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Kim HL, Weber T. Pulsatile Hemodynamics and Coronary Artery Disease. Korean Circ J 2021; 51:881-898. [PMID: 34595882 PMCID: PMC8558570 DOI: 10.4070/kcj.2021.0227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022] Open
Abstract
Coronary artery disease (CAD) is the leading cause of human death and has a high prevalence throughout the world. Therefore, it is important to detect CAD early and to apply individualized therapy according to the patients' risk. There is an increasing interest in pulsatile arterial hemodynamics in the cardiovascular area. Widely used measurements of arterial pulsatile hemodynamics include pulse pressure, pulse wave velocity and augmentation index. Here, we will review underlying pathophysiology linking the association of arterial pulsatile hemodynamics with CAD, and the usefulness of the measurements of pulsatile hemodynamics in the prediction of future cardiovascular events of CAD patients. Clinical and therapeutic implications will be also addressed.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen GmbH, Wels, Austria.
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Chami HA, Isma'eel H, Mitchel GF, Tamim H, Makki M, Berbari A, Al Mulla A. The association of waterpipe smoking with arterial stiffness and wave reflection in a community-based sample. Blood Press 2021; 30:300-309. [PMID: 34236258 DOI: 10.1080/08037051.2021.1947778] [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: 10/20/2022]
Abstract
PURPOSE The evidence linking waterpipe smoking to cardiovascular disease is limited. We evaluated the association of waterpipe smoking (WPS) with arterial stiffness and wave reflection measured by augmentation pressure (AP), augmentation index (AIx), and carotid-femoral pulse wave velocity (CFPWV), which are validated predictors of cardiovascular disease. MATERIALS AND METHODS Community-based, cross-sectional study including 205 exclusive waterpipe smokers and 199 matched never-smokers aged 35 years or older (mean age 51.7 ± 8.9 years, 36% females). Smoking and its extent were assessed using a validated questionnaire and urine cotinine levels. CFPWV, AP, AIx (AP/aortic pulse pressure) and heart rate adjusted AIx (AIx@75) were determined using tonometry and compared between smokers and non-smokers, and the association of WPS with tonometry measures was assessed using linear regression adjusting for possible confounders. RESULTS Waterpipe smokers and non-smokers had similar mean age and sex distribution. Compared to non-smokers, waterpipe smokers had significantly higher adjusted AP (10.5 ± 3.9 vs. 9.4 ± 3.9 mmHg respectively; p = 0.01), AIx (28.1 ± 8.4 vs. 25.7 ± 8.5% respectively; p = 0.01) and AIx@75 (24.2 ± 8.7 vs. 21.8 ± 8.9% respectively; p = 0.01). AIx was significantly associated with WPS extent, measured by a number of waterpipe smoked/day (β = 1.04/waterpipe, 95%CI:[0.50-1.58]), duration of waterpipe smoking (β = 0.77/10-years, 95%CI:[0.16-1.38]), their products in waterpipe-years (β = 0.30/10-waterpipe-year, 95%CI:[0.12-0.47]) and plasma cotinine (β = 0.56/100 ng/ml, 95%CI:[0.14-0.98]), adjusting for possible confounders, and so were AP and AIx@75. CFPWV however, was not associated with waterpipe smoking. CONCLUSION In a community-based sample, exclusive WPS and its extent were associated with a dose-dependent increase in AIx and AP, accounting for other risk factors, suggesting that waterpipe smokers are at increased risk of cardiovascular disease.
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Affiliation(s)
- Hassan A Chami
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussain Isma'eel
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Hani Tamim
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Maha Makki
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Adel Berbari
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ahmad Al Mulla
- Tobacco Control Center-WHO Collaborative Center, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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Kim ST, Ko Y, Beom JW, Boo KY, Lee JG, Choi JH, Kim SY, Joo SJ. Association of changes of pulse wave velocity and augmentation index after isometric handgrip exercise with coronary lesion extent and revascularization. Clin Hypertens 2021; 27:5. [PMID: 33931135 PMCID: PMC8088004 DOI: 10.1186/s40885-021-00163-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background Arterial stiffness is associated with myocardial ischemia and incident coronary artery disease (CAD), and indexes of arterial stiffness are usually increased in patients with CAD. However, these indexes are often increased in elderly without CAD. Arterial stiffness in patients with CAD may become more evident after isometric handgrip exercise which increases systolic pressure and ventricular afterload. We investigated the association of the change of stiffness indexes after isometric handgrip exercise with the lesion extent of CAD and the necessity for coronary revascularization. Methods Patients who were scheduled a routine coronary angiography via a femoral artery were enrolled. Arterial waveforms were traced at aortic root and external iliac artery using coronary catheters at baseline and 3 min after handgrip exercise. Augmentation index (AIx) was measured on the recorded aortic pressure waveform, and pulse wave velocity (PWV) was calculated using the ECG-gated time difference of the upstroke of arterial waveforms and distance between aortic root and external iliac artery. Results Total 37 patients were evaluated. Both PWV and AIx increased after handgrip exercise. ΔPWV was significantly correlated with ΔAIx (r = 0.344, P = 0.037). Patients were divided into higher and lower ΔPWV or ΔAIx groups based on the median values of 0.4 m/sec and 3.3%, respectively. Patients with higher PWV had more 2- or 3-vessel CAD (69% vs. 27%, P = 0.034), and underwent percutaneous coronary intervention (PCI) more frequently (84% vs. 50%, P = 0.038), but higher ΔAIx was not associated with either the lesion extent or PCI. Area under curve (AUC) of ΔPWV in association with PCI by C-statistics was 0.70 (95% confidence interval [CI] 0.51–0.88; P = 0.056). In multiple logistic regression analysis, ΔPWV was significantly associated with PCI (odds ratio 7.78; 95% CI 1.26–48.02; P = 0.027). Conclusions Higher ΔPWV after isometric handgrip exercise was associated with the lesion extent of CAD and the necessity for coronary revascularization, but higher ΔAIx was not.
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Affiliation(s)
- Seong Taeg Kim
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Yeekyoung Ko
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Jong-Wook Beom
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Ki Yung Boo
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Jae-Geun Lee
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea.,Department of Internal Medicine, Jeju National University School of Medicine, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Joon-Hyouk Choi
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea.,Department of Internal Medicine, Jeju National University School of Medicine, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Song-Yi Kim
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea.,Department of Internal Medicine, Jeju National University School of Medicine, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea
| | - Seung-Jae Joo
- Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea. .,Department of Internal Medicine, Jeju National University School of Medicine, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea. .,Institute of Medical Science, Jeju National University, 15 Aran 13-gil, Jeju City, Jeju Province, 63241, Republic of Korea.
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Ben Ahmed H, Allouche E, Chetoui A, Beji M, Boudiche F, Ouechtati W, Bazdeh L. [Relationship between arterial stiffness and the severity of coronary artery disease in acute coronary syndrome]. Ann Cardiol Angeiol (Paris) 2020; 70:33-40. [PMID: 33256951 DOI: 10.1016/j.ancard.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The association between arterial stiffness (AS) and stable coronary artery disease (CAD) has been previously demonstrated. Whether increased arterial stiffness is associated with severe CAD in patients with acute coronary syndrome (ACS) is less explored. AIM We aim to investigate the relationship between AS parameters and the extent and severity of CAD in patients with ACS. METHODS The study population consisted of 275 patients with ACS. We measured various AS parameters including pulse wave velocity (PWV), augmentation index (AIx), and central pulse pressure (cPP). CAD extent and severity was evaluated by the number of vessels with greater than 70% stenosis. RESULTS The study population was predominantly men (77, 5%) with an average age of 56, 4±10, 6 years. One hundred and fifteen patients were diabetic and 97 were hypertensive. One hundred fifty patients were admitted for ST elevation myocardial infarction (54, 5%) and 37, 5% for non ST elevation myocardial infarction. Thirty six percent of patients had single vessel disease and 47, 6% of the study population had multivessel disease. At the multivariate analysis, a positive correlation was observed between the number of coronary vessels disease and PWV. PWV (OR=1,272; IC95% [1,090; 1,483]; p=0,002) and cPP (OR=1,071; IC95% [1,024; 1,121]; p=0,003) were also independent predictors of multivessel disease. CONCLUSION In patient with ACS, PWV is correlated with the extent of coronary artery disease, as measured by the number of vessels disease. PWV and cPP were also independent predictors of multivessel disease.
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Affiliation(s)
- H Ben Ahmed
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie.
| | - E Allouche
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie
| | - A Chetoui
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie
| | - M Beji
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie
| | - F Boudiche
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie
| | - W Ouechtati
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie
| | - L Bazdeh
- Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisie; Faculty of Medicine, University of Tunis El Manar, 2092 Tunis, Tunisie
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Noninvasive validation of central and peripheral augmentation index estimated by a novel wrist-worn tonometer. J Hypertens 2019; 36:2204-2214. [PMID: 29846328 DOI: 10.1097/hjh.0000000000001806] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The validation of new blood pressure devices with easier use and more rapid data collection may facilitate the incorporation of these measures into clinical practice. We analyze the reliability and validity of Pulse Wave Analysis as reported by a novel wrist-worn device, easy and quick to use, comparing central and peripheral augmentation index (AIx) with the same measures from the SphygmoCor. Additionally, we analyzed clinical relevance through the association of the Pulse Wave Analysis, as reported by a novel wrist-worn device, with other cardiovascular parameters. METHODS Cross-sectional study including 254 participants. Mean age was 51.9 ± 13.4 years and 53% were women. MEASUREMENTS peripheral AIx (PAIx) and central AIx (CAIx) by the wrist-worn device and SphygmoCor (MM3); carotid-femoral (cf) pulse wave velocity (PWV) by SphygmoCor (MM3); cardioankle-vascular index (CAVI), ankle-brachial index (ABI) and brachial-ankle (ba) PWV by the Vasera device and carotid-intima media thickness (IMT) by ultrasonography. RESULTS Intra-observer intra-class correlation coefficient (ICC) for PAIx was 0.886 (95% CI 0.803-0.934) and for CAIx 0.943 (95% CI 0.901-0.968) with Bland Altman limits of agreement -0.75 (-23.8 to 21.8) and 0.08 (-15.7 to 15.9), respectively. Inter-observer ICC for PAIx was 0.952 (95% CI 0.915-0.972) and CAIx 0.893 (95% CI 0.811-0.939) with limits of agreement -0.45 (-13.7 to 12.8) and 0.43 (-17.7 to 18.5), respectively. Comparing the wrist-worn device with SphygmoCor, the ICC was 0.849 (95% CI 0.798-0.887) for PAIx, and 0.783 (95% CI 0.711-0.838) for CAIx. In Bland-Altman, limits of agreement for PAIx 1.03 (-20.67 to 22.73), and for CAIx -2.14 (-24.79 to 20.50). PAIx and CAIx, from the wrist-worn device, correlated with age, CAVI, ABI, baPWV, cfPWV, IMT, glomerular filtration and cardiovascular risk. CONCLUSION AIx measurements by wrist-worn device shows a good intra-observer and inter-observer reliability, inter-device noninvasive reliability and validity when compared with SphygmoCor, and clinical relevance by association with measures of vascular structure and function, end-organ damage and cardiovascular risk. TRIAL REGISTRATION Clinicaltrials.gov NCT02623894; https://clinicaltrials.gov/ct2/show/NCT02623894.
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Kizilirmak Yilmaz F, Babur Guler G, Kaya O, Guler E, Gunhan Demir G, Gunes HM, Olgun FE, Barutcu İ, Boztosun B. Relationship between arterial stiffness parameters and the extent and severity of coronary artery disease. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Methodological evaluation of the noninvasive estimation of central systolic blood pressure in nontreated patients: the Bogalusa Heart Study. Blood Press Monit 2016; 22:95-100. [PMID: 27902495 DOI: 10.1097/mbp.0000000000000224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to compare the estimation of central systolic blood pressure (cSBP) obtained by two different noninvasive devices, in addition to its comparisons with measured peripheral systolic blood pressure (pSBP), in a biracial (Black/White) community-based cohort. PARTICIPANTS AND METHODS Estimations of cSBP by applanation tonometry were obtained in 586 participants of the Bogalusa Heart Study (mean age: 43.5 years; 69% White, 54% women) using two different commonly used instruments: Omron HEM-9000AI and SphygmoCor CPV. pSBP was measured using a standard auscultatory technique. RESULTS The estimation of cSBP by the Omron device was higher than that of the SphygmoCor device (124.2±17.1 vs. 111.4±15.2 mmHg, P<0.001). Moreover, cSBP by Omron was significantly higher than peripheral blood pressure (124.2±17.1 vs. 119.4±15.6 mmHg, P<0.001), whereas cSBP by SphygmoCor was significantly lower than pSBP (111.4±15.2 vs. 119.4±15.6 mmHg, P<0.001). Similar results were observed in race-specific and sex-specific analyses. CONCLUSION These findings support the hypothesis that notable differences exist in the estimation of cSBP provided by the instruments utilized in this study. Further standardization studies are required to establish the most appropriate noninvasive estimation of cSBP before this parameter may be considered in the assessment, prediction, and prevention of cardio-metabolic risk and overt cardiovascular disease in clinical practice.
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Wu S, Zhou Y, Li Y, Liu Y, Shi D, Liu X, Liu W, Yu Y, Jia S. Type 2 diabetes compromises the value of non-invasively measured augmentation index in predicting the severity of coronary artery disease: a hospital-based observational study. BMC Cardiovasc Disord 2016; 16:216. [PMID: 27832749 PMCID: PMC5105255 DOI: 10.1186/s12872-016-0392-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 11/05/2016] [Indexed: 11/10/2022] Open
Abstract
Background Central hemodynamic indices have been demonstrated to correlate with coronary artery disease (CAD). However, in the context of type 2 diabetes mellitus (DM), this correlation has not been fully illustrated. Therefore, this study was employed to investigate the impact of DM on the correlation between aortic augmentation index and the severity of coronary artery disease. Methods In this study, we analyzed 197 patients who underwent coronary angiography at Anzhen Hospital from September 2015 to January 2016. Central hemodynamics were non-invasively measured with BPro® device (Health STATS, Singapore). The severity of CAD was defined according to SYNTAX scores. Type 2 diabetes was defined according to ADA guidelines. AIx@75 was defined as AIx normalized to a heart rate of 75 bpm. Receiver operating characteristics (ROC) determined the optimal cut-off value of AIx@75 to predict moderate to severe CAD. Multivariate logistic regression analysis evaluated the correlation between central hemodynamic parameters and CAD severity. Results Eighty-four (42.6 %) of the studied subjects were diabetic patients. Our findings were that (1) AIx@75 was significantly correlated with SYNTAX. (ROC analyzed AUC: 0.638, 95 % CI 0.555–0.721, p < 0.05). The cut-off value of AIx@75 to predict moderate-to-severe CAD as SYNTAX score more than 22 was 71.45. (2) In non-diabetic patients, correlation analysis revealed that AIx@75, augmentation pressure and peak relative time were significantly correlated with CAD severity (p < 0.05). After adjustment, AIx@75 remained as the only independent predictor of moderate-to-severe CAD (odds ratio 1.099, 95 % CI 1.028–1.176, p < 0.05). (3) In diabetic patients, the correlation between central hemodynamic parameters and the severity of CAD did not exist. Conclusions Aortic augmentation index was significantly related to the severity of CAD and was an independent predictor of severe CAD. However, clinical practitioners should note that its value in DM populations was compromised.
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Affiliation(s)
- Sijing Wu
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yujie Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China.
| | - Yueping Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yuyang Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Dongmei Shi
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xiaoli Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Wei Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yi Yu
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Shuo Jia
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
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Pateria P, Jeffrey GP, MacQuillan G, Speers D, Ching H, Chinnaratha MA, Watts GF, Adams LA. The association between chronic hepatitis C infection and cardiovascular risk. Intern Med J 2016; 46:63-70. [PMID: 26477784 DOI: 10.1111/imj.12936] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/29/2015] [Accepted: 10/10/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vascular disease is a common cause of death in patients with chronic hepatitis C (CHC) infection; however, the association between CHC and atherosclerosis is unclear. AIMS To determine whether patients with CHC have increased subclinical vascular disease and whether genotype or antiviral treatment modifies this risk. METHODS Fifty CHC patients and 22 age-matched and sex-matched healthy controls underwent clinical and biochemical assessment for vascular risk factors. In addition, vascular risk was assessed by measuring arterial stiffness (aortic augmentation index and carotid-femoral pulse wave velocity (PWV)), endothelial dysfunction (brachial artery flow-mediated dilatation (FMD) and dilatation post-glycerol trinitrate administration) and carotid intima-media thickness (CIMT). Assessment was repeated in subset of CHC patients (n = 12) undergoing antiviral treatment 18 months after initiation of treatment. RESULTS Baseline vascular risk factors and measures of arterial stiffness, endothelial dysfunction and CIMT were not different between cases and controls (P > 0.2 for all). Genotype 1 CHC patients had greater endothelial dysfunction with lower FMD (8.2 ± 3.5% vs 10.9 ± 5.2%, P = 0.03) and higher right CIMT (0.6 ± 0.1 mm vs 0.5 ± 0.07 mm, P = 0.04) compared with non-genotype 1. Patients who achieved sustained virological response (7/12) showed significant improvement in insulin resistance (homeostasis model of assessment of insulin resistance 2.3 ± 1.2 vs 1.8 ± 0.8, P = 0.02) and arterial stiffness (PWV 7.4 ± 1.1 m/s vs 6.5 ± 0.6 m/s, P = 0.04). CONCLUSIONS Subclinical vascular disease is not greater in CHC subjects compared with controls. However, among CHC subjects, genotype 1 infection is associated with greater endothelial dysfunction and increased carotid-intima medial thickness compared with non-genotype 1 infection. Successful viral eradication may improve insulin resistance and arterial stiffness.
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Affiliation(s)
- P Pateria
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital
| | - G P Jeffrey
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - G MacQuillan
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - D Speers
- PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre
| | - H Ching
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - M A Chinnaratha
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital
| | - G F Watts
- School of Medicine and Pharmacology, University of Western Australia.,Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - L A Adams
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
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Prskalo Z, Brizić I, Markota D, Markota I, Boban M, Tomic M, Starcevic B. Arterial stiffness in patients with coronary artery disease: relation with in-stent restenosis following percutaneous coronary intervention. BMC Cardiovasc Disord 2016; 16:128. [PMID: 27266698 PMCID: PMC4895968 DOI: 10.1186/s12872-016-0305-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coronary artery disease (CAD) is one of the most important issues in modern medicine due to its high mortality and prevalence. An early detection and prevention can reduce morbidity and mortality. Arterial stiffness is a potent and independent predictor of CAD. We aimed to investigate the arterial stiffness in CAD patients undergoing the coronary angiography. Also, we investigated a possible correlation between arterial stiffness and in-stent restenosis (ISR), an important limitation of percutaneous coronary intervention (PCI). METHODS The study included 160 patients undergoing coronary angiography, treated either with PCI or with CABG. The pulse wave velocity (PWV) and augmentation index (AIx) were measured by the Arteriograph. RESULTS PWV in the CAD group (12.24 ± 2.78 m/s) was significantly higher compared to the control group (8.27 ± 1.89 m/s). PWV in ISR and left main (LM) stenosis group (14.03 ± 3.15 and 13.89 ± 2.95 m/s) was significantly higher compared to the control and CAD groups. Peripheral and central AIx were significantly higher in CAD group (1.38 ± 30.63 % and 38.35 ± 15.52 %) than in control group (-11.35 ± 26.74 % and 26.91 ± 10.62 %). Patients with LM stenosis have significantly higher values of peripheral and central AIx (23.37 ± 23.77 % and 49.71 ± 12.02 %) than the CAD and ISR group. CONCLUSIONS The study confirmed a positive correlation between arterial stiffness measures, PWV and AIx, and CAD. Also, this study showed the correlation between PWV and ISR which can help to select more appropriate stent.
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Affiliation(s)
- Zrinko Prskalo
- Department of Cardiology, University Hospital Mostar, Bijeli Brijeg bb, 88 000, Mostar, Bosnia and Herzegovina
| | - Ivica Brizić
- Department of Cardiology, University Hospital Mostar, Bijeli Brijeg bb, 88 000, Mostar, Bosnia and Herzegovina.
| | - Darko Markota
- Department of Cardiology, University Hospital Mostar, Bijeli Brijeg bb, 88 000, Mostar, Bosnia and Herzegovina
| | - Ivica Markota
- Department of Cardiology, University Hospital Mostar, Bijeli Brijeg bb, 88 000, Mostar, Bosnia and Herzegovina
| | - Mladen Boban
- Department of Pharmacology, University of Split, Split, Croatia
| | - Monika Tomic
- Department of Nephrology, University Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Boris Starcevic
- Department of Cardiology, University Hospital Dubrava, Zagreb, Croatia
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11
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Moon SH, Moon JC, Heo DH, Lim YH, Choi JH, Kim SY, Kim KS, Joo SJ. Increased pulse wave velocity and augmentation index after isometric handgrip exercise in patients with coronary artery disease. Clin Hypertens 2015; 21:5. [PMID: 26893918 PMCID: PMC4750784 DOI: 10.1186/s40885-015-0016-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Arterial stiffness of patients with coronary artery disease (CAD), which is expected to be increased due to a generalized atherosclerotic process of human body, may be more evident after the acute increase of blood pressure (BP) or peripheral vascular resistance. Isometric handgrip exercise is a simple and easily applicable method to achieve this goal. We investigated the changes of hemodynamic parameters and arterial stiffness indexes after handgrip exercise in patients with CAD. METHODS Forty-two subjects, who underwent coronary angiography (CAG), were enrolled. After CAG, baseline arterial waveforms were traced at the aortic root and external iliac artery using right coronary catheters. Arterial waveforms were recorded at 1, 2, and 3 min in the aortic root and at 3 min in the external iliac artery after isometric handgrip exercise at 30% ~ 40% of the maximal handgrip power. Augmentation pressure (AP) and augmentation index (AIx) were measured at aortic pressure waveforms. Pulse wave velocity (PWV) was calculated using the ECG-gated time difference of the upstroke of arterial waveforms and the distance between the aortic root and the external iliac artery. RESULTS Thirty patients had CAD (CAD group), and others showed no significant coronary stenosis (non-CAD group). Baseline hemodynamic parameters including AIx and PWV were not different between both groups. After isometric handgrip exercise, central systolic blood pressure (BP), central diastolic BP, central pulse pressure, peripheral systolic BP, and peripheral pulse pressure were increased in all patients. AIx inclined significantly from 1 min after exercise only in patients with CAD (before 17.7% ± 9.7% vs. 3 min after exercise 22.3% ± 10.7%, p < 0.001). PWV also increased significantly after exercise only in patients with CAD (before 10.03 ± 1.99 m/s vs. 3 min after 11.09 ± 2.45 m/s, p < 0.001). CONCLUSIONS Arterial stiffness indexes at rest were not different between patients with and without CAD. After isometric handgrip exercise, increased arterial stiffness became evident only in patients with CAD.
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Affiliation(s)
- Shin-Hang Moon
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Jae-Cheol Moon
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Da-Hee Heo
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Young-Hyup Lim
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Joon-Hyouk Choi
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Song-Yi Kim
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Ki-Seok Kim
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
| | - Seung-Jae Joo
- Cardiology Division, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju City, Jeju Province 690-767 Republic of Korea
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12
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Upadhyay RK. Emerging risk biomarkers in cardiovascular diseases and disorders. J Lipids 2015; 2015:971453. [PMID: 25949827 PMCID: PMC4407625 DOI: 10.1155/2015/971453] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 12/16/2022] Open
Abstract
Present review article highlights various cardiovascular risk prediction biomarkers by incorporating both traditional risk factors to be used as diagnostic markers and recent technologically generated diagnostic and therapeutic markers. This paper explains traditional biomarkers such as lipid profile, glucose, and hormone level and physiological biomarkers based on measurement of levels of important biomolecules such as serum ferritin, triglyceride to HDLp (high density lipoproteins) ratio, lipophorin-cholesterol ratio, lipid-lipophorin ratio, LDL cholesterol level, HDLp and apolipoprotein levels, lipophorins and LTPs ratio, sphingolipids, Omega-3 Index, and ST2 level. In addition, immunohistochemical, oxidative stress, inflammatory, anatomical, imaging, genetic, and therapeutic biomarkers have been explained in detail with their investigational specifications. Many of these biomarkers, alone or in combination, can play important role in prediction of risks, its types, and status of morbidity. As emerging risks are found to be affiliated with minor and microlevel factors and its diagnosis at an earlier stage could find CVD, hence, there is an urgent need of new more authentic, appropriate, and reliable diagnostic and therapeutic markers to confirm disease well in time to start the clinical aid to the patients. Present review aims to discuss new emerging biomarkers that could facilitate more authentic and fast diagnosis of CVDs, HF (heart failures), and various lipid abnormalities and disorders in the future.
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Affiliation(s)
- Ravi Kant Upadhyay
- Department of Zoology, DDU Gorakhpur University, Gorakhpur 273009, India
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13
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The effect of vitamin D supplementation on arterial stiffness in an elderly community-based population. ACTA ACUST UNITED AC 2014; 9:176-83. [PMID: 25681237 DOI: 10.1016/j.jash.2014.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/15/2014] [Accepted: 12/22/2014] [Indexed: 11/20/2022]
Abstract
Vitamin D deficiency may lead to impaired vascular function and abnormalities in central arterial stiffness. We compared the effects of two different doses of vitamin D3 on arterial stiffness in an elderly population with deficient serum 25-hydroxy-vitamin D levels. A total of 119 known vitamin D deficient (<50 nmol/L) subjects were randomized to receive either 50,000 international units (IU) or 100,000 IU single intramuscular vitamin D3. In the group that received 100,000 IU vitamin D, median pulse wave velocity decreased from 12.2 m/s (range, 5.1-40.3 m/s) to 11.59 m/s (range, 4.3-14.9 m/s) after 8 weeks (P = .22). A mean decrease of 3.803 ± 1.7 (P = .032) in augmentation index (a measure of systemic stiffness) was noted. Only 3/51 (5.8%) who received 100,000 IU vitamin D reached levels of sufficiency (>75 nmol/L). A significant decrease in augmentation index was seen in the group that received 100,000 IU vitamin D. Serum levels of 25-hydroxy-vitamin D were still deficient at 8 weeks in the majority of patients, which may be attributable to impaired bioavailability.
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14
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Vakalis K, Bechlioulis A, Naka KK, Chatzikyriakidou A, Gartzonika K, Vezyraki P, Kolios G, Pappas K, Katsouras CS, Georgiou I, Michalis LK. Role of 9p21 and 2q36 variants and arterial stiffness in the prediction of coronary artery disease. Eur J Clin Invest 2014; 44:784-94. [PMID: 24942486 DOI: 10.1111/eci.12295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 06/13/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Genetic polymorphisms and arterial stiffness indices have been associated with cardiovascular prognosis and the presence and extent of angiographic coronary artery disease (CAD). We aimed to investigate whether arterial stiffness indices and 9p21 and 2q36 variants may improve prediction of CAD presence and extent when added to classical cardiovascular risk factors in patients at high risk for CAD. MATERIALS AND METHODS In this cross-sectional study, we enrolled 183 consecutive patients with suspected stable CAD (age 61 ± 9 years, 134 males) referred for diagnostic coronary angiography. Framingham risk score (FRS) was calculated. Arterial stiffness was assessed by carotid-femoral pulse wave velocity (PWV) and central augmentation index (AIx) using applanation tonometry. Genetic polymorphisms of 9p21 (rs1333049) and 2q36 (rs2943634) loci were also analysed. RESULTS Higher FRS and PWV and the presence of rs2943634 risk allele were independent predictors of CAD (Nagelkerke R(2) 0·252, P < 0·001), while higher FRS and the presence of rs1333049 risk allele were independent predictors of multivessel CAD (Nagelkerke R(2) 0·190, P < 0·001). Genetic polymorphisms and vascular indices did not improve the predictive accuracy of FRS-based models (P > 0·1 for all) for CAD presence or extent. CONCLUSIONS In these high-risk patients, 9p21 and 2q36 variants and PWV were independently associated with CAD presence and extent, but the addition of both genetic data and arterial stiffness indices to FRS did not improve the prediction of CAD compared with FRS alone. Further studies are needed to clarify the prognostic role of genetic and vascular indices in the prediction of angiographic CAD.
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Affiliation(s)
- Konstantinos Vakalis
- Michaelidion Cardiac Center and Department of Cardiology, Medical School, University of Ioannina, Ioannina, Greece
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15
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Masaki N, Hakuno D, Toya T, Shiraishi Y, Kujiraoka T, Namba T, Yada H, Kimura K, Miyazaki K, Adachi T. Association between brachial-ankle pulse wave velocity and the ratio of l-arginine to asymmetric dimethylarginine in patients undergoing coronary angiography. J Cardiol 2014; 65:311-7. [PMID: 25043133 DOI: 10.1016/j.jjcc.2014.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/27/2014] [Accepted: 06/06/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endothelial dysfunction causes vasomotor dysregulation and vascular stiffening in addition to structural changes. By influencing NO synthesis, deficiency of l-arginine relative to asymmetric dimethylarginine (ADMA), which is an l-arginine derivative that acts as a competitive NO synthase inhibitor, may lead to the promotion of arterial stiffness. This study investigated the relationship between the l-arginine/ADMA ratio and brachial-ankle pulse wave velocity (baPWV), an indicator of arterial stiffness. METHODS AND RESULTS This cross-sectional study enrolled 74 patients (62 men, 12 women; mean age, 67±10 years) undergoing elective coronary angiography. A total of 54 (73%) patients had coronary artery disease. Serum l-arginine and ADMA were measured by high-performance liquid chromatography with fluorescence detection. The ratio of l-arginine to ADMA and the serum l-arginine level was associated with baPWV in univariate regression analysis (l-arginine/ADMA ratio: β=-0.323, p=0.005; l-arginine: β=-0.247, p=0.034). In addition, baPWV was related to blood hemoglobin concentration, hematocrit, brain natriuretic peptide level, symmetric dimethylarginine, renal function, blood pressure, and heart rate. In multivariate analysis, the l-arginine/ADMA ratio was a significant predictor of baPWV (β=-0.310, p<0.001). In subgroup analyses, the l-arginine/ADMA ratio was associated with baPWV in elderly patients (n=46, β=-0.359, p=0.004), and in younger patients (n=28, β=-0.412, p=0.006). CONCLUSION A low l-arginine/ADMA ratio may be associated with high baPWV in patients undergoing coronary angiography.
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Affiliation(s)
- Nobuyuki Masaki
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan.
| | - Daihiko Hakuno
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Takumi Toya
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Yasunaga Shiraishi
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Takehiko Kujiraoka
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Takayuki Namba
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Hirotaka Yada
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Kazuo Kimura
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Koji Miyazaki
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Takeshi Adachi
- Department of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
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16
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Carotid-femoral pulse wave velocity is negatively correlated with aortic diameter. Hypertens Res 2014; 37:926-32. [DOI: 10.1038/hr.2014.101] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/23/2014] [Accepted: 05/01/2014] [Indexed: 11/08/2022]
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17
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Stoner L, Lambrick DM, Westrupp N, Young J, Faulkner J. Validation of oscillometric pulse wave analysis measurements in children. Am J Hypertens 2014; 27:865-72. [PMID: 24390294 DOI: 10.1093/ajh/hpt243] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pulse wave analysis (PWA) has emerged as a noninvasive, valid, reliable, and widely used technique to investigate central blood pressures and systemic arterial wave reflection (augmentation index). The gold-standard technique is tonometry, but this technique can be challenging, especially when used on children. The purpose of this study was to validate oscillometric PWA for use in children. METHODS Fifty-seven healthy children were recruited for participation. Central blood pressures and peripheral augmentation index (pAIx) were measured objectively using oscillometric (Pulsecor R7) and tonometric (SphygmaCor) devices. All measurements were made during the same visit under standardized conditions between the hours of 8 am and 10 am in the fasted state. RESULTS Tonometric measurements were unsuccessful on 1 child. Comparisons were made on 56 children (mean age = 9.8±1.0 y; 57% male). A very strong relationship was found between devices for central systolic (r = 0.94; P < 0.001), diastolic (r = 0.99; P < 0.001) and mean (r = 0.96; P < 0.001) blood pressures. However, Bland-Altman analysis indicated a bias toward greater systolic blood pressures with the oscillometric monitor (mean difference = 4.5mm Hg; 95% confidence interval (CI) = -5.16 to -3.89). A good relationship was found for pAIx (r = 0.71; P < 0.001); the mean difference between devices was -1.70% (95% CI = -4.47% to 1.08%), which is not significantly different from zero. CONCLUSIONS Findings from this study suggest that oscillometric PWA provides valid measures of central blood pressure and arterial wave reflection in children aged 8-10 years.
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Affiliation(s)
- Lee Stoner
- School of Sport and Exercise, Massey University, Wellington, New Zealand
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18
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Aortic stiffness is increased in patients with premature coronary artery disease: A tissue Doppler imaging study. J Cardiol 2014; 63:223-9. [DOI: 10.1016/j.jjcc.2013.08.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/01/2013] [Accepted: 08/14/2013] [Indexed: 11/22/2022]
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19
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Tanindi A, Erkan AF, Alhan A, Töre HF. Central pulse pressure amplification is associated with more extensive and severe coronary artery disease. SCAND CARDIOVASC J 2014; 48:167-75. [PMID: 24568590 DOI: 10.3109/14017431.2014.898083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We investigate the association between noninvasively determined central pulse waveform characteristics and the extent and severity of coronary artery disease (CAD) in patients undergoing coronary angiography with the clinical diagnosis of CAD. DESIGN We included 145 consecutive patients with stable angina pectoris (SAP), unstable angina pectoris (USAP), or acute myocardial infarction (AMI) who were decided to undergo coronary angiography. Gensini and SYNTAX scores were calculated. Noninvasive PWA was performed with the SphygmoCor system. RESULTS Dividing the patients into tertiles according to augmentation index (AIx), more patients had significant CAD with higher Gensini and SYNTAX scores and lower myocardial blush grade (MBG) (p < 0.001 for all) in the third tertile. The AIx value to predict the presence of moderate to severe CAD as determined by SYNTAX score ≥ 23 was 24.45% (ROC analysis AUC: 0.96; sensitivity 88%, specificity: 93%, 95% CI: 0.93-0.99, p < 0.001). AIx was significantly correlated with Gensini and SYNTAX scores in SAP, USAP, and AMI patients after adjusting for age, gender, height, heart rate, hypertension, and diabetes. CONCLUSIONS Increased AIx is associated with the presence and severity of CAD, and it may be used in selected patients during cardiovascular evaluation in outpatient settings for risk stratification prior to coronary angiography.
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Affiliation(s)
- Asli Tanindi
- Ufuk University Faculty of Medicine, Department of Cardiology , Ankara , Turkey
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Hayashi S, Yamada H, Bando M, Hotchi J, Ise T, Yamaguchi K, Iwase T, Soeki T, Wakatsuki T, Tamaki T, Sata M. Augmentation Index Does Not Reflect Risk of Coronary Artery Disease in Elderly Patients. Circ J 2014; 78:1176-82. [DOI: 10.1253/circj.cj-13-1422] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shuji Hayashi
- Ultrasound Examination Center, Tokushima University Hospital
| | - Hirotsugu Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Mika Bando
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Junko Hotchi
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takashi Iwase
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Toshiaki Tamaki
- Department of Pharmacology, Institute of Health Biosciences, University of Tokushima Graduate School
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital
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