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Butters A, Semsarian CR, Bagnall RD, Yeates L, Stafford F, Burns C, Semsarian C, Ingles J. Clinical Profile and Health Disparities in a Multiethnic Cohort of Patients With Hypertrophic Cardiomyopathy. Circ Heart Fail 2021; 14:e007537. [PMID: 33724884 DOI: 10.1161/circheartfailure.120.007537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical studies of hypertrophic cardiomyopathy are over-represented by individuals of European ethnicity, with less known about other ethnic groups. We investigated differences between patients in a multiethnic Australian hypertrophic cardiomyopathy population. METHODS We performed a retrospective cohort study of 836 unrelated hypertrophic cardiomyopathy probands attending a specialized clinic between 2002 and 2020. Major ethnic groups were European (n=611), East Asian (n=75), South Asian (n=58), and Middle Eastern and North African (n=68). The minor ethnicity groups were Oceanian (n=9), People of the Americas (n=7), and African (n=8). One-way ANOVA with Dunnett post hoc test and Bonferroni adjustment were performed. RESULTS Mean age of the major ethnic groups was 54.9±16.9 years, and 527 (65%) were male. Using the European group as the control, East Asian patients had a lower body mass index (29 versus 25 kg/m2, P<0.0001). South Asians had a lower prevalence of atrial fibrillation (10% versus 31%, P=0.024). East Asians were more likely to have apical hypertrophy (23% versus 6%, P<0.0001) and Middle Eastern and North African patients more likely to present with left ventricular outflow tract obstruction (46% versus 34%, P=0.0003). East Asians were less likely to undergo genetic testing (55% versus 85%, P<0.0001) or have an implantable cardioverter-defibrillator implanted (19% versus 36%, P=0.037). East Asians were more likely to have a causative variant in a gene other than MYBPC3 or MYH7, whereas Middle Eastern and North African and South Asians had the highest rates of variants of uncertain significance (27% and 21%, P<0.0001). CONCLUSIONS There are few clinical differences based on ethnicity, but importantly, we identify health disparities relating to access to genetic testing and implantable cardioverter-defibrillator use. Unless addressed, these gaps will likely widen as we move towards precision-medicine-based care of individuals with hypertrophic cardiomyopathy.
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Affiliation(s)
- Alexandra Butters
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia.,Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia
| | - Caitlin R Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia
| | - Richard D Bagnall
- Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia
| | - Laura Yeates
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia.,Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
| | - Fergus Stafford
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia
| | - Charlotte Burns
- Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
| | - Christopher Semsarian
- Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
| | - Jodie Ingles
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia.,Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
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3
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Bonny A, Ngantcha M, Jeilan M, Okello E, Kaviraj B, Talle MA, Nel G, Marijon E, Sani MU, Yousef Z, Karaye KM, Touré IA, Awad MA, Millogo G, Kologo J, Kane A, Houndolo R, Dzudié A, Mbakwem A, Mayosi BM, Chin A. Statistics on the use of cardiac electronic devices and interventional electrophysiological procedures in Africa from 2011 to 2016: report of the Pan African Society of Cardiology (PASCAR) Cardiac Arrhythmias and Pacing Task Forces. Europace 2019; 20:1513-1526. [PMID: 29309556 PMCID: PMC6123943 DOI: 10.1093/europace/eux353] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/07/2017] [Indexed: 11/14/2022] Open
Abstract
Aims To provide comprehensive information on the access and use of cardiac implantable electronic devices (CIED) and catheter ablation procedures in Africa. Methods and results The Pan-African Society of Cardiology (PASCAR) collected data on invasive management of cardiac arrhythmias from 2011 to 2016 from 31 African countries. A specific template was completed by physicians, and additional information obtained from industry. Information on health care systems, demographics, economics, procedure rates, and specific training programs was collected. Considerable heterogeneity in the access to arrhythmia care was observed across Africa. Eight of the 31 countries surveyed (26%) did not perform pacemaker implantations. The median pacemaker implantation rate was 2.66 per million population per country (range: 0.14–233 per million population). Implantable cardioverter-defibrillator and cardiac resynchronization therapy were performed in 12/31 (39%) and 15/31 (48%) countries respectively, mostly by visiting teams. Electrophysiological studies, including complex catheter ablations were performed in all countries from Maghreb, but only one sub-Saharan African country (South Africa). Marked variation in cost (up to 1000-fold) was observed across countries with an inverse correlation between implant rates and the procedure fees standardized to the gross domestic product per capita. Lack of economic resources and facilities, high cost of procedures, deficiency of trained physicians, and non-existent fellowship programs were the main drivers of under-utilization of interventional cardiac arrhythmia care. Conclusion There is limited access to CIED and ablation procedures in Africa. A quarter of countries did not have pacemaker implantation services, and catheter ablations were only available in one country in sub-Saharan Africa.
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Affiliation(s)
- Aimé Bonny
- University Hospital Laquintinie, Cardiac unit, University of Douala, BP, Douala, Cameroon.,Cameroon Cardiovascular Research Network, BP, Douala, Cameroon.,Centre Hospitalier V. Dupouy, service de cardiologie, 69, rue du Lt-col Prudhon, Argenteuil Cedex, France
| | - Marcus Ngantcha
- Cameroon Cardiovascular Research Network, BP, Douala, Cameroon
| | - Mohamed Jeilan
- Aga Khan University hospital, Department of Medicine, 3rd Parklands Rd, Nairobi, Kenya
| | - Emmy Okello
- Makerere University, Uganda Heart Institute, Mulago Hospital Complex, Department of Cardiology, Mulago Hill Road, PO Box 7051, Kampala, Uganda
| | - Bundhoo Kaviraj
- Dr A.G Jeetoo Hospital, Department of Cardiology, Port Louis, Mauritius
| | - Mohammed A Talle
- Maiduguri Teaching University Hospital, Department of Cardiology, Maiduguri, Nigeria
| | - George Nel
- Pan-African Society of Cardiology (PASCAR), Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Eloi Marijon
- European Georges Pompidou Hospital, Cardiology Department and Global Health Unit (Inserm U970), 20 rue Leblanc, Paris, France
| | - Mahmoud U Sani
- Bayero University/Aminu Kano Teaching Hospital, Department of Medicine, Kano, Nigeria
| | - Zaheer Yousef
- University Hospital of Wales, Department of Cardiology, Cardiff, UK
| | - Kamilu M Karaye
- Bayero University/Aminu Kano Teaching Hospital, Department of Medicine, Kano, Nigeria
| | - Ibrahim A Touré
- Centre Hospitalier Lamorde, service de médecine interne et de cardiologie, Niamey, Niger
| | - Mohamed A Awad
- University of Khartoum, Department of Medicine, Elgaasr street, Khartoum, Sudan
| | - George Millogo
- Centre Hospitalier Yalgado Ouedraogo, Ouagadougou, service de cardiologie, Burkina Faso
| | - Jonas Kologo
- Centre Hospitalier Yalgado Ouedraogo, Ouagadougou, service de cardiologie, Burkina Faso
| | - Adama Kane
- CHU Aristide Le Dantec, service de cardiologie, Dakar, Senegal
| | - Romain Houndolo
- CHU Aristide Le Dantec, service de cardiologie, Dakar, Senegal
| | - Anastase Dzudié
- Douala General Hospital, Department of Internal Medicine, BP, Douala, Cameroon
| | - Amam Mbakwem
- University of Lagos and Lagos University Teaching Hospital, College of Medicine, Department of Medicine, PMB, Lagos, Nigeria
| | - Bongani M Mayosi
- Dean's Office, Barnard Fuller Building, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
| | - Ashley Chin
- Groote Schuur Hospital and University of Cape Town, Cardiac Clinic, Department of Medicine, Main Road, Observatory, Cape Town, South Africa
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6
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Oldgren J, Healey JS, Ezekowitz M, Commerford P, Avezum A, Pais P, Zhu J, Jansky P, Sigamani A, Morillo CA, Liu L, Damasceno A, Grinvalds A, Nakamya J, Reilly PA, Keltai K, Van Gelder IC, Yusufali AH, Watanabe E, Wallentin L, Connolly SJ, Yusuf S. Variations in Cause and Management of Atrial Fibrillation in a Prospective Registry of 15 400 Emergency Department Patients in 46 Countries. Circulation 2014; 129:1568-76. [DOI: 10.1161/circulationaha.113.005451] [Citation(s) in RCA: 261] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Atrial fibrillation (AF) is the most common sustained arrhythmia; however, little is known about patients in a primary care setting from high-, middle-, and low-income countries.
Methods and Results—
This prospective registry enrolled patients presenting to an emergency department with AF at 164 sites in 46 countries representing all inhabited continents. Patient characteristics were compared among 9 major geographic regions. Between September 2008 and April 2011, 15 400 patients were enrolled. The average age was 65.9, standard deviation 14.8 years, ranging from 57.2, standard deviation 18.8 years in Africa, to 70.1, standard deviation 13.4 years in North America,
P
<0.001. Hypertension was globally the most common risk factor for AF, ranging in prevalence from 41.6% in India to 80.7% in Eastern Europe,
P
<0.001. Rheumatic heart disease was present in only 2.2% of North American patients, in comparison with 21.5% in Africa and 31.5% in India,
P
<0.001. The use of oral anticoagulation among patients with a CHADS
2
score of ≥2 was greatest in North America (65.7%) but was only 11.2% in China,
P
<0.001. The mean time in the therapeutic range was 62.4% in Western Europe, 50.9% in North America, but only between 32% and 40% in India, China, Southeast Asia, and Africa,
P
<0.001.
Conclusions—
There is a large global variation in age, risk factors, concomitant diseases, and treatment of AF among regions. Improving outcomes globally requires an understanding of this variation and the conduct of research focused on AF associated with different underlying conditions and treatment of AF and predisposing conditions in different socioeconomic settings.
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Affiliation(s)
- Jonas Oldgren
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Jeff S. Healey
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Michael Ezekowitz
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Patrick Commerford
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Alvaro Avezum
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Prem Pais
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Jun Zhu
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Petr Jansky
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Alben Sigamani
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Carlos A. Morillo
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Lisheng Liu
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Albertino Damasceno
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Alex Grinvalds
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Juliet Nakamya
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Paul A. Reilly
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Katalin Keltai
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Isabelle C. Van Gelder
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Afzal Hussein Yusufali
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Eiichi Watanabe
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Lars Wallentin
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Stuart J. Connolly
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
| | - Salim Yusuf
- From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research Foundation, New York, NY (M.E.); Department of Medicine, University of Cape Town, Cape Town, South Africa (P.C.); Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil (A.A.); St
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