 months and 26.5% at 9 months. In patients previously treated with PCSK9 antibody (PCSK9-mAb), LDL-C reductions were less effective than in PCSK9-mAb-naïve patients (23.6% vs. 41.1% at 3 months). Concomitant statin treatment was associated with more effective LDL-C lowering. There was a high interindividual variability in LDL-C changes from baseline. Altogether, inclisiran was well-tolerated, and side effects were rare (5.9%). CONCLUSION In this real-world patient population referred to German lipid clinics for elevated LDL-C levels, inclisiran demonstrated a high interindividual variability in LDL-C reductions. Further research is warranted to elucidate reasons for the interindividual variability in drug efficacy.
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Affiliation(s)
- U Makhmudova
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, Friedrich-Schiller-University, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Friede Springer Cardiovascular Prevention Center at Charité, Charité Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany, Berlin, Germany
| | - U Schatz
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - N Perakakis
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden (PLID), Helmholtz Center Munich, University Hospital and Faculty of Medicine, TU Dresden, Dresden, Germany
- German Center for Diabetes Research (DZD E.V.), Neuherberg, Germany
| | - U Kassner
- Clinic for Endocrinology and Metabolic Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | - F Schumann
- Clinic for Endocrinology and Metabolic Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | - C Axthelm
- Cardiologicum Dresden and Pirna, Dresden, Germany
| | - P Stürzebecher
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - D L Sinning
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany, Berlin, Germany
| | - A Doevelaar
- Medical Clinic I, Marien Hospital Herne, University Hospital of the Ruhr-University of Bochum, Herne, Germany
| | - B Rohn
- Medical Clinic I, Marien Hospital Herne, University Hospital of the Ruhr-University of Bochum, Herne, Germany
| | - T Westhoff
- Medical Clinic I, Marien Hospital Herne, University Hospital of the Ruhr-University of Bochum, Herne, Germany
| | - A Vogt
- Department of Internal Medicine IV, University Hospital Munich, Munich, Germany
| | - M Scholl
- Medical Care Centre, Nephrocare Mühlhausen GmbH, Mühlhausen/Thuringia, Germany
| | - U Kästner
- Medical Care Centre, Nephrocare Mühlhausen GmbH, Mühlhausen/Thuringia, Germany
| | - J-A Geiling
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, Friedrich-Schiller-University, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - K Stach
- Department of Internal Medicine V, University Hospital Mannheim, Mannheim, Germany
| | - J Mensch
- Institute for Clinical Chemistry, University Medicine Rostock, Rostock, Germany
| | - E Lorenz
- Deutsches Herzzentrum München, Technical University Munich, Munich, Germany
| | - C Paitazoglou
- Department of Internal Medicine II, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Lübeck, Germany
| | - I Eitel
- Department of Internal Medicine II, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Lübeck, Germany
| | - A Baessler
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - E Steinhagen-Thiessen
- Clinic for Endocrinology and Metabolic Medicine, Charité-University Medicine Berlin, Berlin, Germany
- Friede Springer Cardiovascular Prevention Center at Charité, Charité Universitätsmedizin Berlin, Berlin, Germany
- Institute for Clinical Chemistry, University Medicine Rostock, Rostock, Germany
| | - W Koenig
- Deutsches Herzzentrum München, Technical University Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - P C Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, Friedrich-Schiller-University, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - U Landmesser
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Friede Springer Cardiovascular Prevention Center at Charité, Charité Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany, Berlin, Germany
| | - U Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Oliver Weingärtner
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, Friedrich-Schiller-University, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany.
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16
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Stähli BE, Varbella F, Linke A, Schwarz B, Felix SB, Seiffert M, Kesterke R, Nordbeck P, Witzenbichler B, Lang IM, Kessler M, Valina C, Dibra A, Rohla M, Moccetti M, Vercellino M, Gaede L, Bott-Flügel L, Jakob P, Stehli J, Candreva A, Templin C, Schindler M, Wischnewsky M, Zanda G, Quadri G, Mangner N, Toma A, Magnani G, Clemmensen P, Lüscher TF, Münzel T, Schulze PC, Laugwitz KL, Rottbauer W, Huber K, Neumann FJ, Schneider S, Weidinger F, Achenbach S, Richardt G, Kastrati A, Ford I, Maier W, Ruschitzka F. Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction. N Engl J Med 2023; 389:1368-1379. [PMID: 37634190 DOI: 10.1056/nejmoa2307823] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown. METHODS We performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan-Meier estimates at 6 months and at 1 year. RESULTS We assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event. CONCLUSIONS Among patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.).
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Affiliation(s)
- Barbara E Stähli
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Ferdinando Varbella
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Axel Linke
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Bettina Schwarz
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Stephan B Felix
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Moritz Seiffert
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Rahel Kesterke
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Peter Nordbeck
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Bernhard Witzenbichler
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Irene M Lang
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Mirjam Kessler
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Christian Valina
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Alban Dibra
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Miklos Rohla
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Marco Moccetti
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Matteo Vercellino
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Luise Gaede
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Lorenz Bott-Flügel
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Philipp Jakob
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Julia Stehli
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Alessandro Candreva
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Christian Templin
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Matthias Schindler
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Manfred Wischnewsky
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Greca Zanda
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Giorgio Quadri
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Norman Mangner
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Aurel Toma
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Giulia Magnani
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Peter Clemmensen
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Thomas F Lüscher
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Thomas Münzel
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - P Christian Schulze
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Karl-Ludwig Laugwitz
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Wolfgang Rottbauer
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Kurt Huber
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Franz-Josef Neumann
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Steffen Schneider
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Franz Weidinger
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Stephan Achenbach
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Gert Richardt
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Adnan Kastrati
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Ian Ford
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Willibald Maier
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
| | - Frank Ruschitzka
- From the Department of Cardiology, University Heart Center, University Hospital Zurich, the Center for Translational and Experimental Cardiology, and the Faculty of Medicine (B.E.S., R.K., P.J., J.S., A.C., C.T., M. Schindler, W.M., F.R.) and Center for Molecular Cardiology, University of Zurich (T.F.L.), Zurich, the Department of Cardiology, Bern University Hospital, University of Bern, Bern (M.R.), and Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano (M.M.) - all in Switzerland; the Department of Internal Medicine, Cardiology Unit, Rivoli Hospital, Turin (F.V., G.Z., G.Q.), the Department of Internal Medicine, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (M.V.), and the Division of Cardiology, Parma University Hospital, Parma (G.M.) - all in Italy; Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden (A.L., N.M.), the Heart Center, Segeberger Kliniken, Academic Teaching Hospital for the Universities of Kiel, Lübeck and Hamburg, Bad Segeberg (B.S., G.R.), the Department of Internal Medicine B, University Medicine Greifswald, and the German Center for Cardiovascular Research (DZHK) Partner Site Greifswald, Greifswald (S.B.F.), the Department of Cardiology, University Heart and Vascular Center Hamburg, Center for Population Health Innovation, University Clinic Hamburg-Eppendorf, and DZHK Partner site Hamburg/Kiel/Lübeck, Hamburg (M. Seiffert, P.C.), the Department of Internal Medicine I, University Hospital Würzburg, Würzburg (P.N.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau (B.W.), the Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen (L.G., S.A.), Cardiology and Pneumology, Klinikum Landkreis Erding, Erding (L.B.-F.), FB Mathematics and Computer Science, University of Bremen, Bremen (M.W.), the Department of Cardiology, Ulm University Heart Center, Ulm (M.K., W.R.), the Department of Cardiology and Angiology, University of Freiburg Medical Center, and the Faculty of Medicine, University of Freiburg, Freiburg (C.V., F.-J.N.), the Department of Cardiology, University Medical Center Mainz, and the Center for Cardiovascular Research, Johannes Gutenberg University Partner Site Rhine Main, Mainz (T.M.), the Department of Internal Medicine I, Division of Cardiology, Pneumology, and Angiology, and the Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena (P.C.S.), Clinic and Policlinic Internal Medicine I, Cardiology and Angiology, Klinikum rechts der Isar (K.-L.L.), and Klinik für Herz und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, and DZHK, partner site Munich Heart Alliance (A.K.), Munich, and Institut für Herzinfarktforschung, Ludwigshafen (S.S.) - all in Germany; the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna (I.M.L., A.T.), the 3rd Department of Medicine, Cardiology, and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University Medical School (M.R., K.H.), and the 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse (F.W.) - all in Vienna; the Department of Cardiovascular Diseases, University of Medicine, University Hospital Mother Teresa, Tirana, Albania (A.D.); the Department of Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark (P.C.); and the Heart Division, Royal Brompton and Harefield Hospitals, and the National Heart and Lung Institute, Imperial College London, London (T.F.L.), and the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.) - all in the United Kingdom
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Makhmudova U, Samadifar B, Maloku A, Haxhikadrija P, Geiling JA, Römer R, Lauer B, Möbius-Winkler S, Otto S, Schulze PC, Weingärtner O. Intensive lipid-lowering therapy for early achievement of guideline-recommended LDL-cholesterol levels in patients with ST-elevation myocardial infarction ("Jena auf Ziel"). Clin Res Cardiol 2023; 112:1212-1219. [PMID: 36602598 PMCID: PMC10449699 DOI: 10.1007/s00392-022-02147-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS Currently, less than 20% of patients at very high-risk achieve ESC/EAS dyslipidemia guideline-recommended LDL-C target levels in Europe. "Jena auf Ziel-JaZ" is a prospective cohort study in which early combination therapy with atorvastatin 80 mg and ezetimibe 10 mg was initiated on admission in patients with ST-elevation myocardial infarction (STEMI) and lipid-lowering therapy was escalated during follow-up with bempedoic acid and PCSK9 inhibitors to achieve recommended LDL-C targets in all patients. Moreover, we evaluated side-effects of lipid-lowering therapy. METHODS Patients admitted with STEMI at Jena University Hospital were started on atorvastatin 80 mg and ezetimibe 10 mg on admission. Patients were followed for EAS/ESC LDL-C target achievement during follow-up. RESULTS A total of 85 consecutive patients were enrolled in the study. On discharge, 32.9% achieved LDL-C targets on atorvastatin 80 mg and ezetimibe 10 mg. After 4-6 weeks, 80% of all patients on atorvastatin 80 mg and ezetimibe started at the index event were on ESC/EAS LDL-C targets. In 20%, combined lipid-lowering therapy was escalated with either bempedoic acid or PCSK9 inhibitors. All patients achieved LDL-C levels of or below 55 mg/dL during follow-up on triple lipid-lowering therapy. Combined lipid-lowering therapy was well-tolerated with rare side effects. CONCLUSIONS Early combination therapy with a high-intensity statin and ezetimibe and escalation of lipid-lowering therapy with either bempedoic acid or PCSK9 inhibitors gets potentially all patients with STEMI on recommended ESC/EAS LDL-C targets without significant side effects.
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Affiliation(s)
- Umidakhon Makhmudova
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Beasat Samadifar
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Aurel Maloku
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Pellumb Haxhikadrija
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jens-Arndt Geiling
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Robert Römer
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Bernward Lauer
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sven Möbius-Winkler
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sylvia Otto
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - P Christian Schulze
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Oliver Weingärtner
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany.
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18
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Haertel F, Lehmann T, Heller T, Fritzenwanger M, Pfeifer R, Kretzschmar D, Otto S, Bogoviku J, Westphal J, Bruening C, Gecks T, Kaluza M, Moebius-Winkler S, Schulze PC. Impact of a VA-ECMO in Combination with an Extracorporeal Cytokine Hemadsorption System in Critically Ill Patients with Cardiogenic Shock-Design and Rationale of the ECMOsorb Trial. J Clin Med 2023; 12:4893. [PMID: 37568295 PMCID: PMC10420280 DOI: 10.3390/jcm12154893] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Cardiogenic shock and arrest present as critical, life-threatening emergencies characterized by severely compromised tissue perfusion and inadequate oxygen supply. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) serves as a mechanical support system for patients suffering shock refractory to conventional resuscitation. Despite the utilization of VA-ECMO, clinical deterioration due to systemic inflammatory response syndrome (SIRS) resulting from the underlying shock and exposure of blood cells to the artificial surfaces of the ECMO circuit may occur. To address this issue, cytokine adsorbers offer a valuable solution by eliminating blood proteins, thereby controlling SIRS and potentially improving hemodynamics. Consequently, a prospective, randomized, blinded clinical trial will be carried out with ECMOsorb. METHODS AND STUDY DESIGN ECMOsorb is a single-center, controlled, randomized, triple-blinded trial that will compare the hemodynamic effects of treatment with a VA-ECMO in combination with a cytokine adsorber (CytoSorb®, intervention) to treatment with VA-ECMO only (control) in patients with cardiogenic shock (with or without prior cardiopulmonary resuscitation (CPR)) requiring extracorporeal, hemodynamic support. Fifty-four patients will be randomized in a 1:1 fashion to the intervention or control group over a 36-month period. The primary endpoint of ECMOsorb is the improvement of the Inotropic Score (IS) 72 h after the intervention. Prognostic indicators, including mortality rates, hemodynamic parameters, laboratory findings, echocardiographic assessments, quality of life measurements, and clinical parameters, will serve as secondary outcome measures. The safety evaluation encompasses endpoints such as air embolisms, allergic reactions, peripheral ischemic complications, vascular complications, bleeding incidents, and stroke occurrences. CONCLUSIONS The ECMOsorb trial seeks to assess the efficacy of a cytokine adsorber (CytoSorb®; CytoSorbents Europe GmbH, Berlin, Germany) in reducing SIRS and improving hemodynamics in patients with cardiogenic shock who are receiving VA-ECMO. We hypothesize that a reduction in cytokine levels can lead to faster weaning from inotropic and mechanical circulatory support, and ultimately to improved recovery.
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Affiliation(s)
- Franz Haertel
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Thomas Lehmann
- Center of Clinical Studies, University Hospital Jena, Salvador-Allende-Platz 27, 07747 Jena, Germany
| | - Tabitha Heller
- Center of Clinical Studies, University Hospital Jena, Salvador-Allende-Platz 27, 07747 Jena, Germany
| | - Michael Fritzenwanger
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ruediger Pfeifer
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Daniel Kretzschmar
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sylvia Otto
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Jurgen Bogoviku
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Julian Westphal
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Christiane Bruening
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Thomas Gecks
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Mirko Kaluza
- Department of Cardiothoracic Surgery, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sven Moebius-Winkler
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - P. Christian Schulze
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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Vukadinović D, Abdin A, Emrich I, Schulze PC, von Haehling S, Böhm M. Efficacy and safety of intravenous iron repletion in patients with heart failure: a systematic review and meta-analysis. Clin Res Cardiol 2023; 112:954-966. [PMID: 37074386 PMCID: PMC10116902 DOI: 10.1007/s00392-023-02207-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION AFFIRM-AHF and IRONMAN demonstrated lower rates of the combined endpoint recurrent heart failure (HF) hospitalizations and cardiovascular death (CVD) using intravenous (IV) ferric carboxymaltose (FCM) and ferric derisomaltose (FDI), respectively in patients with HF and iron deficiency (ID) utilizing prespecified COVID-19 analyses. MATERIAL AND METHODS We meta-analyzed efficacy, between trial heterogeneity and data robustness for the primary endpoint and CVD in AFFIRM-AHF and IRONMAN. As sensitivity analysis, we analyzed data from all eligible exploratory trials investigating FCM/FDI in HF. RESULTS FCM/FDI reduced the primary endpoint (RR = 0.81, 95% CI 0.69-0.95, p = 0.01, I2 = 0%), with the number needed to treat (NNT) being 7. Power was 73% and findings were robust with fragility index (FI) of 94 and fragility quotient (FQ) of 0.041. Effects of FCM/FDI were neutral concerning CVD (OR = 0.88, 95% CI 0.71-1.09, p = 0.24, I2 = 0%). Power was 21% while findings were fragile with reverse FI of 14 and reversed FQ of 0.006. The sensitivity analysis from all eligible trials (n = 3258) confirmed positive effects of FCM/FDI on the primary endpoint (RR = 0.77, 95% CI 0.66-0.90, p = 0.0008, I2 = 0%), with NNT being 6. Power was 91% while findings were robust (FI of 147 and FQ of 0.045). Effect on CVD was neutral (RR = 0.87, 95% CI 0.71-1.07, p = 0.18, I2 = 0%). Power was 10% while findings were fragile (reverse FI of 7 and reverse FQ of 0.002). Rate of infections (OR = 0.85, 95% CI 0.71-1.02, p = 0.09, I2 = 0%), vascular disorder (OR = 0.84, 95% CI 0.57-1.25, p = 0.34, I2 = 0%) and general or injection-site related disorders (OR = 1.39, 95% CI 0.88-1.29, p = 0.16, I2 = 30%) were comparable between groups. There was no relevant heterogeneity (I2 > 50%) between the trials for any of the analyzed outcomes. CONCLUSIONS Use of FCM/FDI is safe and reduces the composite of recurrent HF hospitalizations and CVD, while effects on CVD alone are based on available level of data indeterminate. Findings concerning composite outcomes exhibit a high level of robustness without heterogeneity between trials with FCM and FDI.
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Affiliation(s)
- Davor Vukadinović
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany.
| | - Amr Abdin
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany
| | - Insa Emrich
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, Friedrich-Schiller-University, University Hospital Jena, Jena, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
| | - Michael Böhm
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany
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Hanke D, Hamadanchi A, Schulze PC, Franz M. Congenital membranous ostial stenosis of the left atrial appendage as a secondary finding in a patient with ST elevation myocardial infarction: a case report. Eur Heart J Case Rep 2023; 7:ytad251. [PMID: 37288346 PMCID: PMC10243859 DOI: 10.1093/ehjcr/ytad251] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/06/2022] [Accepted: 05/17/2023] [Indexed: 06/09/2023]
Abstract
Background Stenoses of the left atrial appendage (LAA) represent a common complication after incomplete surgical ligation. However, the idiopathic entity is very rare. So far, there is uncertainty about the thromboembolic risk and potential benefit of anticoagulation in these patients. We report on congenital ostial stenosis of the LAA as a secondary finding in a patient with myocardial infarction. Case summary A 56-year-old patient presented with acute heart failure secondary to ST elevation myocardial infarction (STEMI) and eventually progressed to cardiogenic shock. A percutaneous coronary intervention and stent placement in the first diagonal branch and in the left anterior descending artery was performed in two sessions. There was a new onset of typical atrial flutter and paroxysmal atrial fibrillation with haemodynamically relevant tachycardia. Before synchronized electrical cardioversion, we performed transoesophageal echocardiography. Left atrial thrombi were ruled out. Surprisingly, we found membranous ostial stenosis of the LAA, resulting in a bidirectional flow pattern. After 28 days of treatment in the intensive care unit the patient had full clinical recovery. Discussion Given the very rare cases of congenital LAA ostial stenosis, there is uncertainty about the thrombogenicity and the potential benefit of anticoagulation or even a percutaneous closure of the LAA. We discuss possible similarities regarding the thromboembolic risk of patients with an idiopathic narrowing of the LAA to patients with incomplete surgical ligation and patients with a device leak after percutaneous LAA closure. Congenital ostial LAA stenosis represents a clinically relevant condition and may be considered as a potential hazard for thromboembolism.
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Affiliation(s)
- David Hanke
- Corresponding author. Tel: +49 3641 9324534,
| | - Ali Hamadanchi
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - P Christian Schulze
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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Haertel F, Babst J, Bruening C, Bogoviku J, Otto S, Fritzenwanger M, Gecks T, Ebelt H, Moebius-Winkler S, Schulze PC, Pfeifer R. Effect of Hemolysis Regarding the Characterization and Prognostic Relevance of Neuron Specific Enolase (NSE) after Cardiopulmonary Resuscitation with Extracorporeal Circulation (eCPR). J Clin Med 2023; 12:jcm12083015. [PMID: 37109353 PMCID: PMC10146981 DOI: 10.3390/jcm12083015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/26/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Hemolysis, a common adverse event associated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), may affect neuron-specific enolase (NSE) levels and potentially confound its prognostic value in predicting neurological outcomes in resuscitated patients without return of spontaneous circulation (ROSC) that require extracorporeal cardiopulmonary resuscitation (eCPR). Therefore, a better understanding of the relationship between hemolysis and NSE levels could help to improve the accuracy of NSE as a prognostic marker in this patient population. METHODS We retrospectively analyzed the records of patients who received a VA-ECMO for eCPR between 2004 and 2021 and were treated in the medical intensive care unit (ICU) of the University Hospital Jena. The outcome was measured clinically by using the Cerebral Performance Category Scale (CPC) four weeks after eCPR. The serum concentration of NSE (baseline until 96 h) was analyzed by enzyme-linked immunosorbent assay (ELISA). To evaluate the ability of individual NSE measurements to discriminate, receiver operating characteristic (ROC) curves were calculated. Serum-free hemoglobin (fHb, baseline until 96 h) served as a marker for identifying a confounding effect of parallel hemolysis. RESULTS 190 patients were included in our study. A total of 86.8% died within 4 weeks after ICU admission or remained unconscious (CPC 3-5), and 13.2% survived with a residual mild to moderate neurological deficit (CPC 1-2). Starting 24h after CPR, NSE was significantly lower and continued to decrease in patients with CPC 1-2 compared to the group with an unfavorable outcome of CPC 3-5. In addition, when evaluating on the basis of receiver operating characteristic curves (ROC), relevant and stable area under the curve (AUC) values for NSE could be calculated (48 h: 0.85 // 72 h: 0.84 // 96 h: 0.80; p < 0.01), and on the basis of a binary logistic regression model, relevant odds ratios for the NSE values were found even after adjusting for fHb regarding the prediction of an unfavorable outcome of CPC 3-5. The respective adjusted AUCs of the combined predictive probabilities were significant (48 h: 0.79 // 72 h: 0.76 // 96 h: 0.72; p ≤ 0.05). CONCLUSIONS Our study confirms NSE as a reliable prognostic marker for poor neurological outcomes in resuscitated patients receiving VA-ECMO therapy. Furthermore, our results demonstrate that potential hemolysis during VA-ECMO does not significantly impact NSE's prognostic value. These findings are crucial for clinical decision making and prognostic assessment in this patient population.
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Affiliation(s)
- Franz Haertel
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Josephine Babst
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Christiane Bruening
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Jurgen Bogoviku
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sylvia Otto
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Michael Fritzenwanger
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Thomas Gecks
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Henning Ebelt
- Department of Cardiology and Intensive Care, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
- Department for Internal Medicine II, Katholisches Krankenhaus "St. Johann Nepomuk", Haarbergstr. 72, 99097 Erfurt, Germany
| | - Sven Moebius-Winkler
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - P Christian Schulze
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ruediger Pfeifer
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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Abstract
Chronic kidney disease is associated with an increased risk for the development and progression of cardiovascular disorders including hypertension, dyslipidemia, and coronary artery disease. Chronic kidney disease may also affect the myocardium through complex systemic changes, resulting in structural remodeling such as hypertrophy and fibrosis, as well as impairments in both diastolic and systolic function. These cardiac changes in the setting of chronic kidney disease define a specific cardiomyopathic phenotype known as uremic cardiomyopathy. Cardiac function is tightly linked to its metabolism, and research over the past 3 decades has revealed significant metabolic remodeling in the myocardium during the development of heart failure. Because the concept of uremic cardiomyopathy has only been recognized in recent years, there are limited data on metabolism in the uremic heart. Nonetheless, recent findings suggest overlapping mechanisms with heart failure. This work reviews key features of metabolic remodeling in the failing heart in the general population and extends this to patients with chronic kidney disease. The knowledge of similarities and differences in cardiac metabolism between heart failure and uremic cardiomyopathy may help identify new targets for mechanistic and therapeutic research on uremic cardiomyopathy.
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Affiliation(s)
- T Dung Nguyen
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
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23
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Haertel F, Baez L, Franz M, Bogoviku J, Klein F, Dannberg G, Schulze PC, Möbius-Winkler S. Use of Autotransfusion following Percutaneous Thrombectomy for Cardiogenic Shock Due to Pulmonary Embolism in a Single Session-A Case Report. Diagnostics (Basel) 2023; 13:diagnostics13081392. [PMID: 37189493 DOI: 10.3390/diagnostics13081392] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
A 64-year-old male patient was admitted to the catheterization laboratory with a suspected myocardial infarction and in cardiogenic shock. Upon further investigation, a massive bilateral pulmonary embolism with signs of right heart dysfunction was discovered, leading to a decision to perform a direct interventional treatment with a thrombectomy device for thrombus aspiration. The procedure was successful in removing almost the entirety of the thrombotic material from the pulmonary arteries. The patient's hemodynamics stabilized and oxygenation improved instantly. The procedure required a total of 18 aspiration cycles. Each aspiration contained approx. 60 mL blood amounting to a total of approx. 1080 mL of blood. During the procedure, a mechanical blood salvage system was used to resupply 50% of the blood via autotransfusion that would otherwise have been lost. The patient was transferred to the intensive care unit for post-interventional care and monitoring. A CT angiography of the pulmonary arteries after the procedure confirmed the presence of only minor residual thrombotic material. The patient's clinical, ECG, echocardiographic, and laboratory parameters returned to normal or near normal ranges. The patient was discharged shortly after in stable conditions on oral anticoagulation.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - Laura Baez
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - Jurgen Bogoviku
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - Friederike Klein
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - Gudrun Dannberg
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07743 Jena, Germany
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24
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Römer R, Schulze PC, Weingärtner O. [51-year-old patient with recurrent pancreatitis and pathologic findings in plasma]. Dtsch Med Wochenschr 2023; 148:347-348. [PMID: 36878236 DOI: 10.1055/a-1995-2953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Affiliation(s)
- Robert Römer
- Universitätsklinik Jena, Klinik für Innere Medizin I, Kardiologie, Angiologie, Internistische Intensivmedizin
| | - P Christian Schulze
- Universitätsklinik Jena, Klinik für Innere Medizin I, Kardiologie, Angiologie, Internistische Intensivmedizin
| | - Oliver Weingärtner
- Universitätsklinik Jena, Klinik für Innere Medizin I, Kardiologie, Angiologie, Internistische Intensivmedizin
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25
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Aftanski P, Thieme M, Klein F, Schulze PC, Möbius-Winkler S, Kretzschmar D. Intravascular Lithotripsy in Calcified Peripheral Lesions: Single-Center JEN-Experience. Int J Angiol 2023; 32:11-20. [PMID: 36727147 PMCID: PMC9886450 DOI: 10.1055/s-0042-1751229] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Peripheral artery disease (PAD) shows increasing need for revascularization therapy. Interventional success in calcified lesions is limited. Here, intravascular lithotripsy (IVL), modifying intimal and medial calcium, is a promising treatment approach. A single-center, prospective all-comers registry for patients undergoing peripheral IVL was established to examine treatment success in PAD with severe vessel calcification. Periprocedural safety events as well as short-term and intermediate follow-up clinical data were evaluated. Between December 2018 and January 2021 all consecutive patients receiving peripheral lithotripsy at our center were analyzed. Clinical and angiographic data were evaluated. Angiographic images were analyzed using a semiautomatic software for quantitative vessel analysis. Eighty-five lesions in 61 limbs were treated with IVL in 51 patients presenting with Rutherford classes 2 to 5. Most lesions (68%) were localized in the superficial femoral artery. Mean calcified lesion length was 102.5 mm (10-390 mm), with a median peripheral arterial calcium score of 3, indicating a highly calcified status. In 58% of the patients, IVL was used as a stand-alone therapy. IVL resulted in a mean acute luminal gain of 2.6 ± 0.9 mm, resulting in stenosis reduction by 42.1 ± 15%. Mean ankle brachial index (ABI) improved significantly from 0.6 to 0.8 ( p < 0.0001) on day 1 after the intervention and remained stable at 6 months. This large real-world data of peripheral IVL reports compelling safety in a complex patient cohort. For the first time, clinical follow-up data demonstrated a sustained significant improvement in ABI after 6 months.
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Affiliation(s)
- Pawel Aftanski
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
| | - Marcus Thieme
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
- Department of Angiology, Cardiology, Diabetology, Regiomed-Vascular Center, Sonneberg, Germany
| | - Friederike Klein
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
| | - Daniel Kretzschmar
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
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26
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Schrage B, Sundermeyer J, Blankenberg S, Colson P, Eckner D, Eden M, Eitel I, Frank D, Frey N, Graf T, Kirchhof P, Kupka D, Landmesser U, Linke A, Majunke N, Mangner N, Maniuc O, Mierke J, Möbius-Winkler S, Morrow DA, Mourad M, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Pazzanese V, Radakovic D, Schulze PC, Scherer C, Schwinger RHG, Skurk C, Thiele H, Varshney A, Wechsler L, Westermann D. Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy. JACC Heart Fail 2023; 11:321-330. [PMID: 36724180 DOI: 10.1016/j.jchf.2022.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND It is currently unclear if active left ventricular (LV) unloading should be used as a primary treatment strategy or as a bailout in patients with cardiogenic shock (CS) treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). OBJECTIVES This study sought to evaluate the association between timing of active LV unloading and implantation of VA-ECMO with outcomes of patients with CS. METHODS Data from 421 patients with CS treated with VA-ECMO and active LV unloading at 18 tertiary care centers in 4 countries were analyzed. Patients were stratified by timing of device implantation in early vs delayed active LV unloading (defined by implantation before up to 2 hours after VA-ECMO). Adjusted Cox and logistic regression models were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as successful weaning from ventilation. RESULTS Overall, 310 (73.6%) patients with CS were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (HR: 0.64; 95% CI: 0.46-0.88) and a higher likelihood of successful weaning from ventilation (OR: 2.17; 95% CI: 1.19-3.93) but not with more complications. Importantly, the relative mortality risk increased and the likelihood of successful weaning from ventilation decreased almost proportionally with the time interval between VA-ECMO implantation and (delayed) initiation of active LV unloading. CONCLUSIONS This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO, although the findings need to be validated in a randomized controlled trial.
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Affiliation(s)
- Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany.
| | - Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Matthias Eden
- Department of Internal Medicine III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Ingo Eitel
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Derk Frank
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; Department of Internal Medicine III-Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Norbert Frey
- Department of Internal Medicine III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; Institute of Cardiovascular Sciences, University of Birmingham and University Hospitals Birmingham and Sandwell and West Birmingham NHS Trusts, Birmingham, United Kingdom
| | - Danny Kupka
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany & German Center for Cardiovascular Research, Partner Site Berlin, Berlin, German
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Mierke
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | | | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire Montpellier, University Montpellier, Montpellier, France
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy; Department of Cardiothoracic Anesthesia and Intensive Care, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St. Rita's Medical Center, Lima, Ohio, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Vittorio Pazzanese
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy; Intensive Cardiac Care Unit, San Raffaele Hospital, Milan, Italy
| | - Darko Radakovic
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | | | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
| | | | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany & German Center for Cardiovascular Research, Partner Site Berlin, Berlin, German
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Anubodh Varshney
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lukas Wechsler
- Medizinische Klinik II, Klinikum Weiden, Weiden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, University Freiburg, Freiburg, Germany.
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27
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Heiss J, Grün K, Tempel L, Matasci M, Schrepper A, Schwarzer M, Bauer R, Förster M, Berndt A, Jung C, Schulze PC, Neri D, Franz M. Targeted Interleukin-9 delivery in pulmonary hypertension: Comparison of immunocytokine formats and effector cell study. Eur J Clin Invest 2023; 53:e13907. [PMID: 36377348 DOI: 10.1111/eci.13907] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/19/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
AIMS Pulmonary hypertension (PH) is accompanied by pulmonary vascular remodelling. By targeted delivery of Interleukin-9 (IL9) via the immunocytokine F8IL9, beneficial effects could be demonstrated in a mouse model of PH. This study aimed to compare two immunocytokine formats (single-chain Fv and full IgG) and to identify potential target cells of IL9. METHODS The Monocrotaline mouse model of PH (PH, n = 12) was chosen to evaluate the treatment effects of F8IL9F8 (n = 12) and F8IgGIL9 (n = 6) compared with sham-induced animals (control, n = 10), the dual endothelin receptor antagonist Macitentan (MAC, n = 12) or IL9-based immunocytokines with irrelevant antigen specificity (KSFIL9KSF, n = 12; KSFIgGIL9 n = 6). Besides comparative validation of treatment effects, the study was focused on the detection and quantification of mast cells (MCs) and regulatory T cells (Tregs). RESULTS There was a significantly elevated systolic right ventricular pressure (104 ± 36 vs. 45 ± 17 mmHg) and an impairment of right ventricular echocardiographic parameters (RVbasal: 2.52 ± 0.25 vs. 1.94 ± 0.13 mm) in untreated PH compared with controls (p < 0.05). Only the groups treated with F8IL9, irrespective of the format, showed consistent beneficial effects (p < 0.05). Moreover, F8IL9F8 but not F8IgGIL9 treatment significantly reduced lung tissue damage compared with untreated PH mice (p < 0.05). There was a significant increase in Tregs in F8IL9-treated compared with control animals, the untreated PH and the MAC group (p < 0.05). CONCLUSIONS Beneficial treatment effects of targeted IL9 delivery in a preclinical model of PH could be convincingly validated. IL9-mediated recruitment of Tregs into lung tissue might play a crucial role in the induction of anti-inflammatory and anti-proliferative mechanisms potentially contributing to a novel disease-modifying concept.
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Affiliation(s)
- Judith Heiss
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany.,Else Kröner Graduate School for Medical Students "JSAM", Jena University Hospital, Jena, Germany
| | - Katja Grün
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
| | - Laura Tempel
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
| | | | - Andrea Schrepper
- Department of Cardiothoracic Surgery, University Hospital Jena, Jena, Germany
| | - Michael Schwarzer
- Department of Cardiothoracic Surgery, University Hospital Jena, Jena, Germany
| | - Reinhard Bauer
- Institute of Molecular Cell Biology, Center for Molecular Biomedicine, University Hospital Jena, Jena, Germany
| | - Martin Förster
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
| | - Alexander Berndt
- Section Pathology, Institute of Legal Medicine, University Hospital Jena, Jena, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | | | | | - Marcus Franz
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
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28
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Schulze PC, Bogoviku J, Westphal J, Aftanski P, Haertel F, Grund S, von Haehling S, Schumacher U, Möbius-Winkler S, Busch M. Response by Schulze et al to Letter Regarding Article, "Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients With Acute Decompensated Heart Failure (EMPAG-HF)". Circulation 2023; 147:e75. [PMID: 36745697 DOI: 10.1161/circulationaha.122.062688] [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] [Indexed: 02/08/2023]
Affiliation(s)
- P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Jürgen Bogoviku
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Julian Westphal
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Pawel Aftanski
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Franz Haertel
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Sissy Grund
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Stephan von Haehling
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Ulrike Schumacher
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
| | - Martin Busch
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research, Partner Site Göttingen, Germany (S.v.H.)
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Mazrouei S, Petry SF, Sharifpanah F, Javanmard SH, Kelishadi R, Schulze PC, Franz M, Jung C. Pathophysiological correlation of arginase-1 in development of type 2 diabetes from obesity in adolescents. Biochim Biophys Acta Gen Subj 2023; 1867:130263. [PMID: 36309295 DOI: 10.1016/j.bbagen.2022.130263] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/22/2022] [Accepted: 10/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is great interest to understand causal pathophysiological correlation between obesity and diabetes mellitus (DM). Vascular endothelial dysfunction is crucially involved in pathogenesis of vascular complications in DM. Recently, increased arginase expression and activity have been described as underlying mechanisms of endothelial dysfunction in DM and vascular inflammation in obesity. By limiting L-arginine bioavailability to endothelial nitric oxide synthase (NOS III), nitric oxide production is potentially impaired. METHODS We investigated the impact of plasma from diabetic and obese adolescents on arginase and NOS III expression in cultured human endothelial cells (ECs). A total of 148 male adolescents participated in this study including 18 obese, 28 type 1-, 28 type 2-DM patients, and 74 age-matched healthy volunteers. RESULTS A concurrent increase in arginase-1 (1.97-fold) and decrease in NOS III expression (1.45-fold) was observed in ECs exposed to type 2 diabetic plasma compared to control subjects. ECs incubated with type 1 DM plasma had a diminished NOS III level without impact on arginase-1 expression. Urea-assay featured an increased arginase activity in treated ECs with type 1- or 2-DM plasma. Despite increased pro-inflammatory cytokines and chemokines in obese plasma, arginase-1 expression/activity did not change in treated ECs. However, NOS III expression was significantly reduced. Pearson analysis revealed positive correlation between arginase-1, but not NOS III, expression with FBS in ECs treated with type 2-DM plasma. CONCLUSIONS Our data demonstrate that increased arginase-1 expression/activity in ECs, as critical pathogenic factor is correlated with development of obesity-related type 2-DM and linked vascular disease.
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Affiliation(s)
- Safoura Mazrouei
- Department of Internal Medicine I, University Hospital Jena, Germany
| | - Sebastian Friedrich Petry
- Clinical Research Unit, Center of Internal Medicine, Medical Clinic and Polyclinic III, Justus Liebig University, Giessen, Germany
| | - Fatemeh Sharifpanah
- Dentistry Department, Faculty of Medicine, Philipps University of Marburg, Germany
| | | | - Roya Kelishadi
- Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Marcus Franz
- Department of Internal Medicine I, University Hospital Jena, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Germany.
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Schumann A, Gaser C, Sabeghi R, Schulze PC, Festag S, Spreckelsen C, Bär KJ. Using machine learning to estimate the calendar age based on autonomic cardiovascular function. Front Aging Neurosci 2023; 14:899249. [PMID: 36755773 PMCID: PMC9899796 DOI: 10.3389/fnagi.2022.899249] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 12/20/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Aging is accompanied by physiological changes in cardiovascular regulation that can be evaluated using a variety of metrics. In this study, we employ machine learning on autonomic cardiovascular indices in order to estimate participants' age. Methods We analyzed a database including resting state electrocardiogram and continuous blood pressure recordings of healthy volunteers. A total of 884 data sets met the inclusion criteria. Data of 72 other participants with an BMI indicating obesity (>30 kg/m²) were withheld as an evaluation sample. For all participants, 29 different cardiovascular indices were calculated including heart rate variability, blood pressure variability, baroreflex function, pulse wave dynamics, and QT interval characteristics. Based on cardiovascular indices, sex and device, four different approaches were applied in order to estimate the calendar age of healthy subjects, i.e., relevance vector regression (RVR), Gaussian process regression (GPR), support vector regression (SVR), and linear regression (LR). To estimate age in the obese group, we drew normal-weight controls from the large sample to build a training set and a validation set that had an age distribution similar to the obesity test sample. Results In a five-fold cross validation scheme, we found the GPR model to be suited best to estimate calendar age, with a correlation of r=0.81 and a mean absolute error of MAE=5.6 years. In men, the error (MAE=5.4 years) seemed to be lower than that in women (MAE=6.0 years). In comparison to normal-weight subjects, GPR and SVR significantly overestimated the age of obese participants compared with controls. The highest age gap indicated advanced cardiovascular aging by 5.7 years in obese participants. Discussion In conclusion, machine learning can be used to estimate age on cardiovascular function in a healthy population when considering previous models of biological aging. The estimated age might serve as a comprehensive and readily interpretable marker of cardiovascular function. Whether it is a useful risk predictor should be investigated in future studies.
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Affiliation(s)
- Andy Schumann
- Lab for Autonomic Neuroscience, Imaging and Cognition (LANIC), Department of Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Christian Gaser
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Rassoul Sabeghi
- Lab for Autonomic Neuroscience, Imaging and Cognition (LANIC), Department of Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Jena, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Jena University Hospital, Jena, Germany
| | - Sven Festag
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
- SMITH Consortium of the German Medical Informatics Initiative, Leipzig, Germany
| | - Cord Spreckelsen
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
- SMITH Consortium of the German Medical Informatics Initiative, Leipzig, Germany
| | - Karl-Jürgen Bär
- Lab for Autonomic Neuroscience, Imaging and Cognition (LANIC), Department of Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Jena, Germany
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Bäz L, Möbius-Winkler S, Diab M, Kräplin T, Westphal JG, Ibrahim K, Schulze PC, Franz M. Prognostic relevance of mitral and tricuspid regurgitation after transcatheter aortic valve implantation: Impact of follow-up time point for decision-making. Front Cardiovasc Med 2023; 10:990373. [PMID: 36873389 PMCID: PMC9977804 DOI: 10.3389/fcvm.2023.990373] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
Background In patients with aortic stenosis treated by transcatheter aortic valve implantation (TAVI), mitral and tricuspid regurgitation (MR and TR) at baseline and after TAVI are likely to be of prognostic relevance, and questions such as whether and when treatment further improves prognosis in these patients arise. Aims Against that background, the purpose of this study was to analyze a variety of clinical characteristics including MR and TR with respect to their potential value as predictors of 2-year mortality after TAVI. Methods A cohort of 445 typical TAVI patients was available for the study and clinical characteristics were evaluated baseline, 6 to 8 weeks as well as 6 months after TAVI. Results In 39% of the patients relevant (moderate or severe) MR and in 32% of the patients relevant (moderate or severe) TR could be detected at baseline. The rates were 27% for MR (p = 0.001, compared to baseline) and 35% for TR (p = n.s., compared to baseline) at the 6- to 8-week follow-up. After 6 months, relevant MR was observable in 28% (p = 0.036, compared to baseline) and relevant TR in 34% (p = n.s., compared to baseline) of the patients. As predictors of 2-year mortality, a multivariate analysis identified the following parameters for the different time points: sex, age, AS entity, atrial fibrillation, renal function, relevant TR, systolic pulmonary artery pressure (PAPsys), and 6-min walk distance at baseline; clinical frailty scale and PAPsys 6-8 weeks after TAVI and BNP and relevant MR 6 months after TAVI. There was a significantly worse 2-year survival in patients with relevant TR at baseline (68.4% vs. 82.6%, p < 0.001; whole population, n = 445) and in patients with relevant MR at 6 months (87.9% vs. 95.2%, p = 0.042; landmark analysis: n = 235). Conclusion This real-life study demonstrated the prognostic relevance of repeated evaluation of MR and TR before and after TAVI. Choosing the right time point for treatment is a remaining clinical challenge, which should be further addressed in randomized trials.
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Affiliation(s)
- Laura Bäz
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany.,Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | | | - Mahmoud Diab
- Department of Cardiothoracic Surgery, University Hospital Jena, Jena, Germany
| | | | - Julian G Westphal
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
| | - Karim Ibrahim
- Department of Internal Medicine I, Klinikum Chemnitz, Chemnitz, Germany
| | | | - Marcus Franz
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
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Otto S, Albrecht R, Hamadanchi A, Franz M, Westphal JG, Schulze PC. Prevalence of cardiac amyloidosis among cardiac- and non-cardiac patients undergoing echocardiography at a large university echo lab in Germany: a cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1766] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Cardiac amyloidosis (CA) is a progressive infiltrative cardiomyopathy that leads to severe heart failure and, once clinically relevant, poses a high mortality risk. Epidemiological data for CA are still sparse and heterogeneous, but urgently needed since novel therapies against ATTR-CA are now available.
Aim
We aimed to assess minimum prevalence rates of CA among cardiac and non-cardiac patients undergoing routine echocardiography in an echo lab of a large university clinic serving all medical specialities in central Germany.
Methods
We established a retro- and prospective database based on suspicious findings in echocardiography for all echocardiographic exams over an 8.5 year period (03/2013 and 09/2021). During this time, 41,375 patients underwent at least one echo exam. Indication for echos were mixed, and consisted of non-cardiac and cardiac patients with acute and chronic illnesses as well as screening exams (e.g. before major surgery or chemotherapy). Suspicious echocardiography were retrospectively analysed whether they underwent further diagnostic or if it remained an unproven suspicion (figure). All echos of suspicious cases were comprehensively re-analysed regarding novel surrogate parameters and indices for CA. Various clinical and laboratory parameters were collected.
Results
The mean age of the cohort of 41,375 patients was 65.1±15.8 years for the first or only echo examination with a slightly unbalanced gender distribution (45% female). The age distribution is shown in the table. While 128 patients were suspected, the diagnosis was falsified in 16 patients and proven in 47 patients (light chain n=16, ATTR n=31; figure). A substantial proportion of patients with suspicious echo received no further diagnostic work-up (N=65). Over the given time frame of 101 months, the prevalence of suspicious echocardiograms was 1 per 323 patients (or 31 per 10,000). The proven cases had a prevalence of 1 per 880 patients (or 11.3 per 10,000). Since ATTR-CA is a disease of the elderly, we saw a vanishingly small number of cases in persons younger than 70 years (table), whereas 90% of all CA patients were older than 70 years. At timing of diagnosis, AL-CA patients were almost 10 years younger compared to diagnosis of ATTR-CA (69.1±8.4 years vs. 77.4±8.5 years). In patients older than 80 years, the prevalence rate of ATTR-CA peaked with 22.6 cases per 10.000 patients (0.23%). The prevalence rate of ATTR-CA was roughly twice as high compared to AL-CA.
Conclusion
For the first time, an estimation of minimum prevalence rates for CA for a defined volume of echocardiograms in an all-comers population is provided. In a mixed population of a hospital of maximum care CA prevalence rate is much higher than expected. Awareness for this “rare” disease is needed, since routine echo exams can prompt suspicion in clinically silent or so far unrecognized CA cases.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Otto
- University Hospital Jena , Jena , Germany
| | - R Albrecht
- University Hospital Jena , Jena , Germany
| | | | - M Franz
- University Hospital Jena , Jena , Germany
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Diab M, Franz M, Hamadanchi A, Faerber G, Safarov R, Kirov H, Lehmann T, Schulze PC, Doenst T. Adding troponin to echocardiography improves preoperative abscess detection in infective endocarditis. A REMOVE Trial analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1549] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Detection of cardiac abscess in patients with infective endocarditis (IE) is important for surgical planning and decision-making. While transesophageal echocardiography (TEE) is the method of choice for abscess detection, in many cases uncertainty remains. Since IE abscesses often affect ventricular muscle, biomarker release may be a helpful adjunct for abscess detection.
Purpose
We assessed the accuracy of TEE and the value of combining it with preoperative measurement of cardiac Troponin (cTn) in the diagnosis of abscess, using surgical inspection as a reference.
Methods
Data collected in the electronic clinical report form for patients included in the prospective, multicenter, randomized, controlled trial (REMOVE Trial) were analyzed. Continuous variables are presented as median (25th–75th percentile) and categorical data as absolute and relative frequencies. The diagnostic performance of TEE was identified by comparing preoperative TEE findings with intraoperative findings. The concordance rate is expressed as a percentage. Receiver operating characteristic (ROC) curve was used to assess the ability of cTn to predict the presence of abscess intraoperatively. Area under curve (AUC) with 95% confidence interval as well as sensitivity and specificity are provided as measures of accuracy. Youden index was used to estimate an optimal cut-off value for cTn.
Results
Among the 282 patients included, 84 had abscesses detected intraoperatively. The sensitivity and specificity of TEE to detect abscess were 58.3% and 86.4%, respectively. cTn-I and cTn-T were measured preoperatively in 113 and 96 patients, respectively. Median cTn-I in patients with abscess was 132 pg/ml (interquartile range (IQR): 54–1528) vs 53 pg/ml (IQR: 17–250) in patients without abscess, p=0.002. Median cTn-T in patients with abscess was 941 pg/ml (IQR: 387–1527) vs 697 pg/ml (IQR: 282–1423) in patients without abscess, p=0.353. The incidence of recent preoperative myocardial infarction was not different between patients with or without abscess (7.1% vs 5.6%, respectively, p=0.593). The AUC for predicting abscess was 0.69 (95% CI: 0.57 to 0.80, p=0.002) and 0.56 (95% CI: 0.43 to 0.69, p=0.353) for preoperative cTn-I and cTn-T, respectively. Optimal cut-offs according to the Youden index are 38 pg/ml for cTn-I and 1632 pg/ml for cTn-T. By adding preoperative cTn-I or cTn-T to the TEE findings, the AUC increased to 0.82 (95% CI: 0.73 to 0.91, p<0.001) and 0.72 (95% CI: 0.59 to 00.84, p=0.001), respectively.
Conclusion
The results suggest that using TEE alone is a poor method for abscess detection in IE. Adding preoperative troponin values to TEE findings significantly improved IE abscess detection.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Federal Ministry of Education and Research (BMBF), Germany
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Affiliation(s)
- M Diab
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - M Franz
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - A Hamadanchi
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - G Faerber
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - R Safarov
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - H Kirov
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - T Lehmann
- University Hospital Jena, Center for Clinical Studies , Jena , Germany
| | - P C Schulze
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - T Doenst
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
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Aftanski P, Thieme M, Schulze PC, Klein F, Moebius-Winkler S, Kretzschmar D. Course of ankle-brachial-index 12 months after intravascular lithotripsy in calcified peripheral lesions. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1943] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Intravascular lithotripsy (IVL) is a relatively novel treatment option for calcified lesions in peripheral artery disease. Little is known about the mid to long-term functional status of the patients and target lesion revascularization rate (TLR) after IVL only procedure.
Purpose
To evaluate the course of ankle-brachial-index (ABI) and to assess the rate of revascularization 1 year after intravascular lithotripsy performed on calcified peripheral lesions.
Methods
Between December 2018 and January 2021 IVL was performed on 61 limbs of 51 patients presenting with Rutherford classes 2–5. Ankle-brachial-index (ABI) was documented before the procedure as well as 1 day, 6 months and 1 year after the procedure within a single center real-life registry. Further endpoint was revascularization with PTA or peripheral bypass surgery. The vast majority of cases were done as IVL only procedure (58%) All procedures were done in upper leg/pelvic stenosis.
Results
ABI measurement after 12 months was done in 42 of 51 patients (82%). Three pts were missed due to media sclerosis. Due to loss of follow-up, ABI after 6 months could not be performed on 4/61 patients (7,8%) and 12-month-ABI in another 8/51 cases (15,6%). Initial baseline ABI of 0.6±0.26 before the procedure increased to 0.8±0.25 (p<0.0001) one day afterward. After 6 months, the ABI of 0.8±0.27 (n=49; p<0.0001) was still significantly improved compared to baseline. After 1 year, ABI with 0.7±0.22 was still improved, however not significantly different from baseline (Figure 1). Target lesion revascularization was needed in 7 patients (13%), 4 with subsequent IVL, 3 with PTA and 2 with peripheral bypass surgery.
Conclusions
In our large single center registry, IVL performed mainly as a stand-alone procedure was safe and effective even after a mid-term follow up. TLR was necessary in 13%, which is lower than in previous published IVL data (20,7% as in DISRUPT-PAD-II) [1]. ABI after 12 months improved but did maintain statistical significance, compared with other procedure like scoring balloon [2].
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- P Aftanski
- University hospital Jena , Jena , Germany
| | - M Thieme
- University hospital Jena , Jena , Germany
| | | | - F Klein
- University hospital Jena , Jena , Germany
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Schrage B, Sundermeyer J, Blankenberg S, Eitel I, Kirchhof P, Mangner N, Moebius-Winkler S, Orban M, Thiele H, Morrow DA, Schulze PC, Westermann D. Timing of active left ventricular unloading in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1504] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aim
To evaluate the impact of timing of active left ventricular (LV) unloading in relation to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation on outcomes of patients with cardiogenic shock (CS).
Methods and results
Data from 421 patients with CS treated with active LV unloading on top of VA-ECMO at 18 tertiary-care centers in 4 countries were collected. Only patients in whom both devices were implanted within 24 hours of each other were considered and patients were stratified by timing of device implantation in early vs. delayed active LV unloading (e.g. active LV unloading before vs. after VA-ECMO). Cox and logistic regression models (adjusted for age, sex, lactate, cardiopulmonary resuscitation (CPR), VA-ECMO assisted CPR and enrollment center) were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as several safety outcomes.
Overall, 310 (73.6%) patients were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (hazard ratio 0.63, 95% confidence interval 0.46–0.87) and a higher likelihood of weaning from mechanical ventilation (odds ratio 1.25, 95% confidence interval 1.03–1.52), but not with more complications. Importantly, postponing active LV unloading in these patients was associated with higher mortality risk (Figure 1), and lower likelihood of successful weaning from mechanical ventilation.
Conclusion
This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO as a primary treatment strategy, as opposed to a bail-out approach.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Unrestricted research grant from Abiomed
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Affiliation(s)
- B Schrage
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - J Sundermeyer
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - S Blankenberg
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - I Eitel
- University Heart Center , Luebeck , Germany
| | - P Kirchhof
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - N Mangner
- Heart Centre Dresden - Dresden Technical University Hospital , Dresden , Germany
| | | | - M Orban
- University Hospital of Munich , Munich , Germany
| | - H Thiele
- Heart Center of Leipzig , Leipzig , Germany
| | - D A Morrow
- Brigham and Women's Hospital , Boston , United States of America
| | | | - D Westermann
- Heart Center, University of Freiburg , Freiburg , Germany
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Makhmudova U, Schatz U, Kassner U, Axthelm C, Rohn B, Westhoff T, Vogt A, Scholl M, Stach K, Sinnig DL, Stuerzebecher P, Schulze PC, Landmesser U, Laufs U, Weingaertner O. High individual variability in LDL-reductions after inclisiran administration in a “real-world setting”. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2671] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and aims
Inclisiran inhibits hepatic synthesis of proprotein convertase subtilisin-kexin type 9 (PCSK9) (1). Previous studies suggest that inclisiran provides sustained reductions in low-density lipoprotein (LDL) cholesterol levels with infrequent dosing. Patients included in the ORION program received inclisiran on top of maximally tolerated statin therapy and demonstrated a profound 50% LDL-C reduction as early as 3 months (2). The aim of this retrospective, multi-center analysis was to use individual patient data to determine the extent of the variability in LDL-C reduction in response to inclisiran administration in a real-world setting.
Methods
Since February 2021 the German Inclisiran Network (GIN) enrolled patients who received inclisiran due elevated LDL-cholesterol (LDL-C) levels in German lipid clinics. In contrast to patients included in the ORION program inclisiran could be administered to a broad range of patients with elevated LDL-C levels, including patients naive of lipid-lowering drugs, as well as patients on apheresis who failed to attain LDL-C goals.
Results
In 10 lipid clinics in Germany a total of 117 consecutive patients received inclisiran. Patients, who were not on stable lipid-lowering medication at least 3 months prior to inclisiran administration, were excluded. Thus, a total of 61 patients were analyzed. Mean LDL-C level at baseline was 151.86±64.31 mg/dl (95 percent confidence interval (CI): 135.39 to 168.33 mg/dl). After 3 months, inclisiran reduced LDL-C levels by 34.6% (95% CI: 29.3 to 39.8%), mean LDL-C levels were 103.26±60.36 mg/dl (95% CI: 87.8 to 118.72 mg/dl). At baseline 18 (30%) patients received statins, 22 (36%) ezetimibe and 13 (21%) bempedoic acid. Twenty-five (41%) patients were not on any lipid lowering therapy at baseline and 15 (25%) were on apheresis and failed to attain LDL-C target levels at baseline. Altogether there was a high inter-individual variability in LDL-C reduction 3 months after the first administration of inclisiran (Figure 1). Interestingly, patients who received statins at baseline demonstrated a trend towards a more profound LDL-C reduction (42.6±20.6 vs. 30.33±19.2%). This effect, however, was not significant. Two patients did not demonstrate any LDL-C reduction after the first administration. Inclisiran was well tolerated. Only one patient reported a minor injection-site reaction. No further side-effects were reported.
Conclusion
These results indicate that there is substantial individual variability in the LDL-C reduction after the first administration of inclisiran. Inclisiran was well tolerated without any serious side-effects. A longer follow-up period and further research is warranted to elucidate reasons for the high inter-individual variability in LDL-reductions in this real-world setting.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- U Makhmudova
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - U Schatz
- Universitätsklinikum Dresden, Medizinische Klinik III , Dresden , Germany
| | - U Kassner
- Charite Universitatsmedizin Berlin, Klinik für Endokrinologie und Stoffwechselmedizin , Berlin , Germany
| | - C Axthelm
- Cardiologicum Dresden & Pirna , Dresden , Germany
| | - B Rohn
- University Hospital St. Mary's Hospital Herne, Medizinische Klinik I , Herne , Germany
| | - T Westhoff
- University Hospital St. Mary's Hospital Herne, Medizinische Klinik I , Herne , Germany
| | - A Vogt
- University Hospital of Munich, Medizinische Klinik und Poliklinik IV , Munich , Germany
| | - M Scholl
- Nephrocare Mühlhausen GmbH , Muelhausen , Germany
| | - K Stach
- University Hospital Mannheim, Medizinische Klinik V , Mannheim , Germany
| | - D L Sinnig
- Charité - University Medicine Berlin, Klinik für Kardiologie, Campus Benjamin Franklin , Berlin , Germany
| | - P Stuerzebecher
- University Hospital Leipzig, Klinik und Poliklinik für Kardiologie , Leipzig , Germany
| | - P C Schulze
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - U Landmesser
- Charité - University Medicine Berlin, Klinik für Kardiologie, Campus Benjamin Franklin , Berlin , Germany
| | - U Laufs
- University Hospital Leipzig, Klinik und Poliklinik für Kardiologie , Leipzig , Germany
| | - O Weingaertner
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
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Bogoviku J, Nguyen TD, Westphal JG, Haertel F, Grund S, Aftanski P, Moebius-Winkler S, Busch M, Schulze PC. Acute effect of empagliflozin on serum uric acid – a subanalysis of the EMPAG-HF trial (effects of empagliflozin on diuresis and renal function in patients with acute decompensated heart failure). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.970] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Elevated levels of uric acid (UA) have been associated with worsening of outcomes in cardiovascular and renal disease and may lead to gout. Patients with acute decompensated heart failure (ADHF) may develop hyperuricemia under intensified diuretic treatment. In this setting, the effect of empagliflozin on serum uric acid remains unknown.
Aim/Purpose
The aim of this subanalysis in patients with ADHF was to assess how additive treatment with empagliflozin influences the concentration of serum uric acid and potential related outcomes.
Methods
In the single-center, prospective, double-blind, placebo-controlled EMPAG-HF trial, patients with ADHF were screened and randomized within 12 hours following hospital admission to receive either empagliflozin 25 mg or placebo in addition to standard medical treatment over five days. Sixtypatients (mean age 74,7±9,9, 39% female) were enrolled and randomized 1:1 irrespective of left ventricular ejection fraction or the presence of diabetes. UA in serum was determined daily and renal handling of UA was evaluated by fractional excretion of UA (FEUA). Two-way mixed ANOVA and Wilcoxon rank-sum test were used for statistical analyses.
Results
The empagliflozin group comprised 30 patients and the placebo group comprised 29 patients. There were no differences in baseline patient characteristics including LVEF, NT-proBNP, eGFR, HbA1c. In the placebo group, UA increased from baseline 487.86±32.21 μmol/l to 500.38±28.37 μmol/l at day (d) 2 (p=0.045), 512.36±29.43 μmol/l at d3 (p=0.018), and 518.46±31.14 μmol/l at d4 (p=0.021). By contrast, in the empagliflozin group, UA tended to decrease compared to baseline and was significantly lower compared to placebo at d3 (436.08±23.94 vs. 512.36±29.43 μmol/l, p=0.049), d4 (423.20±24.12 vs. 518.46±31.14 μmol/l, p=0.018), and d5 (423.17±24.75 vs. 508.62±31.08 μmol/l, p=0.037). Serum UA returned to baseline levels in both groups 30 days after cessation of empagliflozin. The reduction of UA in the empagliflozin group was associated with a significant enhancement in FEUA (5.49±0.81% vs. 9.38±1.07%, p=0.004).
Conclusion
Our data suggest that the additive treatment with empagliflozin in patients with acute decompensated heart failure lowers the levels of serum uric acid compared to loop diuretics alone. This effect may be attributed to an improved renal elimination of UA and a better preservation of kidney function. It remains to be clarified whether this uricosuric effect of empagliflozin also contributes to its prognostic benefits in heart failure.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany) Boehringer Ingelheim Inc.
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Affiliation(s)
- J Bogoviku
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - T D Nguyen
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - J G Westphal
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - F Haertel
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - S Grund
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - P Aftanski
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - S Moebius-Winkler
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - M Busch
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
| | - P C Schulze
- University Hospital Jena, Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care , Jena , Germany
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Makhmudova U, Samadifar B, Maloku A, Haxhikadrija P, Otto S, Schulze PC, Weingaertner O. Jena auf Ziel: get all patients with ST-elevation myocardial infarction on EAS/ESC-LDL-C targets. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2334] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and aims
Low-density lipoprotein cholesterol (LDL-C) reduction is an essential part of the 2019 ESC/EAS dyslipidemia guidelines [1]. Only 18% of patients achieve 2019 ESC/EAS LDL-C target goal in secondary prevention [2]. “Jena auf Ziel – JaZ” (“Jena on target”) is a prospective study that aims at LDL-C target attainment in all patients with ST-elevation myocardial infarction (STEMI) and determination of reasons for failed target attainment.
Methods
All STEMI patients were started on atorvastatin 80 mg/ezetimibe 10 mg on admission. LDL-C levels were monitored during the hospital stay and a 12 months follow-up period. Patients were educated about cardiovascular risk factor optimization. Individual patient cards to document LDL-C levels over time were used to enforce LDL-C target attainment.
Results
In the first 50 consecutive patients, LDL-C levels were 3.39±1.23 mmol/L on admission, 1.84±0.86 mmol/L on discharge and 1.30±0.65 mmol/L during the first follow-up visit (6–8 weeks). On atorvastatin 80 mg/ezetimibe 10 mg 14 out of 50 patients (28%) reached the LDL-C goal on discharge, 36 out of 50 patients (72%) after 6–8 weeks. After addition of bempedoic acid or PCSK9-inhibitors all patients which were followed up in our lipid clinic reach the EAS/ESC-LDL-C target. Only two patients reported myalgias of which one patient refused to continue with lipid-lowering drugs. One patient had elevated liver enzymes, which resolved after switching to a lower statin dose.
Conclusions
One out three STEMI patients reached the EAS/ESC-LDL-C target during the initial hospital stay on atorvastatin 80 mg/ezetimibe 10 mg. Adding bempedoic acid or PCSK9 inhibitors resulted in LDL-C target attainment of all patients during follow-up. EAS/ESC-LDL-C target attainment is feasible and well-tolerated in empowered, well-educated patients.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- U Makhmudova
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - B Samadifar
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - A Maloku
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - P Haxhikadrija
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - S Otto
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - P C Schulze
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
| | - O Weingaertner
- University Hospital Jena, Klinik für Innere Medizin I , Jena , Germany
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Haertel F, Metz C, Kraeplin T, Schulze PC, Otto S. Impact of myocardial infarction with non-obstructive coronary arteries (MINOCA) vs. classic myocardial infarction on hospital resources. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1453] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Due to the high volume and broad availability of troponin testing and invasive coronary diagnostic in Germany, the entity of myocardial infarction with non-obstructive coronary arteries (MINOCA) is gaining increasing clinical and economic significance. As a main feature, no detectable obstructive coronary artery can be found upon angiography despite clinical symptoms related to acute coronary syndrome. Our investigation focuses on the procedural and economic impact of MINOCA and related clinical outcomes in a single-center patient collective of a university heart center.
Methods
All patients who were admitted to our hospital under the suspicion of an acute coronary syndrome within a 12-month period (2017–2018) for further diagnostics and treatment were screened. Included patients showed a pathological troponin elevation and received invasive coronary angiography. Associated costs, procedural and various clinical parameters as well as timelines and parameters of work-flow were obtained.
Results
3021 patients were initially screened and 660 were included. Of those, 103 patients were attributed to the MINOCA group. 542 patients presented with a “classical” myocardial infarction, and thus formed the MIOCA (myocardial infarction with obstructive coronary arteries) group. Baseline characteristics were summarized in Table 1. MINOCA patients were less frail, less diabetic, more likely female and showed no relevant difference in age or other selected comorbidities. The emergency department was the primary point of hospital admission for >70% of the patients from both groups. 50% of the patients arrived in the afternoon on a weekday. MINOCA patients were less present during the weekend as MIOCA patients (8.5% vs. 19.7%; p=0.002). With regard to a potential seasonal occurrence, both MINOCA and MIOCA cases show a pattern with two peaks (Figure 1). In-hospital mortality (MIOCA vs. MINOCA: 59 (11.1%) vs. 0 (0%) patients; p<0.001), and 30-day mortality (MIOCA vs. MINOCA: 94 (17.3%) vs. 5 (4.2%) patients; p<0.001) after the clinical index event were significantly higher in the MIOCA group. MINOCA patients were more likely to receive coronary angiography later after admission (44.6±78.6 h vs. 25.4±69.5h; p=0.014). Conversely, overall length of hospital stay (9.5±8.7 days vs. 12.5±12.7 days; p=0.005) as well as mean duration of high care monitoring (ICU, IMC, CCU) (2.4±4.6 days vs. 4.7±7.7 days; p=0.006) were shorter in the MINOCA group compared to MIOCAs. With an average of 6871.5±5670.8 EUR per index, MINOCA treatment costs were lower compared to the real myocardial infarction group (14277.5±7896.9 EUR; p<0.001) with a mean difference of approximately 7406 EUR.
Conclusion
Despite MINOCA being mostly a benign syndrome with favorable clinical outcome, it still utilizes relevant financial and capacity resources including high care monitoring and an in-hospital treatment of relevant length.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- F Haertel
- University Hospital of Jena, Cardiology , Jena , Germany
| | - C Metz
- University Hospital of Jena, Cardiology , Jena , Germany
| | - T Kraeplin
- University Hospital of Jena, Cardiology , Jena , Germany
| | - P C Schulze
- University Hospital of Jena, Cardiology , Jena , Germany
| | - S Otto
- University Hospital of Jena, Cardiology , Jena , Germany
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Franz M, Baez L, Moebius-Winkler S, Diab M, Ibrahim K, Kraeplin T, Schulze PC. Prognostic relevance of mitral regurgitation at different follow-up timepoints after transcatheter aortic valve implantation (TAVI): implications for therapeutic decision making? Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1573] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly patients suffering from severe symptomatic degenerative aortic stenosis (AS). The extent of mitral regurgitation (MR) following TAVI is likely to be of prognostic relevance. This raises the question whether treating MR following TAVI improves outcome of patients with significant MR.
Purpose
The current study was aimed to elucidate the prognostic value of MR at different follow-up (FU) timepoints after TAVI in a prospective real-world single-center registry study.
Methods
A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included and a wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed. Mortality was recorded at 30 days, 1 year and 2 years after TAVI. Complete FU data including echocardiography were available at 6 to 8 weeks (n=334) as well as 6 months (n=235) after TAVI.
Results
All patients (mean age: 78.7±7.3 years, 52% female, mean STS score: 5±3.9%) were successfully treated by transfemoral TAVI using balloon- or self-expanding prostheses and showed mortality rates of 3.6% after 30 days, 16.4% after 1 year and 22.6% after 2 years. Moderate or severe (relevant) MR was detectable in 39% of the patients at baseline, in 27% of patients after 6 weeks (p=0.001) and in 28% of patients after 6 months (p=0.036, compared to baseline). Multivariate analysis identified independent predictors of 2-year mortality: clinical frailty scale and PAPsys at 6 to 8 weeks post-TAVI as well as BNP and relevant MR 6 months post TAVI. Among those parameters, MR after 6 months was the strongest predictor of long-term mortality (OR 3.192, CI 0.971–10.487, p=0.056). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant MR at 6 months (12.1% versus 4.8%, p=0.042).
Conclusions
Taken together, this real-life single-center experience underlines the prognostic value of relevant MR 6 months after TAVI with respect to long-term survival. Interestingly, MR was not predictive at the 6 to 8 weeks FU suggesting that early remodeling includes MR with prognostic relevance in those patients. Whether MR treatment, e.g., by transcatheter edge-to-edge repair, will improve patient outcomes post-TAVI has to be tested in prospective trials.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- M Franz
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - L Baez
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - S Moebius-Winkler
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - M Diab
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - K Ibrahim
- Klinikum Chemnitz, Klinik für Innere Medizin I - Kardiologie, Angiologie, Intensivmedizin , Chemnitz , Germany
| | - T Kraeplin
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - P C Schulze
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
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Baez L, Moebius-Winkler S, Diab M, Ibrahim K, Kraeplin T, Schulze PC, Franz M. Tricuspid regurgitation and atrial fibrillation at baseline independently predict two-year survival after transcatheter aortic valve implantation (TAVI). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1572] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Transcatheter aortic valve implantation (TAVI) is the accepted state-of-the-art treatment for elderly patients suffering from severe symptomatic aortic stenosis (AS). Co-morbidities at baseline are of great impact not only for individual peri-procedural risk stratification but also for the determination of long-term prognosis. The latter is of certain clinical interest, since a variety of co-existing disorders can be effectively treated in addition to TAVI.
Purpose
The current study aimed to elucidate the prognostic value of a wide range of baseline characteristics and co-morbidities with respect to long-term survival of TAVI patients in a prospective real-world single-center registry study.
Methods
A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included. A wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed at baseline prior to TAVI. Mortality was recorded at 30 days, 1 year and 2 years after TAVI.
Results
The mean age of patients in this typical TAVI cohort was 78.7±7.3 years, 52% were female and the mean STS score was 5±3.9%. The mortality rates were as follows: 3.6% after 30 days, 16.4% after 1 and 22.6% after 2 years. Multivariate analysis could identify the following independent predictors of 2-year mortality assessed at baseline: sex, age, AS entity other than high-gradient, atrial fibrillation (Afib), renal function, relevant TR, systolic pulmonary artery pressure (PAPsys) and six-minute walk distance (SMWD). Among those, the strongest predictive value could be shown for Afib (OR 2.505, CI 1.509–4.157, p<0.001) and TR (OR 2.179, CI 1.105–4.299, p=0.025). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant TR (31.6% versus 17.4%, p<0.001) and Afib (29.4% versus 14.8%, p<0.001).
Conclusions
Taken together, the results of the current study demonstrate the prognostic value of cardiovascular co-morbidities assessed prior to TAVI. We identified relevant TR and Afib as the strongest independent predictors of long-term mortality in our cohort. Since both conditions are effectively treatable, special emphasis should be placed on the question, which patient might benefit from treatment, e.g., by transcatheter edge-to-edge repair of TR or rhythm control, in addition to TAVI.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Else Kröner-Fresenius-Stiftung, Research Program “Else Kröner-Forschungskolleg AntiAge”
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Affiliation(s)
- L Baez
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - S Moebius-Winkler
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - M Diab
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - K Ibrahim
- Klinikum Chemnitz, Klinik für Innere Medizin I - Kardiologie, Angiologie, Intensivmedizin , Chemnitz , Germany
| | - T Kraeplin
- University Hospital Jena, Department of Cardiothoracic Surgery , Jena , Germany
| | - P C Schulze
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
| | - M Franz
- University Hospital Jena, Department of Internal Medicine I , Jena , Germany
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Sundermeyer J, Beer BN, Blankenberg S, Kirchhof P, Luedike P, Mangner N, Nordbeck P, Orban M, Pazdernik M, Proudfoot A, Schulze PC, Tavazzi G, Thiele H, Westermann D, Schrage B. Impact of left ventricular ejection fraction on mortality and use of mechanical circulatory support in non-ischaemic cardiogenic shock. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1013] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Evidence in non-ischaemic cardiogenic shock (CS), especially regarding prognostic markers and use of mechanical circulatory support (MCS), is scarce.
Aim
The aim of this study was to evaluate left ventricular ejection fraction (LVEF) as a prognostic marker as well as a factor to guide the use of MCS in non-ischaemic CS.
Methods
In this international observational study, patients with non-ischaemic CS (e.g. caused by severe de-novo or acute on chronic heart failure; but not by acute myocardial infarction) treated with or without MCS from 18 tertiary-care centers in five countries were enrolled. Cox regression models adjusted for age, sex, SCAI class, lactate, prior resuscitation, mechanical ventilation and pH were fitted to evaluate the association between LVEF and 30-day mortality as well as the interaction between MCS use, LVEF and 30-day mortality.
Results
A total of 807 patients were enrolled, of whom 387 (47,9%) were treated with and 418 (52.1%) without MCS; mean age was 63 [interquartile range (IQR) 51.5–72) years, 601 (74.5%) were male, 486 (60.2%) had acute on chronic heart failure, 221 (32.7%) had an ischaemic cardiomyopathy and 277 (34.5%) had prior cardiac arrest. The baseline LVEF was 20 (IQR 15–30) % and baseline lactate was 4.9 (IQR 2.6–8.5) mmol/l.
There was no significant association between LVEF and 30-day mortality risk [hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.74–1.22 if LVEF was considered as a continuous variable; HR 1.09, 95% CI 0.83–1.44 if LVEF was considered as a categorical variable with ≤20% vs. >20%]. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with a depressed LVEF (HR 0.74, 95% CI 0.52–1.05, interaction-p = 0.04).
Conclusion
In this retrospective, multicenter, international study of patients with non-ischaemic CS, LVEF was not a predictor of 30-day mortality risk. However, we observed a significant interaction between MCS use and LVEF, indicating a lower morality risk with MCS use only in patients with a depressed LVEF. This provides rationale to use LVEF as a parameter to guide MCS therapy in non-ischaemic CS, and calls for a randomized trial on this topic.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Sundermeyer
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - B N Beer
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - S Blankenberg
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - P Kirchhof
- University Heart & Vascular Center Hamburg , Hamburg , Germany
| | - P Luedike
- University of Duisburg-Essen - West-German Heart and Vascular Center , Essen , Germany
| | - N Mangner
- Heart Centre Dresden - Dresden Technical University Hospital , Dresden , Germany
| | - P Nordbeck
- University Hospital of Wurzburg, Department of Internal Medicine I, , Würzburg , Germany
| | - M Orban
- University Hospital of Munich , Munich , Germany
| | - M Pazdernik
- Institute for Clinical and Experimental Medicine , Prague , Czechia
| | - A Proudfoot
- St Bartholomew's Hospital , London , United Kingdom
| | | | - G Tavazzi
- Policlinic Foundation San Matteo IRCCS , Pavia , Italy
| | - H Thiele
- Heart Center of Leipzig , Leipzig , Germany
| | - D Westermann
- Heart Center, University of Freiburg , Freiburg , Germany
| | - B Schrage
- University Heart & Vascular Center Hamburg , Hamburg , Germany
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Wu JM, Bekfani T, Hinze A, Westphal JG, Steinacker B, Zeller M, Hartmann C, Möbius‐Winkler S, Hochhaus A, Schulze PC, Ernst T. Clonal haematopoiesis of indeterminate potential-related mutations and outcome in dilated and ischaemic cardiomyopathy. ESC Heart Fail 2022; 9:3954-3960. [PMID: 35979940 PMCID: PMC9773636 DOI: 10.1002/ehf2.14115] [Citation(s) in RCA: 2] [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: 03/02/2022] [Revised: 07/19/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS Clonal haematopoiesis of indeterminate potential (CHIP)-associated mutation is a risk factor for the development of ischaemic cardiomyopathy (ICM), but its association with non-ischaemic dilated cardiomyopathy (DCM) remains unclear. We aimed to determine the prevalence of CHIP in patients with DCM and define its risk for disease progression. METHODS AND RESULTS Next-generation sequencing targeting 54 common CHIP-associated genes was performed in 48 ICM and 52 DCM patients. The patients were monitored for a median of 3.1 years, and a COX proportional hazards model was used to examine the association between CHIP and adverse clinical outcome with regard to all-cause death or all-cause hospitalization. Overall, the prevalence of CHIP mutations was 19% and 13% in DCM and ICM, respectively. Seventeen per cent of ICM patients over 75 years were CHIP carriers. In DCM cohort, mutation event had already been observed in the patients who were under the age of 45 (13%). Among 54 genes analysed, DNMT3A had the highest mutation frequency, followed by TET2 and CUX1. Kaplan-Meier curve over a median of 3.1 year tracking period showed a trend towards poor clinical outcome in the DCM patients who carried DNMT3A or TET2 mutation; however, such association was not statistically significant. CONCLUSIONS The prevalence of CHIP is detected at a young age in DCM, and accumulation of mutational frequency in DCM patients is independent of age. However, a larger patient cohort is required to validate the association between CHIP and clinical progression in the DCM patients.
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Affiliation(s)
- Jasmine M.F. Wu
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Tarek Bekfani
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany,Clinic for Cardiology, Angiology and PneumologyUniversity Hospital Magdeburg A.ö.RMagdeburgGermany
| | - Anna Hinze
- Department of Internal Medicine II, Division of Hematology and OncologyUniversity Hospital Jena, FSU JenaJenaGermany
| | - Julian Georg Westphal
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Berit Steinacker
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Max Zeller
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Charlotte Hartmann
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Sven Möbius‐Winkler
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Andreas Hochhaus
- Department of Internal Medicine II, Division of Hematology and OncologyUniversity Hospital Jena, FSU JenaJenaGermany
| | - P. Christian Schulze
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Thomas Ernst
- Department of Internal Medicine II, Division of Hematology and OncologyUniversity Hospital Jena, FSU JenaJenaGermany
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Haertel F, Lenk K, Fritzenwanger M, Pfeifer R, Franz M, Memisevic N, Otto S, Lauer B, Weingärtner O, Kretzschmar D, Dannberg G, Westphal J, Baez L, Bogoviku J, Schulze PC, Moebius-Winkler S. Rationale and Design of JenaMACS-Acute Hemodynamic Impact of Ventricular Unloading Using the Impella CP Assist Device in Patients with Cardiogenic Shock. J Clin Med 2022; 11:jcm11154623. [PMID: 35956238 PMCID: PMC9369529 DOI: 10.3390/jcm11154623] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Cardiogenic shock due to myocardial infarction or heart failure entails a reduction in end organ perfusion. Patients who cannot be stabilized with inotropes and who experience increasing circulatory failure are in need of an extracorporeal mechanical support system. Today, small, percutaneously implantable cardiac assist devices are available and might be a solution to reduce mortality and complications. A temporary, ventricular, continuous flow propeller pump using magnetic levitation (Impella®) has been approved for that purpose. METHODS AND STUDY DESIGN JenaMACS (Jena Mechanical Assist Circulatory Support) is a monocenter, proof-of-concept study to determine whether treatment with an Impella CP® leads to improvement of hemodynamic parameters in patients with cardiogenic shock requiring extracorporeal, hemodynamic support. The primary outcomes of JenaMACS are changes in hemodynamic parameters measured by pulmonary artery catheterization and changes in echocardiographic parameters of left and right heart function before and after Impella® implantation at different support levels after 24 h of support. Secondary outcome measures are hemodynamic and echocardiographic changes over time as well as clinical endpoints such as mortality or time to hemodynamic stabilization. Further, laboratory and clinical safety endpoints including severe bleeding, stroke, neurological outcome, peripheral ischemic complications and occurrence of sepsis will be assessed. JenaMACS addresses essential questions of extracorporeal, mechanical, cardiac support with an Impella CP® device in patients with cardiogenic shock. Knowledge of the acute and subacute hemodynamic and echocardiographic effects may help to optimize therapy and improve the outcome in those patients. CONCLUSION The JenaMACS study will address essential questions of extracorporeal, mechanical, cardiac support with an Impella CP® assist device in patients with cardiogenic shock. Knowledge of the acute and subacute hemodynamic and echocardiographic effects may help to optimize therapy and may improve outcome in those patients. ETHICS AND DISSEMINATION The protocol was approved by the institutional review board and ethics committee of the University Hospital of Jena. Written informed consent will be obtained from all participants of the study. The results of this study will be published in a renowned international medical journal, irrespective of the outcomes of the study. Strengths and Limitations: JenaMACS is an innovative approach to characterize the effect of additional left ventricular mechanical unloading during cardiogenic shock via a minimally invasive cardiac assist system (Impella CP®) 24 h after onset and will provide valuable data for acute interventional strategies or future prospective trials. However, JenaMACS, due to its proof-of-concept design, is limited by its single center protocol, with a small sample size and without a comparison group.
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Affiliation(s)
- Franz Haertel
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
- Correspondence: ; Tel.: +0049-364-1932-4554
| | - Karsten Lenk
- Department of Cardiology, University Hospital Leipzig, Liebigstrasse 20, Haus 4, 04103 Leipzig, Germany
| | - Michael Fritzenwanger
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ruediger Pfeifer
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Marcus Franz
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Nedim Memisevic
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sylvia Otto
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Bernward Lauer
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Oliver Weingärtner
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Daniel Kretzschmar
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Gudrun Dannberg
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Julian Westphal
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Laura Baez
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Jurgen Bogoviku
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - P. Christian Schulze
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sven Moebius-Winkler
- Department of Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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Baldus S, Bauersachs J, Beckmann A, Bleiziffer S, Böning A, Conradi L, Ensminger S, Falk V, Frerker C, Liebetrau C, Möllmann H, Rudolph V, Schächinger V, Schulze PC, Thiele H, Walther T, Beyersdorf F. Gemeinsamer Kommentar der Deutschen Gesellschaft für Kardiologie (DGK) und der Deutschen Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG) zu den Leitlinien (2021) der ESC/EACTS zum Management von Herzklappenerkrankungen. Z Herz- Thorax- Gefäßchir 2022. [DOI: 10.1007/s00398-022-00521-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Schulze PC, Bogoviku J, Westphal J, Aftanski P, Haertel F, Grund S, von Haehling S, Schumacher U, Möbius-Winkler S, Busch M. Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients With Acute Decompensated Heart Failure (EMPAG-HF). Circulation 2022; 146:289-298. [PMID: 35766022 DOI: 10.1161/circulationaha.122.059038] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Effective diuretic regimens using loop diuretics in patients with acute decompensated heart failure are often limited by the development of worsening kidney function. Sodium-glucose cotransporter-2 inhibitors induce glucosuria and sodium excretion with nephroprotective effects in patients with stable heart failure but their role in acute decompensated heart failure is unclear. METHODS In this single-center, prospective, double-blind, placebo-controlled, randomized study, we randomly assigned patients with acute decompensated heart failure to empagliflozin 25 mg daily or placebo in addition to standard decongestive treatments that included loop diuretics. The primary end point was cumulative urine output over 5 days. Secondary end points included diuretic efficiency, dynamics in markers of kidney function and injury, and NT-proBNP (N-terminal pro-B-type natriuretic peptide). RESULTS Sixty patients were randomized within 12 hours of hospitalization for acute decompensated heart failure. Addition of empagliflozin daily to standard medical treatment of acute decompensated heart failure resulted in a 25% increase in cumulative urine output over 5 days (median 10.8 versus 8.7 L mL in placebo, group difference estimation 2.2 L [95% CI, 8.4 to 3.6]; P=0.003). Empagliflozin increased diuretic efficiency compared with placebo (14.1 mL urine per milligram furosemide equivalent [95% CI, 0.6-27.7]; P=0.041) without affecting markers of renal function (estimated glomerular filtration rate, 51±19 versus 54±17 mL/min per 1.73 m²; P=0.599) or injury (total urinary protein, 492±845 versus 503±847 mg/g creatinine; P=0.975; and urinary α1-microglobulin, 55.4±38.6 versus 31.3±33.6 mg/g creatinine; P=0.066) with more pronounced decrease in NT-proBNP in the empagliflozin group compared with placebo (-1861 versus -727.2 pg/mL after 5 days; quotient in slope, 0.89 [95% CI, 0.83-0.95]; P<0.001). There were no differences in the incidence of safety events between groups. CONCLUSIONS Early addition of empagliflozin to standard diuretic therapy increases urine output without affecting renal function in patients with acute decompensated heart failure. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04049045.
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Affiliation(s)
- P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Jürgen Bogoviku
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Julian Westphal
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Pawel Aftanski
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Franz Haertel
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Sissy Grund
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Germany (S.v.H.)
| | - Ulrike Schumacher
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Martin Busch
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
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Schulze PC, Barten MJ, Boeken U, Färber G, Hagl CM, Jung C, Leistner D, Potapov E, Bauersachs J, Raake P, Reiss N, Saeed D, Schibilsky D, Störk S, Veltmann C, Rieth AJ, Gummert J. Implantation mechanischer Unterstützungssysteme und Herztransplantation bei Patienten mit terminaler Herzinsuffizienz. Z Herz- Thorax- Gefäßchir 2022. [DOI: 10.1007/s00398-022-00525-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Makhmudova U, Kretzschmar D, Schulze PC, Weingärtner O. Lipid-lowering therapy in patients with peripheral artery disease – a call for action. VASA 2022; 51:193-195. [DOI: 10.1024/0301-1526/a001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
A 45-year-old healthy woman presented with claudication of the right leg. The resting ankle-brachial index (ABI) was reduced to 0.6, and a duplex scan revealed an occlusion of the right popliteal artery. Angiography presented a patent superficial femoral artery that ends above the knee joint. Laterally, there was delayed retrograde contrast filling of the popliteal artery. After exploring the internal iliac artery, we crossed a thrombotic occlusion of a persisting sciatic artery (PSA). Local thrombolysis with recombinant tissue plasminogen activator (1 mg/h) was initiated. The Angiography 18 hours later showed a reduction of thrombotic material and relevant stenosis in the proximal part of the vessel. Residual thrombus and the stenosis were covered by two stentgrafts (Gore Viabahn Endoprosthesis) that were stabilized by an interwoven stent (Supera). Final angiography displayed a patent sciatic artery and a three-vessel run off. Postinterventional ABI was normalized to 1.0. The magnetic resonance imaging 6 days after the intervention demonstrated a patent PSA again and a normal blood flow on the left leg. A PSA should be included in the differential diagnosis of lower limb ischemia or suspected aneurysm formation. We demonstrated the feasibility of an interventional approach with an excellent outcome in this case.
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Affiliation(s)
- Daniel Kretzschmar
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany,HUGG-Herz and Gefäßmedizin Goslar, Fleischscharren 4, 38640 Goslar, Germany,Address for correspondence Daniel Kretzschmar, MD HUGG-Herz and Gefäßmedizin GoslarFleischscharren 4, 38640 GoslarGermany
| | - Marcus Thieme
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany,Department of Angiology, Cardiology, Diabetology, Regiomed-Vascular Center, Sonneberg, Germany
| | - Rene Aschenbach
- Department of Radiology, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
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Grosse A, Borisov G, Kirsch K, Alothman O, Surber R, Geller JC, Schulze PC, Raffa S. New onset of AV-nodal reentrant tachycardia (AVNRT) in the elderly- an uncommon diagnosis? Europace 2022. [DOI: 10.1093/europace/euac053.303] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Arrhythmias in elderly patients (pat) are common. In this subset of pat, atrial fibrillation is by far the most frequent sustained arrhythmia but not the only one. Clinical, ECG and electrophysiological (EP) features of AV-nodal reentrant tachycardia (AVNRT) have rarely been described in the elderly, and this represents the aim of the current study.
Methods
At 2 EP-centres in Germany, data from all pat undergoing an EP-study (EPS) and diagnosed with AVNRT between January 2018 and May 2021 were collected and analysed. Pat > 65 years constituted the study population.
Results
During the study period AVNRT was diagnosed in a total of 329 pat. 93 pat (28%) were > 65 years and represent the study population [median age 74 (65-89) years, 48% female]. In the majority (85%), the duration of symptoms was short (< 1 year), 14 pat had symptoms of paroxysmal tachycardia for longer than 10 years. Most of the pat (n=88, 94%) had at least one ECG-documentation. In SR, the PR interval was relatively long [median 180 (120-380) ms)]. In 84% of pat, sustained AVNRT [median cycle length (CL) 400 (270-800) ms] was induced during EPS. In the remaining pat, at least 2 typical AV-nodal-echo beats were induced. Slow pathway (SP) ablation/modification was performed in all but one patient presenting with a very long baseline PR-interval, low antegrade Wenckebach-point (WP) and very slow AVNRT. In this case, the pat was treated with ß-blocker after pacemaker (PM) implantation. In 3 additional pat, PM implantation was necessary after ablation due to intermittent high-degree AV-block. In comparison to the rest of the study population, these four pat had a longer baseline PQ interval [median 275 (IQR 248- 303) ms vs. 180 (IQR 160- 192) ms], a longer baseline AH interval [median 207ms (IQR 185- 234) ms vs. 95 (IQR 80- 107) ms], a lower baseline antegrade WP CL [median 510 (IQR 435- 645) vs. 390ms (IQR 355- 470) ms], and a longer tachycardia CL [TCL 557 (IQR 454- 661) ms vs. 400 (IQR 364- 443) ms; p value <0,01 for all comparisons]. The overall complication rate (other than AV block) was low (2 pat with AV fistula treated conservatively) and comparable to the one described in younger pat.
Discussion
Elderly pat also have AVNRT, there are a slight differences in physiology (i.e. relatively long baseline PR-interval and TCL, likely due to changes of the conduction system with aging), and as in young pat, ablation is curative treatment with similar (low) complication rate. A subset of pat, characterized by longer PR- and AH-intervals, lower WP and longer TCL may be at higher risk for AV-block after SP modification. Whether this is due to pre-existing damage or to posterior location of the FP remains unknown.
SP ablation is safe and effective even in elderly pat. In pat presenting with EP characteristics presumptive of a baseline impairment of the conduction properties of the FP, ablation of the FP could be attempted to avoid postprocedural high degree AV block.
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Affiliation(s)
- A Grosse
- University hospital Jena, Jena, Germany
| | | | - K Kirsch
- University hospital Jena, Jena, Germany
| | | | - R Surber
- University hospital Jena, Jena, Germany
| | | | | | - S Raffa
- Zentralklinik, Bad Berka, Germany
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