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Seferović PM, Polovina M, Rosano G, Bozkurt B, Metra M, Heymans S, Mullens W, Bauersachs J, Sliwa K, de Boer RA, Farmakis D, Thum T, Olivotto I, Rapezzi C, Linhart A, Corrado D, Tschöpe C, Milinković I, Bayes Genis A, Filippatos G, Keren A, Ašanin M, Krljanac G, Maksimović R, Skouri H, Ben Gal T, Moura B, Volterrani M, Abdelhamid M, Lopatin Y, Chioncel O, Coats AJS. State-of-the-art document on optimal contemporary management of cardiomyopathies. Eur J Heart Fail 2023; 25:1899-1922. [PMID: 37470300 DOI: 10.1002/ejhf.2979] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 07/21/2023] Open
Abstract
Cardiomyopathies represent significant contributors to cardiovascular morbidity and mortality. Over the past decades, a progress has occurred in characterization of the genetic background and major pathophysiological mechanisms, which has been incorporated into a more nuanced diagnostic approach and risk stratification. Furthermore, medications targeting core disease processes and/or their downstream adverse effects have been introduced for several cardiomyopathies. Combined with standard care and prevention of sudden cardiac death, these novel and emerging targeted therapies offer a possibility of improving the outcomes in several cardiomyopathies. Therefore, the aim of this document is to summarize practical approaches to the treatment of cardiomyopathies, which includes the evidence-based novel therapeutic concepts and established principles of care, tailored to the individual patient aetiology and clinical presentation of the cardiomyopathy. The scope of the document encompasses contemporary treatment of dilated, hypertrophic, restrictive and arrhythmogenic cardiomyopathy. It was based on an expert consensus reached at the Heart Failure Association online Workshop, held on 18 March 2021.
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Affiliation(s)
- Petar M Seferović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Biykem Bozkurt
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Stephane Heymans
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wilfried Mullens
- Hasselt University, Hasselt, Belgium
- Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), Hannover, Germany
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Meyer Children's Hospital and Careggi University Hospital, Florence, Italy
| | - Claudio Rapezzi
- Cardiology Centre, University of Ferrara, Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Aleš Linhart
- Second Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carsten Tschöpe
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ivan Milinković
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Antoni Bayes Genis
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Andre Keren
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Milika Ašanin
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Gordana Krljanac
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ružica Maksimović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, Belgrade, Serbia
| | - Hadi Skouri
- Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Brenda Moura
- Armed Forces Hospital, Porto, & Faculty of Medicine, University of Porto, Porto, Portugal
| | - Maurizio Volterrani
- IRCCS San Raffaele Pisana, Rome, Italy
- Department of Human Science and Promotion of Quality of Life, San Raffaele Open University of Rome, Rome, Italy
| | - Magdy Abdelhamid
- Department of Cardiovascular Medicine, Faculty of Medicine, Kasr Al Ainy, Cairo University, Giza, Egypt
| | - Yuri Lopatin
- Volgograd Medical University, Cardiology Centre, Volgograd, Russian Federation
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu' Bucharest; University for Medicine and Pharmacy 'Carol Davila' Bucharest, Bucharest, Romania
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Lemus Barrios GA, Lopez‐Lopez JP, Barbosa‐Balaguera S, Correa AM. Left-dominant arrhythmogenic cardiomyopathy due to desmoplakin mutation: a case report. ESC Heart Fail 2023; 10:3190-3194. [PMID: 37632291 PMCID: PMC10567658 DOI: 10.1002/ehf2.14504] [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: 05/07/2023] [Revised: 07/07/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
The case of a 49-year-old man with acute onset of heart failure is presented. The initial work-up showed a dilated cardiomyopathy with severely reduced left ventricular ejection fraction. In the differential diagnostic process, hypertensive, ischaemic, and valvular aetiologies were discarded. Subsequently, a cardiac magnetic resonance revealed global hypokinesis and inferior and anterior subepicardial fibrosis. Once differential diagnoses of subepicardial fibrosis (myocarditis, sarcoidosis, and Chagas disease) were discarded, a genetic panel was performed, resulting in a heterozygous mutation of desmoplakin (DSP) gene c.6697_6698del. A left-dominant DSP arrhythmogenic cardiomyopathy mutation was diagnosed. Structural myocardial abnormalities and ventricular arrhythmias characterize arrhythmogenic cardiomyopathy. Up to 50% of cases are associated with mutations in DSP genes (JUP, DSP, and PKP2). DSP is the fundamental component of the desmosome structure and provides structural support through intercellular adhesion. Therefore, when frequent differential diagnoses are discarded, genetic studies for dilated cardiomyopathy and DSP mutation should be considered.
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Affiliation(s)
- Gustavo A. Lemus Barrios
- Cardiology UnitHospital Universitario San IgnacioBogotáColombia
- Faculty of MedicinePontificia Universidad JaverianaBogotáColombia
| | - Jose P. Lopez‐Lopez
- Cardiology UnitHospital Universitario San IgnacioBogotáColombia
- Faculty of MedicinePontificia Universidad JaverianaBogotáColombia
| | - Stephany Barbosa‐Balaguera
- Cardiology UnitHospital Universitario San IgnacioBogotáColombia
- Faculty of MedicinePontificia Universidad JaverianaBogotáColombia
| | - Alejandro Mariño Correa
- Cardiology UnitHospital Universitario San IgnacioBogotáColombia
- Faculty of MedicinePontificia Universidad JaverianaBogotáColombia
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Silvetti E, Lanza O, Romeo F, Martino A, Fedele E, Lanzillo C, Crescenzi C, Fanisio F, Calò L. The pivotal role of ECG in cardiomyopathies. Front Cardiovasc Med 2023; 10:1178163. [PMID: 37404739 PMCID: PMC10315483 DOI: 10.3389/fcvm.2023.1178163] [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: 03/02/2023] [Accepted: 05/15/2023] [Indexed: 07/06/2023] Open
Abstract
Cardiomyopathies are a heterogeneous group of pathologies characterized by structural and functional alterations of the heart. Recent technological advances in cardiovascular imaging offer an opportunity for deep phenotypic and etiological definition. Electrocardiogram (ECG) is the first-line diagnostic tool in the evaluation of both asymptomatic and symptomatic individuals. Some electrocardiographic signs are pathognomonic or fall within validated diagnostic criteria of individual cardiomyopathy such as the inverted T waves in right precordial leads (V1-V3) or beyond in individuals with complete pubertal development in the absence of complete right bundle branch block for the diagnosis of arrhythmogenic cardiomyopathy of the right ventricle (ARVC) or the presence of low voltages typically seen in more than 60% of patients with amyloidosis. Most other electrocardiographic findings such as the presence of depolarization changes including QRS fragmentation, the presence of epsilon wave, the presence of reduced or increased voltages as well as alterations in the repolarization phase including the negative T waves in the lateral leads, or the profound inversion of the T waves or downsloping of the ST tract are more non-specific signs which can however raise the clinical suspicion of cardiomyopathy in order to initiate a diagnostic procedure especially using imaging techniques for diagnostic confirmation. Such electrocardiographic alterations not only have a counterpart in imaging investigations such as evidence of late gadolinium enhancement on magnetic resonance imaging, but may also have an important prognostic value once a definite diagnosis has been made. In addition, the presence of electrical stimulus conduction disturbances or advanced atrioventricular blocks that can be seen especially in conditions such as cardiac amyloidosis or sarcoidosis, or the presence of left bundle branch block or posterior fascicular block in dilated or arrhythmogenic left ventricular cardiomyopathies are recognized as a possible expression of advanced pathology. Similarly, the presence of ventricular arrhythmias with typical patterns such as non-sustained or sustained ventricular tachycardia of LBBB morphology in ARVC or non-sustained or sustained ventricular tachycardia with an RBBB morphology (excluding the "fascicular pattern") in arrhythmogenic left ventricle cardiomyopathy could have a significant impact on the course of each disease. It is therefore clear that a learned and careful interpretation of ECG features can raise suspicion of the presence of a cardiomyopathy, identify diagnostic "red flags" useful for orienting the diagnosis toward specific forms, and provide useful tools for risk stratification. The purpose of this review is to emphasize the important role of the ECG in the diagnostic workup, describing the main ECG findings of different cardiomyopathies.
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Crea F. Cardiomyopathies and myocardial fibrosis: diagnostic and therapeutic challenges. Eur Heart J 2022; 43:4665-4668. [PMID: 36450341 DOI: 10.1093/eurheartj/ehac688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Smedsrud MK, Chivulescu M, Forså MI, Castrini I, Aabel EW, Rootwelt-Norberg C, Bogsrud MP, Edvardsen T, Hasselberg NE, Früh A, Haugaa KH. Highly malignant disease in childhood-onset arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2022; 43:4694-4703. [PMID: 36036653 PMCID: PMC9712025 DOI: 10.1093/eurheartj/ehac485] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 01/05/2023] Open
Abstract
AIMS This study aimed to explore the incidence of severe cardiac events in paediatric arrhythmogenic right ventricular cardiomyopathy (ARVC) patients and ARVC penetrance in paediatric relatives. Furthermore, the phenotype in childhood-onset ARVC was described. METHODS Consecutive ARVC paediatric patients and genotype positive relatives ≤18 years of age were followed with electrocardiographic, structural, and arrhythmic characteristics according to the 2010 revised Task Force Criteria. Penetrance of ARVC disease was defined as fulfilling definite ARVC criteria and severe cardiac events were defined as cardiac death, heart transplantation (HTx) or severe ventricular arrhythmias. Childhood-onset disease was defined as meeting definite ARVC criteria ≤12 years of age. RESULTS Among 62 individuals [age 9.8 (5.0-14.0) years, 11 probands], 20 (32%) fulfilled definite ARVC diagnosis, of which 8 (40%) had childhood-onset disease. The incidence of severe cardiac events was 23% (n = 14) by last follow-up and half of them occurred in patients ≤12 years of age. Among the eight patients with childhood-onset disease, five had biventricular involvement needing HTx and three had severe arrhythmic events. Among the 51 relatives, 6% (n = 3) met definite ARVC criteria at time of genetic diagnosis, increasing to 18% (n = 9) at end of follow-up. CONCLUSIONS In a paediatric ARVC cohort, there was a high incidence of severe cardiac events and half of them occurred in children ≤12 years of age. The ARVC penetrance in genotype positive paediatric relatives was 18%. These findings of a high-malignant phenotype in childhood-onset ARVC indicate a need for ARVC family screening at younger age than currently recommended.
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Affiliation(s)
- Marit Kristine Smedsrud
- Department of Paediatric Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway,ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway
| | - Monica Chivulescu
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway
| | - Marianne Inngjerdingen Forså
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Postboks 1078 Blindern, 0316 Oslo, Norway
| | - Isotta Castrini
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Postboks 1078 Blindern, 0316 Oslo, Norway
| | - Eivind Westrum Aabel
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Postboks 1078 Blindern, 0316 Oslo, Norway
| | - Christine Rootwelt-Norberg
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Postboks 1078 Blindern, 0316 Oslo, Norway
| | - Martin Prøven Bogsrud
- Unit for Cardiac and Cardiovascular Genetics, Oslo University Hospital, Ullevål, Kirkeveien 166, 0424 Oslo, Norway
| | - Thor Edvardsen
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Postboks 1078 Blindern, 0316 Oslo, Norway
| | - Nina Eide Hasselberg
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 9, 0372 Oslo, Norway
| | - Andreas Früh
- Department of Paediatric Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
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Crea F. The challenge of predicting sudden cardiac death: complementary role of risk scores, genetic testing, and clinical judgement. Eur Heart J 2022; 43:3001-3004. [DOI: 10.1093/eurheartj/ehac451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome , Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart , Rome , Italy
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Corrado D, Link MS, Schwartz PJ. Implantable defibrillators in primary prevention of genetic arrhythmias. A shocking choice? Eur Heart J 2022; 43:3029-3040. [PMID: 35725934 PMCID: PMC9443985 DOI: 10.1093/eurheartj/ehac298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/10/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
Many previously unexplained life-threatening ventricular arrhythmias and sudden cardiac deaths (SCDs) in young individuals are now recognized to be genetic in nature and are ascribed to a growing number of distinct inherited arrhythmogenic diseases. These include hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (VT), and short QT syndrome. Because of their lower frequency compared to coronary disease, risk factors for SCD are not very precise in patients with inherited arrhythmogenic diseases. As randomized studies are generally non-feasible and may even be ethically unjustifiable, especially in the presence of effective therapies, the risk assessment of malignant arrhythmic events such as SCD, cardiac arrest due to ventricular fibrillation (VF), appropriate implantable cardioverter defibrillator (ICD) interventions, or ICD therapy on fast VT/VF to guide ICD implantation is based on observational data and expert consensus. In this document, we review risk factors for SCD and indications for ICD implantation and additional therapies. What emerges is that, allowing for some important differences between cardiomyopathies and channelopathies, there is a growing and disquieting trend to create, and then use, semi-automated systems (risk scores, risk calculators, and, to some extent, even guidelines) which then dictate therapeutic choices. Their common denominator is a tendency to favour ICD implantation, sometime with reason, sometime without it. This contrasts with the time-honoured approach of selecting, among the available therapies, the best option (ICDs included) based on the clinical judgement for the specific patient and after having assessed the protection provided by optimal medical treatment.
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Affiliation(s)
- Domenico Corrado
- Inherited Arrhythmogenic Cardiomyopathies and Sports Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Padova, Italy
| | - Mark S Link
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Peter J Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Milan, Italy
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New Variant in Placophilin-2 Gene Causing Arrhythmogenic Myocardiopathy. Genes (Basel) 2022; 13:genes13050782. [PMID: 35627167 PMCID: PMC9141741 DOI: 10.3390/genes13050782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction: Arrhythmogenic cardiomyopathy (ACM) is an inherited disease characterized by progressive fibroadipose replacement of cardiomyocytes. Its diagnosis is based on imaging, electrocardiographic, histological and genetic/familial criteria. The development of the disease is based mainly on desmosomal genes. Knowledge of the phenotypic expression of each of these genes will help in both diagnosis and prognosis. The objective of this study is to describe the genotype–phenotype association of an unknown PKP2 gene variant in a family diagnosed with ACM. Methods: Clinical and genetic study of a big family carrying the p.Tyr168* variant in the PKP2 gene, in order to demonstrate pathogenicity of this variant, causing ACM. Results: Twenty-two patients (proband and relatives) were evaluated. This variant presented with high arrhythmic load at an early age, but without evidence of structural heart disease after 20 years of follow-up, with low risk in predictive scores. We demonstrate evidence of its pathogenicity. Conclusions: The p.Tyr168* variant in the PKP2 gene causes ACM with a high arrhythmic load and with an absence of structural heart disease. This fact emphasizes the value of knowing the phenotypic expression of each variant.
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Arrhythmogenic Cardiomyopathy: Diagnosis, Evolution, Risk Stratification and Pediatric Population—Where Are We? J Cardiovasc Dev Dis 2022; 9:jcdd9040098. [PMID: 35448074 PMCID: PMC9024428 DOI: 10.3390/jcdd9040098] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 02/07/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a cardiomyopathy characterized by the occurrence of a high risk of life-threatening ventricular arrhythmias and sudden cardiac death even at presentation. Diagnosis, evolution and outcomes in adults have been extensively reported, but little data in pediatric population are available. Risk stratification in this particular setting is still a matter of debate and new risk factors are needed in a model of an ever more “individualized medicine”.
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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