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Olanisa OO, Parab P, Chaudhary P, Mukhtar S, Moradi A, Kodali A, Okoye C, Klein D, Mohamoud I, Mohammed L. Racial Disparities and Outcomes of Percutaneous Coronary Interventions in Patients Above 65 Years in America: A Systematic Review. Cureus 2023; 15:e42457. [PMID: 37637537 PMCID: PMC10450101 DOI: 10.7759/cureus.42457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
This systematic review aims to examine the racial disparities and outcomes of percutaneous coronary interventions (PCIs) in patients above 65 years in America. The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020 and includes a comprehensive search strategy, study selection, data extraction, and quality assessment. The search strategy identified 10 relevant articles that were included in the review. The findings indicate that racial disparities exist in access to PCI, door-to-balloon (DTB) time, procedure utilization, and outcomes among elderly patients. African American and Hispanic patients were found to experience longer door-to-balloon time and lower rates of PCI utilization compared to White patients. Moreover, racial and ethnic minorities had worse clinical outcomes, including higher mortality rates and increased risk of major adverse cardiovascular events. The review also highlights the impact of Medicaid expansion on reducing disparities in access, treatment, and outcomes for patients with acute myocardial infarction (AMI). However, limitations in data availability and representation of racial and ethnic minorities in clinical trials were identified. The discussion section provides a robust analysis of the findings, exploring potential underlying factors contributing to the observed disparities. The review concludes that addressing racial disparities in PCI outcomes among elderly patients is crucial for achieving equitable healthcare delivery and improving cardiovascular health outcomes in America.
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Affiliation(s)
- Olawale O Olanisa
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Panah Parab
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Priti Chaudhary
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sonia Mukhtar
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
| | - Ali Moradi
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Athri Kodali
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Chiugo Okoye
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Dhadon Klein
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Iman Mohamoud
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Bhasin V, Hiltner E, Singh A, Elsaid O, Awasthi A, Kassotis J, Sethi A. Disparities in Drug-Eluting Stent Utilization in Patients With Acute ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample. Angiology 2022:33197221121027. [PMID: 35977920 DOI: 10.1177/00033197221121027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The superiority of drug-eluting stents (DES) compared with bare-metal stents (BMS) is well-established, but data regarding DES use in ST-elevation myocardial infarction (STEMI) as a function of race is limited. Our goal was to examine stent utilization patterns and disparities based on race, sex, and insurance status in patients with STEMI undergoing percutaneous coronary intervention. The National Inpatient Sample database was used to retrospectively compare DES vs BMS use in patients admitted with STEMI from 2009 to 2018. Multivariable logistic regression was performed to assess the independent predictors of DES use. DES utilization increased significantly from 62.8% in 2009 to 94.0% in 2018. However, African Americans were less likely to receive a DES (odds ratio [OR] .82, 95% confidence interval [CI] .77-.87) compared with Caucasians. Women were more likely to undergo DES implantation (OR 1.07, 95% CI 1.05-1.10). Patients insured by Medicaid (OR .84, 95% CI .80-.89) and those classified as Self-pay (OR .63, 95% CI .61-.66) were less likely to undergo DES implantation compared to those with private insurance (OR 1.33, 95% CI 1.29-1.38). Disparities based on race and insurance status continue to persist despite a significant increase in DES utilization in STEMI patients across the identified subgroups.
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Affiliation(s)
- Varun Bhasin
- Division of Cardiology, Department of Medicine, 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Emily Hiltner
- Division of Cardiology, Department of Medicine, 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anjuli Singh
- Division of Cardiology, Department of Medicine, 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ossama Elsaid
- Division of Cardiology, Department of Medicine, 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ashish Awasthi
- Division of Cardiology, 25044Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - John Kassotis
- Division of Cardiology, Department of Medicine, 12287Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ankur Sethi
- Division of Cardiology, 25044Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Golomb M, Redfors B, Crowley A, Smits PC, Serruys PW, von Birgelen C, Madhavan MV, Ben-Yehuda O, Mehran R, Leon MB, Stone GW. Prognostic Impact of Race in Patients Undergoing PCI: Analysis From 10 Randomized Coronary Stent Trials. JACC Cardiovasc Interv 2021; 13:1586-1595. [PMID: 32646701 DOI: 10.1016/j.jcin.2020.04.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/26/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to assess race-based differences in patients undergoing percutaneous coronary intervention from a large pooled database of randomized controlled trials. BACKGROUND Data on race-based outcomes after percutaneous coronary intervention are limited, deriving mainly from registries and single-center studies. METHODS Baseline characteristics and outcomes at 30 days, 1 year, and 5 years were assessed across different races, from an individual patient data pooled analysis from 10 randomized trials. Endpoints of interest included death, myocardial infarction, and major adverse cardiac events (defined as cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization). Multivariate Cox proportional hazards regression was performed to assess associations between race and outcomes, controlling for differences in 12 baseline covariates. RESULTS Among 22,638 patients, 20,585 (90.9%) were white, 918 (4.1%) were black, 404 (1.8%) were Asian, and 473 (2.1%) were Hispanic. Baseline and angiographic characteristics differed among groups. Five-year major adverse cardiac event rates were 18.8% in white patients (reference group), compared with 23.9% in black patients (p = 0.0009), 11.2% in Asian patients (p = 0.0007), and 21.5% in Hispanic patients (p = 0.07). Multivariate analysis demonstrated an independent association between black race and 5-year risk for major adverse cardiac events (hazard ratio: 1.28; 95% confidence interval: 1.05 to 1.57; p = 0.01). CONCLUSIONS In the present large-scale individual patient data pooled analysis, comorbidities were significantly more frequent in minority-group patients than in white patients enrolled in coronary stent randomized controlled trials. After accounting for these differences, black race was an independent predictor of worse outcomes, whereas Hispanic ethnicity and Asian race were not. Further research examining race-based outcomes after percutaneous coronary intervention is warranted to understand these differences.
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Affiliation(s)
- Mordechai Golomb
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York; Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | - Patrick W Serruys
- Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland; Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Clemens von Birgelen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Mahesh V Madhavan
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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Abstract
PURPOSE OF REVIEW Significant racial and ethnic healthcare disparities exist in the management and outcomes of patients with acute myocardial infarction (AMI). This review will highlight the recent studies focusing on disparities in AMI care and how practice patterns have changed over time, and discuss solutions and future directions to overcome disparities in AMI care. RECENT FINDINGS AMI continues to be a leading cause of morbidity and mortality in the USA. Racial and ethnic disparities continue to be present in the care and outcomes associated with AMI. Non-white individuals continue to receive less guideline-concordant care and experience higher rates of adverse outcomes compared with white individuals. Health policy and quality improvement interventions have helped to narrow the gap; however, ongoing efforts are needed to continue to attempt to eliminate this disparity. Racial and ethnic disparities persist in the presentation, management, and outcomes of patients with AMI. Improvements in care have narrowed some of the inequalities. Ongoing research and efforts directed at improving access to care, eliminating bias in healthcare, and focusing on coronary heart disease prevention are needed to eliminate disparities.
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Ellis SG, Cho L, Raymond R, Nair R, Simpfendorfer C, Tuzcu M, Bajzer C, Lincoff AM, Kapadia S. Comparison of Long-Term Clinical Outcomes After Drug-Eluting Stenting in Blacks-vs-Whites. Am J Cardiol 2019; 124:1179-1185. [PMID: 31439280 DOI: 10.1016/j.amjcard.2019.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
Abstract
Patients of different racial backgrounds may have socioeconomic, cultural, or genetic differences that impact outcomes after percutaneous coronary intervention (PCI). There are limited data beyond 2 to 3 years for Blacks to inform discussions and perhaps improve outcomes. We studied consecutive limus-stent treated patients, having their first PCI at our institution January 2003 to March 2010 in 2 cohorts; Cohort 1: standard 3-year follow-up (n = 3,782, 12.4% Blacks) and Cohort 2: from nearby zip codes with intended detailed follow-up through 8 to 13 years (n = 616, 31.8% Blacks). The primary outcomes of interest were mortality and death/MI/revascularization (DMIR) (Cohort 1) or major adverse cardiac events (cardiac DMIR) (Cohort 2). In all cohorts, Blacks had a higher prevalence of many risk factors. In Cohort 1, 3-year mortalities were 14.6% and 9.6% (p = 0.001) and DMIR were 32.1% and 25.0% (p = 0.001), for Blacks and Whites, respectively. In Cohort 2, over 9.5 ± 2.0 years, treatment intensity was as high or higher for Blacks, but they continued to have higher low-density lipoprotein-cholesterol and blood pressure values. Major adverse cardiac events and mortality at 10 years were higher for Blacks (59.0% vs 48.1%, p = 0.024 and 44.3% vs 23.0%, p < 0.001). Differences in outcomes, except 10 year mortality, were not significantly different after adjustment for baseline characteristics. Blacks have a higher risk profile at the time of PCI and worse long-term outcomes after drug-eluting stent, most of which is explained by baseline differences.
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Can We Identify Minority Patients at Risk of Nonadherence to Antiplatelet Medication at the Time of Coronary Stent Placement? J Cardiovasc Nurs 2017; 32:522-529. [PMID: 28060084 DOI: 10.1097/jcn.0000000000000387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lack of medication adherence is associated with significant morbidity and mortality, particularly among minorities. We aim to identify predictors of nonadherence to antiplatelet medications at the time of percutaneous coronary intervention (PCI) with stent among African American and Hispanic patients. METHODS We used data collected for a randomized clinical trial that recruited 452 minority patients from a large US health insurance organization in 2010 post-PCI to compare telephone-based motivational interviewing by trained nurses with an educational video. The primary outcome was 12-month adherence to antiplatelet medications measured by the claims-based medication possession ratio (MPR). Adequate adherence was defined as an MPR of 0.80 or higher. RESULTS More than half of the sample (age, 69.52 ± 8.8 years) was male (57%) and Hispanic (57%). Most (78%) had a median income below $30 000 and 22% completed high school or higher. Univariate analyses revealed that symptoms of depression (<.01) and not having a spouse (P = .03) were associated with inadequate adherence. In multivariate analysis, baseline self-reported adherence (1.4; 95% confidence interval [CI], 1.05-1.89), depressive symptoms (0.49; 95% CI, 0.7-0.90), comorbidity (0.89; 95% CI, 0.80-0.98), and telephone-based motivational interviewing by trained nurses (3.5; 95% CI, 1.9-2.70) were associated with adherence. CONCLUSIONS Having multiple comorbidities, depression, suboptimal adherence to medications, and low English proficiency at the time of PCI increase the risk of poor 12-month adherence to antiplatelets among minorities. Identifying these risk factors can guide PCI therapy and the use of evidence-based strategies to improve long-term adherence.
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Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention after Kawasaki Disease: The Pediatric Canadian Series. Pediatr Cardiol 2017; 38:36-43. [PMID: 27663723 DOI: 10.1007/s00246-016-1480-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 09/15/2016] [Indexed: 10/21/2022]
Abstract
Coronary artery (CA) aneurysms are serious complications of Kawasaki disease (KD) responsible for ischemic events. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are reported with limited data on indications and comparative efficacy. Retrospective multicenter comparison of CA intervention following KD is performed in this study. Twenty two cases were available from 5 centers, of whom 11 underwent CABG, 10 PCI and 1 systemic thrombolysis. Age at intervention (8.3 ± 3.9 vs 11.3 ± 4.9 years, p = 0.14) and interval from diagnosis (5.6 ± 4.1 vs 6.5 ± 4.7 years, p = 0.64) were similar between CABG and PCI. Interventions were based on angiography in 15 patients or cardiac event in 7, with no difference between CABG and PCI (p = 0.24). Patients with CABG were more likely to undergo multivessel intervention (73 vs 10 %, p = 0.006). None of the patients needed reintervention after CABG, compared to 6 after PCI and 1 after systemic thrombolysis (p = 0.004). Signs of ischemia on stress testing or MIBI were present in 15 patients before intervention and persisted in 9 patients following last intervention, in a significantly higher proportion after CABG than PCI (80 vs 17 %, p = 0.01). In this series, CABG, which mostly involved multivessel intervention, was superior to PCI. Nevertheless, larger-scale studies may help define patient selection criteria for a beneficial PCI approach.
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Owlia M, Bangalore S. Is the Use of Bare-Metal Stents Justifiable in the Era of Second-Generation Drug-Eluting Stents? Can J Cardiol 2016; 32:941.e7-9. [PMID: 27140948 DOI: 10.1016/j.cjca.2016.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 03/13/2016] [Accepted: 03/13/2016] [Indexed: 11/25/2022] Open
Affiliation(s)
- Mina Owlia
- New York University School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- New York University School of Medicine, New York, New York, USA.
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Leigh JA, Alvarez M, Rodriguez CJ. Ethnic Minorities and Coronary Heart Disease: an Update and Future Directions. Curr Atheroscler Rep 2016; 18:9. [PMID: 26792015 PMCID: PMC4828242 DOI: 10.1007/s11883-016-0559-4] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heart disease remains the leading cause of death in the USA. Overall, heart disease accounts for about 1 in 4 deaths with coronary heart disease (CHD) being responsible for over 370,000 deaths per year. It has frequently and repeatedly been shown that some minority groups in the USA have higher rates of traditional CHD risk factors, different rates of treatment with revascularization procedures, and excess morbidity and mortality from CHD when compared to the non-Hispanic white population. Numerous investigations have been made into the causes of these disparities. This review aims to highlight the recent literature which examines CHD in ethnic minorities and future directions in research and care.
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Affiliation(s)
- J Adam Leigh
- Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Manrique Alvarez
- Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carlos J Rodriguez
- Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
- Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Liu Z, Jin G, Qi Y, Shan S, Zhang J, Ye F, Tian N, Chen J, Chen S. Efficacy of one- vs. two-stent implantation for coronary bifurcation lesions in diabetic patients utilizing AIR2 as an endpoint. Int J Clin Exp Med 2015; 8:11831-11842. [PMID: 26380025 PMCID: PMC4565408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 06/03/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE This study aimed to assess the long term outcomes (all-cause death, myocardial infarction, target vessel revascularization, and silent restenosis at 12 months) of one-stent vs. two-stent implantation due to coronary bifurcation lesionsin diabetic patients using AIR2 as a new endpoint. METHODS AND RESULTS A total of 178 diabetic patients with true coronary bifurcation lesions underwent percutaneous coronary intervention in the DK-Crush trials. All patients were stratified based on the stent placement strategy: one-stent group (n=76) and two-stent group (n=102). Results showed the primary endpoint, AIR2, in one-stent group was twice that in two-stent group (32.9% vs. 16.7%, P=0.013). The incidence of silent restenosis at 12 months was also significantly higher in one-stent group (19.7% versus 4.9%, P=0.003). Moreover, Kaplan-Meier analysis revealed the cumulative AIR2-free survival rate after a 12-month follow-up was markedly lower in one-stent group than in two-stent group. Interestingly, MACEs, including death, myocardial infarction and repeat revascularization, were not comparable between 2 groups (13.2% vs. 12.7%, P=0.935). Likewise, the incidence of definite or probable ST in one-stent group was also similar to that in two-stent group (2.6% vs. 4.9%, P=0.761). CONCLUSION Our study indicates that, in terms of the AIR2 as a combined clinical and angiographic endpoint, two-stent implantation is superior to one-stent implantation for the treatment of coronary bifurcation intervention in diabetic patients.
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Affiliation(s)
- Zhizhong Liu
- Laboratory of Coronary Heart Diseases, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Guozhen Jin
- Laboratory of Coronary Heart Diseases, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Yuzhen Qi
- Department of Electrocardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Shoujie Shan
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Junjie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Fei Ye
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Nailiang Tian
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Jiupei Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
| | - Shaoliang Chen
- Laboratory of Coronary Heart Diseases, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical UniversityNanjing 210006, Jiangsu Province, China
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