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Cohen B, Tor R, Grossman A, Kornowski R, Porter A, Hasdai D. Sex Differences in the Diagnosis, Management, and Outcomes of Suspected Non-ST-Elevation Acute Coronary Syndromes Meeting Rapid Rule-Out Criteria. J Clin Med 2023; 12:5704. [PMID: 37685771 PMCID: PMC10488340 DOI: 10.3390/jcm12175704] [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: 07/12/2023] [Revised: 08/07/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: patients who meet current rapid rule-out criteria for myocardial infarction (MI) are considered low risk, yet their management remains nebulous, especially among women. We aimed to examine sex differences in the diagnosis, management, and outcomes of patients meeting the rapid rule-out criteria. (2) Methods: by simulating application of the rapid rule-out MI criteria, we analyzed consecutively triaged men and women with suspected NSTE-ACS who had high-sensitivity cardiac troponin T (hs-cTnT) values that met criteria (n = 11,477), in particular, those who were admitted (n = 3775). (3) Results: men constituted ~55% of triaged patients who met the rule-out criteria, whether admitted or discharged. Men were more likely to be admitted (33.7% vs. 31.9%, p = 0.04), more commonly with hs-cTnT values between level of detection (LOD, 5 ng/ml) and the 99th percentile (59.4% of all admissions vs. 40.5% for women), whereas women were more likely to be admitted with values < level of blank (LOB, 3 ng/mL; 22.9% vs. 9.2% for men). Thirty-day mortality (1 man and 1 woman) and in-hospital MI (9 men vs. 1 woman) were uncommon among admitted patients, yet resource utilization during 3-4 hospitalization days was substantial for both sexes, with men undergoing coronary angiography (6.8% vs. 2.9%) and revascularization (3.4% vs. 1.1%) more commonly. Long-term survival for both men and women, whether admitted or discharged, was significantly worse for hs-cTnT values between LOD and the 99th percentile, even after adjusting for age and cardiovascular comorbidities. (4) Conclusions: reporting actual hs-cTnT values < 99th percentile allows for better risk stratification, especially for women, possibly closing the sex gap.
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Affiliation(s)
- Ben Cohen
- Cardiology Department, Rabin Medical Center, Petah Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ruth Tor
- Department of Laboratory Medicine, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Alon Grossman
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Internal Medicine B, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Avital Porter
- Cardiology Department, Rabin Medical Center, Petah Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - David Hasdai
- Cardiology Department, Rabin Medical Center, Petah Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Westwood M, Ramaekers B, Grimm S, Worthy G, Fayter D, Armstrong N, Buksnys T, Ross J, Joore M, Kleijnen J. High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-276. [PMID: 34061019 PMCID: PMC8200931 DOI: 10.3310/hta25330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early diagnosis of acute myocardial infarction is important, but only 20% of emergency admissions for chest pain will actually have an acute myocardial infarction. High-sensitivity cardiac troponin assays may allow rapid rule out of myocardial infarction and avoid unnecessary hospital admissions. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of high-sensitivity cardiac troponin assays for the management of adults presenting with acute chest pain, in particular for the early rule-out of acute myocardial infarction. METHODS Sixteen databases were searched up to September 2019. Review methods followed published guidelines. Studies were assessed for quality using appropriate risk-of-bias tools. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies; otherwise, random-effects logistic regression was used. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different troponin testing methods. The de novo model consisted of a decision tree and a state-transition cohort model. A lifetime time horizon (of 60 years) was used. RESULTS Thirty-seven studies (123 publications) were included in the review. The high-sensitivity cardiac troponin test strategies evaluated are defined by the combination of four factors (i.e. assay, number and timing of tests, and threshold concentration), resulting in a large number of possible combinations. Clinical opinion indicated a minimum clinically acceptable sensitivity of 97%. When considering single test strategies, only those using a threshold at or near to the limit of detection for the assay, in a sample taken at presentation, met the minimum clinically acceptable sensitivity criterion. The majority of the multiple test strategies that met this criterion comprised an initial rule-out step, based on high-sensitivity cardiac troponin levels in a sample taken on presentation and a minimum symptom duration, and a second stage for patients not meeting the initial rule-out criteria, based on presentation levels of high-sensitivity cardiac troponin and absolute change after 1, 2 or 3 hours. Two large cluster randomised controlled trials found that implementation of an early rule-out pathway for myocardial infarction reduced length of stay and rate of hospital admission without increasing cardiac events. In the base-case analysis, standard troponin testing was both the most effective and the most costly. Other testing strategies with a sensitivity of 100% (subject to uncertainty) were almost equally effective, resulting in the same life-year and quality-adjusted life-year gain at up to four decimal places. Comparisons based on the next best alternative showed that for willingness-to-pay values below £8455 per quality-adjusted life-year, the Access High Sensitivity Troponin I (Beckman Coulter, Brea, CA, USA) [(symptoms > 3 hours AND < 4 ng/l at 0 hours) OR (< 5 ng/l AND Δ < 5 ng/l at 0 to 2 hours)] would be cost-effective. For thresholds between £8455 and £20,190 per quality-adjusted life-year, the Elecsys® Troponin-T high sensitive (Roche, Basel, Switzerland) (< 12 ng/l at 0 hours AND Δ < 3 ng/l at 0 to 1 hours) would be cost-effective. For a threshold > £20,190 per quality-adjusted life-year, the Dimension Vista® High-Sensitivity Troponin I (Siemens Healthcare, Erlangen, Germany) (< 5 ng/l at 0 hours AND Δ < 2 ng/l at 0 to 1 hours) would be cost-effective. CONCLUSIONS High-sensitivity cardiac troponin testing may be cost-effective compared with standard troponin testing. STUDY REGISTRATION This study is registered as PROSPERO CRD42019154716. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Sabine Grimm
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | | | | | | | | | | | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University, Maastricht, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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Kim S, Yoo SJ, Kim J. Evaluation of the new Beckman Coulter Access hsTnI: 99th percentile upper reference limits according to age and sex in the Korean population. Clin Biochem 2020; 79:48-53. [DOI: 10.1016/j.clinbiochem.2020.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 01/20/2023]
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Garcia-Osuna A, Gaze D, Grau-Agramunt M, Morris T, Telha C, Bartolome A, Bishop JJ, Monsalve L, Livingston R, Estis J, Nolan N, Sandlund J, Ordonez-Llanos J. Ultrasensitive quantification of cardiac troponin I by a Single Molecule Counting method: analytical validation and biological features. Clin Chim Acta 2018; 486:224-231. [PMID: 30110608 DOI: 10.1016/j.cca.2018.08.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/03/2018] [Accepted: 08/11/2018] [Indexed: 02/07/2023]
Abstract
AIM To evaluate analytical and biological characteristics of the Singulex Clarity® cTnI assay, based upon Single Molecule Counting technology. METHODS Assay's analytical sensitivity, precision, linearity, hook effect, cross-reactivity or interference by endogenous and exogenous substances, stability, 99th reference percentile [p99th] in EDTA plasma were evaluated in single or multi-site studies. RESULTS Detection limit was 0.12 ng/L. Sensitivity was 0.14 ng/L at 20% CV (functional sensitivity) and 0.53 ng/L at 10% CV. Imprecision was 3.16%-10.0% in a multi-lot, single-site study, and 5.5%-12.0% in a single-lot, multi-site study; assay was linear from 0.08 to 25,000 ng/L. No hook effect was observed; any cross-reactivity/interference exceeded the 10%. Healthy subjects were recruited using clinical history, normal NT-proBNP and eGFR (n = 560) or plasma creatinine (n = 535) as inclusion criteria. cTnI was detectable in 96.8% of healthy subjects. The p99th were 8.01 (eGFR used) and 8.15 ng/L (plasma creatinine); both were measured with ≤5.7% CV. Median cTnI were significantly higher in older and male than in young and female subjects. CONCLUSIONS The Singulex Clarity cTnI assay show analytical features and % detection in healthy subjects that improve the corresponding values of most of the existing high-sensitivity cTnI assays.
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Affiliation(s)
- Alvaro Garcia-Osuna
- Department of Clinical Biochemistry, IIB-Hospital de Sant Pau, Barcelona, Spain
| | - David Gaze
- Department of Biomedical Sciences, University of Westminster, London, United Kingdom; Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Thomas Morris
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Catarina Telha
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | | | | | | | | | | | | | - Jordi Ordonez-Llanos
- Department of Clinical Biochemistry, IIB-Hospital de Sant Pau, Barcelona, Spain; Department of Biochemistry and Molecular Biology, Universitat Autònoma, Barcelona, Spain.
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Boeckel JN, Palapies L, Klotsche J, Zeller T, von Jeinsen B, Perret MF, Kleinhaus SL, Pieper L, Tzikas S, Leistner D, Bickel C, Stalla GK, Lehnert H, Lindahl B, Wittchen HU, Silber S, Baldus S, Maerz W, Dimmeler S, Blankenberg S, Münzel T, Zeiher AM, Keller T. Adjusted Troponin I for Improved Evaluation of Patients with Chest Pain. Sci Rep 2018; 8:8087. [PMID: 29799020 PMCID: PMC5967336 DOI: 10.1038/s41598-018-26120-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/03/2018] [Indexed: 11/29/2022] Open
Abstract
The use of cardiac troponins (cTn) is the gold standard for diagnosing myocardial infarction. Independent of myocardial infarction (MI), however, sex, age and kidney function affect cTn levels. Here we developed a method to adjust cTnI levels for age, sex, and renal function, maintaining a unified cut-off value such as the 99th percentile. A total of 4587 individuals enrolled in a prospective longitudinal study were used to develop a model for adjustment of cTn. cTnI levels correlated with age and estimated glomerular filtration rate (eGFR) in males/females with rage = 0.436/0.518 and with reGFR = -0.142/-0.207. For adjustment, these variables served as covariates in a linear regression model with cTnI as dependent variable. This adjustment model was then applied to a real-world cohort of 1789 patients with suspected acute MI (AMI) (N = 407). Adjusting cTnI showed no relevant loss of diagnostic information, as evidenced by comparable areas under the receiver operator characteristic curves, to identify AMI in males and females for adjusted and unadjusted cTnI. In specific patients groups such as in elderly females, adjusting cTnI improved specificity for AMI compared with unadjusted cTnI. Specificity was also improved in patients with renal dysfunction by using the adjusted cTnI values. Thus, the adjustments improved the diagnostic ability of cTnI to identify AMI in elderly patients and in patients with renal dysfunction. Interpretation of cTnI values in complex emergency cases is facilitated by our method, which maintains a single diagnostic cut-off value in all patients.
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Affiliation(s)
- Jes-Niels Boeckel
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, Goethe University Frankfurt, Frankfurt, Germany
- Department of Internal Medicine, Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Lars Palapies
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Jens Klotsche
- Clinical Psychology und Psychotherapy, Technical University Dresden, Dresden, Germany
| | - Tanja Zeller
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
| | - Beatrice von Jeinsen
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Maya F Perret
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Soeren L Kleinhaus
- Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Lars Pieper
- Clinical Psychology und Psychotherapy, Technical University Dresden, Dresden, Germany
| | - Stergios Tzikas
- 3rd Department of Cardiology, Ippokrateio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - David Leistner
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | - Günter K Stalla
- Max Plank Institute for Psychiatry, Neuroendocrinology, Munich, Munich, Germany
| | - Hendrik Lehnert
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | - Hans-Ulrich Wittchen
- Clinical Psychology und Psychotherapy, Technical University Dresden, Dresden, Germany
| | - Sigmund Silber
- Praxisklinik, Kardiologische Gemeinschaftspraxis, Munich, Germany
| | - Stephan Baldus
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
- Heart Center, University of Cologne, Cologne, Germany
| | - Winfried Maerz
- Synlab Akademie für ärztliche Fortbildung, Synlab Services GmbH, Mannheim, Germany
| | - Stefanie Dimmeler
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Stefan Blankenberg
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Clinic for General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
- Department of Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Andreas M Zeiher
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany
| | - Till Keller
- Department of Internal Medicine III, Cardiology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany.
- German Center for Cardiovascular Disease (DZHK), Berlin, Germany.
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.
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Mingels AMA, Kimenai DM. Sex-Related Aspects of Biomarkers in Cardiac Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:545-564. [PMID: 30051406 DOI: 10.1007/978-3-319-77932-4_33] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Biomarkers play an important role in the clinical management of cardiac care. In particular, cardiac troponins (cTn) and natriuretic peptides are the cornerstones for the diagnosis of acute myocardial infarction (AMI) and for the diagnosis of heart failure (HF), respectively. Current guidelines do not make a distinction between women and men. However, the commonly used "one size fits all" algorithms are topic of debate to improve assessment of prognosis, particularly in women. Due to the high-sensitivity assays (hs-cTn), lower cTn levels (and 99th percentile upper reference limits) were observed in women as compared with men. Sex-specific diagnostic thresholds may improve the diagnosis of AMI in women, though clinical relevance remains controversial and more trials are needed. Also other diagnostic aspects are under investigation, like combined biomarkers approach and rapid measurement strategies. For the natriuretic peptides, previous studies observed higher concentrations in women than in men, especially in premenopausal women who might benefit from the cardioprotective actions. Contrary to hs-cTn, natriuretic peptides are particularly incorporated in the ruling-out algorithms for the diagnosis of HF and not ruling-in. Clinical relevance of sex differences here seems marginal, as clinical research has shown that negative predictive values for ruling-out HF were hardly effected when applying a universal diagnostic threshold that is independent from sex or other risk factors. Apart from the diagnostic issues of AMI in women, we believe that in the future most sex-specific benefits of cardiac biomarkers can be obtained in patient follow-up (guiding therapy) and prognostic applications, fitting modern ideas on preventive and personalized medicine.
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Affiliation(s)
- Alma M A Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Dorien M Kimenai
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
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Lippi G, Ferrari A, Gandini G, Gelati M, Lo Cascio C, Salvagno GL. Analytical evaluation of the new Beckman Coulter Access high sensitivity cardiac troponin I immunoassay. Clin Chem Lab Med 2017; 56:157-161. [PMID: 28704179 DOI: 10.1515/cclm-2017-0350] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 06/01/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study was aimed to evaluate the analytical performance of the novel chemiluminescent and fully-automated Beckman Coulter Access hsTnI high-sensitivity immunoassay for measurement of cardiac troponin I (cTnI). METHODS The study, using lithium heparin samples, included assessment of limit of blank (LOB), limit of detection (LOD), functional sensitivity, linearity, imprecision (within run, between-run and total), calculation of 99th percentile upper reference limit (URL) in 175 healthy blood donors (mean age, 36±12 years; 47% women) and comparison with two other commercial cTnI immunoassays. RESULTS The LOB, LOD and functional sensitivity of Access hsTnI were 0.14, 0.34 and 1.35 ng/L, respectively. The within-run, between-run and total imprecision was 2.2%-2.9%, 4.6%-5.4%, and 5.4%-6.1%, respectively. The linearity was excellent in the range of cTnI values between 0.95 and 4195 ng/L (r=1.00). The 99th percentile URL was 15.8 ng/L. Measurable cTnI values were found in 173/175 healthy subjects (98.9%). Good agreement of cTnI values was found with AccuTnI+3 (r=0.97; mean bias, -9.3%), whereas less satisfactory agreement was found with Siemens Dimension Vista cTnI (r=0.95; mean bias, -55%). CONCLUSIONS The results of our evaluation of the Beckman Coulter Access hsTnI indicate that the analytical performance of this fully-automated immunoassay is excellent.
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Abstract
PURPOSE OF REVIEW Women with suspected acute coronary syndrome are less likely to undergo investigation or receive treatment than men, and women consistently have poorer outcomes. This review summarises how the latest development in cardiac biomarkers could improve both diagnosis and outcomes in women. RECENT FINDINGS Novel high-sensitivity cardiac troponin assays have identified differences in the reference range and therefore diagnostic threshold for myocardial infarction in men and women. These differences are present across multiple populations with different ethnic backgrounds and for a range of assays. The use of a uniform threshold for cardiac troponin does not provide equivalent prediction in men and women, with lower thresholds needed for women to provide comparable risk stratification. Sex differences in cardiac troponin concentrations are not widely recognised in clinical practice and may be contributing to the under-diagnosis of myocardial infarction in women and discrepancies in patient care and outcomes.
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Affiliation(s)
- Anoop S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK.
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK
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Pasterkamp G, den Ruijter HM, Libby P. Temporal shifts in clinical presentation and underlying mechanisms of atherosclerotic disease. Nat Rev Cardiol 2016; 14:21-29. [DOI: 10.1038/nrcardio.2016.166] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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