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Duca F, Rettl R, Kronberger C, Binder C, Mann C, Dusik F, Schrutka L, Dalos D, Öztürk B, Dachs TM, Cherouny B, Camuz Ligios L, Agis H, Kain R, Koschutnik M, Donà C, Badr-Eslam R, Kastner J, Beitzke D, Loewe C, Nitsche C, Hengstenberg C, Kammerlander AA, Bonderman D. Myocardial structural and functional changes in cardiac amyloidosis: insights from a prospective observational patient registry. Eur Heart J Cardiovasc Imaging 2023; 25:95-104. [PMID: 37549339 PMCID: PMC10735280 DOI: 10.1093/ehjci/jead188] [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: 11/02/2022] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023] Open
Abstract
AIMS The pathophysiological hallmark of cardiac amyloidosis (CA) is the deposition of amyloid within the myocardium. Consequently, extracellular volume (ECV) of affected patients increases. However, studies on ECV progression over time are lacking. We aimed to investigate the progression of ECV and its prognostic impact in CA patients. METHODS AND RESULTS Serial cardiac magnetic resonance (CMR) examinations, including ECV quantification, were performed in consecutive CA patients. Between 2012 and 2021, 103 CA patients underwent baseline and follow-up CMR, including ECV quantification. Median ECVs at baseline of the total (n = 103), transthyretin [(ATTR) n = 80], and [light chain (AL) n = 23] CA cohorts were 48.0%, 49.0%, and 42.6%, respectively. During a median period of 12 months, ECV increased significantly in all cohorts [change (Δ) +3.5% interquartile range (IQR): -1.9 to +6.9, P < 0.001; Δ +3.5%, IQR: -2.0 to +6.7, P < 0.001; and Δ +3.5%, IQR: -1.6 to +9.1, P = 0.026]. Separate analyses for treatment-naïve (n = 21) and treated (n = 59) ATTR patients revealed that the median change of ECV from baseline to follow-up was significantly higher among untreated patients (+5.7% vs. +2.3%, P = 0.004). Survival analyses demonstrated that median change of ECV was a predictor of outcome [total: hazard ratio (HR): 1.095, 95% confidence interval (CI): 1.047-1.0145, P < 0.001; ATTR: HR: 1.073, 95% CI: 1.015-1.134, P = 0.013; and AL: HR: 1.131, 95% CI: 1.041-1.228, P = 0.003]. CONCLUSION The present study supports the use of serial ECV quantification in CA patients, as change of ECV was a predictor of outcome and could provide information in the evaluation of amyloid-specific treatments.
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Affiliation(s)
- Franz Duca
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - René Rettl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christina Kronberger
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christina Binder
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christopher Mann
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Fabian Dusik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lore Schrutka
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Daniel Dalos
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Begüm Öztürk
- Division of Cardiology, Favoriten Clinic, Kundratstraße 3, 1100 Vienna, Austria
| | - Theresa Marie Dachs
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Bernhard Cherouny
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Luciana Camuz Ligios
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Hermine Agis
- Department of Internal Medicine I, Division of Hematology, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Carolina Donà
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Roza Badr-Eslam
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Johannes Kastner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Dietrich Beitzke
- Department of Bioimaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Department of Bioimaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Andreas Anselm Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Diana Bonderman
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Division of Cardiology, Favoriten Clinic, Kundratstraße 3, 1100 Vienna, Austria
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Duca F, Rettl R, Binder C, Dusik F, Schrutka L, Dalos D, Öztürk B, Capelle CD, Qin H, Dachs TM, Camuz Ligios L, Agis H, Kain R, Hengstenberg C, Badr-Eslam R, Kastner J, Bonderman D. Cardiac amyloidosis: a significant blind spot of the H2FPEF score. Panminerva Med 2023; 65:491-498. [PMID: 36789997 DOI: 10.23736/s0031-0808.22.04649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Cardiac amyloidosis (CA) often mimics heart failure with preserved ejection fraction (HFpEF). Due to very different treatment strategies, an exact diagnosis and differentiation between pure HFpEF and CA-related heart failure (HF) is important. In the present study, we assessed the recently published H2FPEF score in patients with pure HFpEF, transthyretin (ATTR), as well as light chain (AL) amyloidosis-related HFpEF and tested whether it differentiates between these entities. METHODS The H2FPEF scores consists of easy-to-assess clinical (Body Mass Index, number of hypertensive drugs, presence of atrial fibrillation, age) and echocardiographic (systolic pulmonary arterial pressure, E/E´) parameters. It can be computed in a categorical way resulting in scores between 0 and 9 points (0-1: HFpEF rule out, 2-5: further testing required, 6-9: HFpEF rule in), or in a continual way providing an exact percentage of a patient's HFpEF probability. Continuous and categorical variables were compared using the Kruskal-Wallis, Mann-Whitney-U, and χ2-tests. Diagnostic accuracy was computed from 2x2 tables. Survival analysis was performed with Kaplan-Meier curves. A P value of <0.05 was set as the level of significance. RESULTS A total of 100 patients with pure HFpEF, 53 patients with ATTR, and 34 patients with AL CA were included in the present study. Median age (HFpEF: 71.5 years; ATTR CA: 77.0 years; AL CA: 60.0 years; P<0.001), gender distribution (HFpEF [female]: 73.0%, ATTR (female): 18.9%, AL [female]: 38.2%; P<0.001), and N-terminal prohormone of brain natriuretic peptide (HFpEF: 1045pg/mL; ATTR CA: 1927pg/mL; AL CA: 4308pg/mL; P<0.001) differed significantly between study cohorts. Median H2FPEF scores were highest among HFpEF (categorical: 5.0 points; continual: 95.1%), followed by ATTR (categorical: 4.0 points; continual: 89.0%), and AL CA (categorical: 3.0 points; continual: 31.2%). Respective P values were <0.001. Low H2FPEF scores (0-1 points) were found among patients in the AL CA cohort (29.4%), but not among HFpEF or ATTR CA patients (P<0.001). The majority of patients, irrespective of disease entity were in the intermediate score range (2-5 points, HFpEF: 80.0% ATTR CA: 94.3%, AL CA: 67.9%; P=0.006). High scores (6-9 points) were most often found among HFpEF patients (20.0%), followed by ATTR CA (5.7%) and AL CA (2.9%), (P=0.007). CONCLUSIONS The H2FPEF score should be used with caution, as there is a significant overlap between HFpEF and CA-related HF.
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Affiliation(s)
- Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Rene Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Fabian Dusik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Begüm Öztürk
- Division of Cardiology, Favoriten Clinic, Vienna, Austria
| | | | - Hong Qin
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Theresa M Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Hermine Agis
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Division of Hematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roza Badr-Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria -
- Division of Cardiology, Favoriten Clinic, Vienna, Austria
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Rettl R, Duca F, Binder C, Dachs TM, Cherouny B, Camuz Ligios L, Mann C, Schrutka L, Dalos D, Charwat-Resl S, Badr Eslam R, Kastner J, Bonderman D. Impact of tafamidis on myocardial strain in transthyretin amyloid cardiomyopathy. Amyloid 2023; 30:127-137. [PMID: 36251806 DOI: 10.1080/13506129.2022.2131385] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Indexed: 11/01/2022]
Abstract
AIMS The impact of tafamidis on myocardial strain in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) have been barely investigated. We aimed to determine tafamidis-induced changes using serial speckle tracking echocardiography and to identify imaging parameters for specific therapy monitoring. METHODS AND RESULTS ATTR-CM patients underwent serial TTE with two-dimensional (2 D) speckle tracking imaging. Patients receiving tafamidis free acid 61 mg (n = 62) or tafamidis meglumine 20 mg (n = 21) once daily (QD) showed stable measurements at follow-up (61 mg: 8.5 months, 20 mg: 7.0 months) in LV global longitudinal strain (GLS) (61 mg: -11.75% vs. -11.58%, p = 0.534; 20 mg: -10.61% vs. -10.12%, p = 0.309), right ventricular (RV) GLS (61 mg: -14.18% vs. -13.72%, p = 0.377; 20 mg: -14.53% vs. -13.99%, p = 0.452) and left atrial (LA) reservoir strain (LASr; 61 mg: 8.80% vs. 9.42%, p = 0.283; 20 mg: 8.23% vs. 8.67%, p = 0.589), whereas treatment-naïve ATTR-CM patients (n = 54) had clear signs of disease progression at the end of the observation period (10.5 months; LV-GLS: -11.71% vs. -10.59%, p = 0.001; RV-GLS: -14.36% vs. -12.99%, p = 0.038; LASr: 10.67% vs. 8.41%, p = 0.005). Between-group comparison at follow-up revealed beneficial effects of tafamidis free acid 61 mg on LASr (p = 0.003) and the LV (LV-GLS: p = 0.030, interventricular septum (IVS): p = 0.006), resulting in clinical benefits (six-minute walk distance (6-MWD): p = 0.006, NT-proBNP: p= <0.001), while patients treated with tafamidis meglumine 20 mg QD showed positive effects on LASr (p = 0.039), but no differences with respect to the LV (LV-GLS: p = 0.274, IVS: p = 0.068) and clinical status (6-MWD: p = 0.124, NT-proBNP: p = 0.053) compared to the natural course. CONCLUSIONS Treatment with tafamidis free acid 61 mg in ATTR-CM patients delays the deterioration of LA and LV longitudinal function, resulting in significant clinical benefits compared with natural history. Serial TTE with 2 D speckle tracking imaging may be appropriate for disease-specific therapy monitoring.
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Affiliation(s)
- René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Bernhard Cherouny
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christopher Mann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Silvia Charwat-Resl
- Division of Cardiology, Department of Internal Medicine V, Favoriten Clinic, Vienna, Austria
| | - Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Division of Cardiology, Department of Internal Medicine V, Favoriten Clinic, Vienna, Austria
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4
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Dachs TM, Duca F, Rettl R, Binder-Rodriguez C, Dalos D, Ligios LC, Kammerlander A, Grünig E, Pretsch I, Steringer-Mascherbauer R, Ablasser K, Wargenau M, Mascherbauer J, Lang IM, Hengstenberg C, Badr-Eslam R, Kastner J, Bonderman D. Riociguat in pulmonary hypertension and heart failure with preserved ejection fraction: the haemoDYNAMIC trial. Eur Heart J 2022; 43:3402-3413. [PMID: 35909264 PMCID: PMC9492239 DOI: 10.1093/eurheartj/ehac389] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 06/12/2022] [Accepted: 07/06/2022] [Indexed: 12/16/2022] Open
Abstract
AIMS The presence of pulmonary hypertension (PH) severely aggravates the clinical course of heart failure with preserved ejection fraction (HFpEF). To date, neither established heart failure therapies nor pulmonary vasodilators proved beneficial. This study investigated the efficacy of chronic treatment with the oral soluble guanylate cyclase stimulator riociguat in patients with PH-HFpEF. METHODS AND RESULTS The phase IIb, randomized, double-blind, placebo-controlled, parallel-group, multicentre DYNAMIC trial assessed riociguat in PH-HFpEF. Patients were recruited at five hospitals across Austria and Germany. Key eligibility criteria were mean pulmonary artery pressure ≥25 mmHg, pulmonary arterial wedge pressure >15 mmHg, and left ventricular ejection fraction ≥50%. Patients were randomized to oral treatment with riociguat or placebo (1:1). Patients started at 0.5 mg three times daily (TID) and were up-titrated to 1.5 mg TID. The primary efficacy endpoint was change from baseline to week 26 in cardiac output (CO) at rest, measured by right heart catheterization. Primary efficacy analyses were performed on the full analysis set. Fifty-eight patients received riociguat and 56 patients placebo. After 26 weeks, CO increased by 0.37 ± 1.263 L/min in the riociguat group and decreased by -0.11 ± 0.921 L/min in the placebo group (least-squares mean difference: 0.54 L/min, 95% confidence interval 0.112, 0.971; P = 0.0142). Five patients dropped out due to riociguat-related adverse events but no riociguat-related serious adverse event or death occurred. CONCLUSION The vasodilator riociguat improved haemodynamics in PH-HFpEF. Riociguat was safe in most patients but led to more dropouts as compared to placebo and did not change clinical symptoms within the study period.
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Affiliation(s)
- Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christina Binder-Rodriguez
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Andreas Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
| | - Ingrid Pretsch
- Division of Cardiology and Intensive Care, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Muellner Hauptstraße 48, 5020 Salzburg, Austria
| | - Regina Steringer-Mascherbauer
- Division of Cardiology, Angiology and Intensive Care, Department of Internal Medicine II, Public Hospital Elisabethinen Linz, Fadingerstraße 1, 4020 Linz, Austria
| | - Klemens Ablasser
- Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Manfred Wargenau
- M.A.R.C.O. GmbH & Co. KG, Institute for Clinical Research and Statistics, Schirmerstraße 71, 40211 Duesseldorf, Germany
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.,Division of Cardiology, Department of Internal Medicine III, University Hospital of St. Poelten, Dunant-Platz 1, 3100 St. Poelten, Austria
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Roza Badr-Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.,Division of Cardiology, Department of Internal Medicine V, Favoriten Clinic, Kundratstraße 3, 1100 Vienna, Austria
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5
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Badr Eslam R, Öztürk B, Rettl R, Capelle CDJ, Qin H, Binder C, Dachs TM, Camuz Ligios L, Duca F, Dalos D, Schrutka L, Alasti F, Kastner J, Vila G, Bonderman D. Impact of Tafamidis and Optimal Background Treatment on Physical Performance in Patients With Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2022; 15:e008381. [PMID: 35766028 DOI: 10.1161/circheartfailure.121.008381] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with transthyretin amyloid cardiomyopathy, tafamidis was shown to slow the decline in 6-minute walking distance as compared with placebo. We aimed to define the impact of tafamidis and optimal background treatment on functional capacity as determined by cardiopulmonary exercise testing (CPET). METHODS Seventy-eight consecutive patients were enrolled in the study. They underwent CPET at baseline, and outcome defined as death or heart failure hospitalization was obtained for a time period of up to 30 months. Fifty-four patients completed a follow-up CPET at 9±3 months (range, 4-16 months). Improvement in peak VO2 at follow-up was defined as ∆peak VO2≥1.0 mL/(kg·min), stable peak VO2 was defined as 0≤∆peak VO2<1.0 mL/(kg·min), and decline in peak VO2 was defined by ∆peak VO2<0 mL/(kg·min). RESULTS Baseline peak VO2>14 mL/(kg·min) as well as minute ventilation/carbon dioxide production slope≤34 were associated with a lower risk of death or heart failure hospitalization (P=0.002, P=0.007, respectively). In 54 patients, who received tafamidis and underwent repeat CPET testing, an improvement in physical performance (P=0.002) was observed at follow-up. When comparing pre and post-treatment parameters, 29 patients (54%) showed an increase in percent predicted peak VO2 (P<0.0001), an improvement of peak VO2 (P<0.0001), and better physical performance at follow-up (P<0.0001). Patients with stable or improved peak VO2 had less advanced heart disease at baseline (P=0.046). CONCLUSIONS Our findings demonstrate that baseline peak VO2 and baseline minute ventilation/carbon dioxide production slope predict outcomes and an improvement in physical performance as measured by CPET was observed in patients receiving tafamidis, who had less advanced disease at baseline, emphasizing the importance of early diagnosis.
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Affiliation(s)
- Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Begüm Öztürk
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Christophe Denis Josef Capelle
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Hong Qin
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Farideh Alasti
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria (F.A.)
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III (G.V.), Medical University of Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
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Rettl R, Mann C, Duca F, Dachs TM, Binder C, Ligios LC, Schrutka L, Dalos D, Koschutnik M, Donà C, Kammerlander A, Beitzke D, Loewe C, Charwat-Resl S, Hengstenberg C, Kastner J, Eslam RB, Bonderman D. Tafamidis treatment delays structural and functional changes of the left ventricle in patients with transthyretin amyloid cardiomyopathy. Eur Heart J Cardiovasc Imaging 2021; 23:767-780. [PMID: 34788394 DOI: 10.1093/ehjci/jeab226] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [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: 09/09/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Tafamidis improves outcomes in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). However, it is not yet known whether tafamidis affects cardiac amyloid deposition and structural changes in the myocardium. We aimed to determine disease-modifying effects on myocardial amyloid progression and to identify imaging parameters that could be applied for specific therapy monitoring. METHODS AND RESULTS ATTR-CM patients underwent serial cardiac magnetic resonance (CMR) imaging using T1 mapping techniques to derive extracellular volume (ECV). Patients receiving tafamidis 61 mg (n = 35) or 20 mg (n = 15) once daily showed stable measurements at follow-up (FU) {61 mg: 9.0 [interquartile range (IQR) 7.0-11.0] months, 20 mg: 11.0 (IQR 8.0-18.0) months} in left ventricular (LV) ejection fraction (LVEF; 61 mg: 47.6% vs. 47.5%, P = 0.935; 20 mg: 52.4% vs. 52.1%, P = 0.930), LV mass index (LVMI; 61 mg: 110.2 vs. 106.2 g/m2, P = 0.304; 20 mg: 114.5 vs. 115.4 g/m2, P = 0.900), and ECV (61 mg: 47.5% vs. 47.7%, P = 0.861; 20 mg: 56.7% vs. 57.5%, P = 0.759), whereas treatment-naïve ATTR-CM patients (n = 19) had clear signs of disease progression at the end of the observation period [12.0 (IQR 10.0-21.0) months; LVEF: 53.3% vs. 45.7%, P = 0.031; LVMI: 98.9 vs. 106.9 g/m2, P = 0.027; ECV: 49.3% vs. 54.6%, P = 0.023]. Between-group comparison at FU revealed positive effects in tafamidis 61 mg-treated compared to treatment-naïve patients (LVEF: P = 0.035, LVMI: P = 0.036, ECV: P = 0.030), while those treated with 20 mg showed no difference in the above LV measurements when compared with treatment-naïve (P = 0.120, P = 0.287, P = 0.158). However, both treatment groups showed clinically beneficial effects compared to the natural course [61 mg, 6-min walk distance (6-MWD): P = 0.005, N-terminal prohormone of brain natriuretic peptide (NT-proBNP): P = 0.002; 20 mg, 6-MWD: P = 0.023, NT-proBNP: P = 0.003]. CONCLUSION Tafamidis delays myocardial amyloid progression in ATTR-CM patients, resulting in structural, functional, and clinical benefits compared to the natural course. Serial CMR including measurement of ECV may be appropriate for disease-specific therapy monitoring.
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Affiliation(s)
- René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christopher Mann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Andreas Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Dietrich Beitzke
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Silvia Charwat-Resl
- Department of Cardiology, Clinic Favoriten, Kundratstraße 3, 1100 Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.,Department of Cardiology, Clinic Favoriten, Kundratstraße 3, 1100 Vienna, Austria
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Binder C, Poglitsch M, Duca F, Rettl R, Dachs TM, Dalos D, Schrutka L, Seirer B, Ligios LC, Capelle C, Eslam RB, Qin H, Hengstenberg C, Bonderman D. Renin Feedback Is an Independent Predictor of Outcome in HFpEF. J Pers Med 2021; 11:jpm11050370. [PMID: 34063595 PMCID: PMC8147649 DOI: 10.3390/jpm11050370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/03/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
Drugs which interact with the renin angiotensin aldosterone system (RAAS) aim to reduce the negative effects of angiotensin (Ang) II. Treatment with these drugs anticipate a compensatory up-regulation of renin; however, it has been shown that there is a large variability in circulating plasma renin (PRA), even in patients with optimal medical therapy in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Our aim was to measure plasma renin activity (PRA-S), its response to RAAS inhibitor (RAASi) therapies and its effects on outcome in patients with HF with preserved ejection fraction (HFpEF). For this purpose, 150 HFpEF patients were included into a prospective single-center registry. Equilibrium (eq) angiotensin metabolites were measured from serum samples using mass spectroscopy. PRA-S (eqAng I + eqAng II) was calculated and compared in respect to the primary endpoint defined as all-cause death. PRA-S in patients with RAASi therapy was not significantly higher than in patients without RAASi (p = 0.262). Even after adjusting for confounding factors, PRA-S remained predictive for all-cause death in the multivariable model with a hazard ratio of 2.14 (95%CI 1.20–3.82, p = 0.010). We conclude that high PRA-S is associated with poor prognosis in patients with HFpEF, regardless of RAASi treatment, which could ultimately result in hyperactivated RAAS and consecutive negative effects on the cardiovascular and renal system, leading to poor outcome in patients with HFpEF.
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Affiliation(s)
- Christina Binder
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | | | - Franz Duca
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - René Rettl
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Theresa Marie Dachs
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Daniel Dalos
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Lore Schrutka
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Benjamin Seirer
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Luciana Camuz Ligios
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Christophe Capelle
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Roza Badr Eslam
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Hong Qin
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Christian Hengstenberg
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
| | - Diana Bonderman
- Division of Cardiology, Medical University of Vienna, 1090 Wien, Austria; (C.B.); (F.D.); (R.R.); (T.M.D.); (D.D.); (L.S.); (B.S.); (L.C.L.); (C.C.); (R.B.E.); (H.Q.); (C.H.)
- Correspondence: ; Tel.: +43-140-400-46-140
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8
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Rettl R, Dachs TM, Duca F, Binder C, Dusik F, Seirer B, Schönauer J, Kronberger C, Camuz Ligios L, Hengstenberg C, Derkits N, Kastner J, Badr Eslam R, Bonderman D. What Type of Patients Did PARAGON-HF Select? Insights from a Real-World Prospective Cohort of Patients with Heart Failure and Preserved Ejection Fraction. J Clin Med 2020; 9:jcm9113669. [PMID: 33203151 PMCID: PMC7697501 DOI: 10.3390/jcm9113669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 12/17/2022] Open
Abstract
The PARAGON-HF clinical trial suggested that sacubitril/valsartan may become a treatment option for particular subgroups of patients with heart failure and preserved ejection fraction (HFpEF). However, the proportion of real-world HFpEF patients who are theoretically superimposable with the PARAGON-HF population is yet unknown. The present study was performed to define the proportion of real-world PARAGON-HF-like patients and to describe their clinical characteristics and long-term prognosis in comparison with those who would not meet PARAGON-HF criteria. We systematically applied PARAGON-HF inclusion and exclusion criteria to a total of 427 HFpEF patients who have been participating in a prospective national registry between December 2010 and December 2019. In total, only 170 (39.8%) registry patients were theoretically eligible for PARAGON-HF. Patients not meeting inclusion criteria (41.0%) were less impaired with respect to exercise capacity (median 6-min walk distance: 385 m (IQR: 300-450) versus 323 m (IQR: 240-383); p < 0.001) had lower pulmonary pressures (mean pulmonary artery pressure (mPAP): 31.2 mmHg, standard deviation (SD): ±10.2 versus 32.8 mmHg, SD: ±9.7; p < 0.001) and better outcomes (log-rank: p < 0.001) as compared to the PARAGON-like cohort. However, patients theoretically excluded from the trial (19.2%) were those with most advanced heart failure symptoms (median 6-min walk test: 252 m (IQR: 165-387); p < 0.001), highest pulmonary pressures (mPAP: 38.2 mmHg, SD: ±12.4; p < 0.001) and worst outcome (log-rank: p = 0.037). We demonstrate here that < 40% of real-world HFpEF patients meet eligibility criteria for PARAGON-HF. We conclude that despite reasons for optimism after PARAGON-HF, a large proportion of HFpEF patients will remain without meaningful treatment options.
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Affiliation(s)
- René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Fabian Dusik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Benjamin Seirer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Johannes Schönauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Christina Kronberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Nina Derkits
- Novartis Pharma GmbH, Stella-Klein-Loew-Weg 17, 1020 Vienna, Austria;
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
| | - Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (R.R.); (T.-M.D.); (F.D.); (C.B.); (F.D.); (B.S.); (J.S.); (C.K.); (L.C.L.); (C.H.); (J.K.)
- Correspondence: (R.B.E.); (D.B.); Tel.: +43-1-40-400-46140 (R.B.E.); +43-1-601-91-2508 (D.B.)
| | - Diana Bonderman
- Division of Cardiology, Klinik Favoriten, Kundratstraße 3, 1100 Vienna, Austria
- Correspondence: (R.B.E.); (D.B.); Tel.: +43-1-40-400-46140 (R.B.E.); +43-1-601-91-2508 (D.B.)
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