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Davis EF, Crousillat DR, Peteiro J, Lopez-Sendon J, Senior R, Shapiro MD, Pellikka PA, Lyubarova R, Alfakih K, Abdul-Nour K, Anthopolos R, Xu Y, Kunichoff DM, Fleg JL, Spertus JA, Hochman J, Maron D, Picard MH, Reynolds HR. Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA Study. J Am Soc Echocardiogr 2024; 37:89-99. [PMID: 37722490 PMCID: PMC10842002 DOI: 10.1016/j.echo.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA). OBJECTIVES To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA. METHODS Left ventricular GLS was calculated offline on resting SE images at enrollment (n = 144) and 1-year follow-up (n = 120) in the CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial screen failures with no obstructive CAD on computed tomography [CT] angiography) study, which enrolled participants with moderate or severe ischemia by local SE interpretation (≥3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) on coronary computed tomography angiography. RESULTS Global longitudinal strain values were normal in 83.3% at enrollment and 94.2% at follow-up. Global longitudinal strain values were not associated with a positive SE at enrollment (GLS = -21.5% positive SE vs GLS = -19.9% negative SE, P = .443) or follow-up (GLS = -23.2% positive SE vs GLS = -23.1% negative SE, P = .859). Significant change in GLS was not associated with positive SE in follow-up (P = .401). Regional strain was not associated with colocalizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β = 0.41; 95% CI, 0.16, 0.67; P = .002). CONCLUSIONS In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity, or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.
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Affiliation(s)
- Esther F Davis
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Victorian Heart Institute and Victorian Heart Hospital, Victoria, Australia
| | - Daniela R Crousillat
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, Florida; Department of Obstetrics and Gynecology, Tampa General-Heart and Vascular Institute, University of South Florida, Tampa, Florida
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña, CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Michael D Shapiro
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Rebecca Anthopolos
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Yifan Xu
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Dennis M Kunichoff
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Jerome L Fleg
- National Institute of Health-National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Judith Hochman
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - David Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Michael H Picard
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York.
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Patel H, Aggarwal NT, Rao A, Bryant E, Sanghani RM, Byrnes M, Kalra D, Dairaghi L, Braun L, Gabriel S, Volgman AS. Microvascular Disease and Small-Vessel Disease: The Nexus of Multiple Diseases of Women. J Womens Health (Larchmt) 2020; 29:770-779. [PMID: 32074468 PMCID: PMC7307673 DOI: 10.1089/jwh.2019.7826] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Microvascular disease, or small-vessel disease, is a multisystem disorder with a common pathophysiological basis that differentially affects various organs in some patients. The prevalence of small-vessel disease in the heart has been found to be higher in women compared with men. Additionally, other diseases prominently affecting women, including heart failure with preserved ejection fraction, Takotsubo cardiomyopathy, cerebral small-vessel disease, preeclampsia, pulmonary arterial hypertension (PAH), endothelial dysfunction in diabetes, diabetic cardiomyopathy, rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis, may have a common etiologic linkage related to microvascular disease. To the best of our knowledge this is the first article to investigate this potential linkage. We sought to identify various diseases with a shared pathophysiology involving microvascular/endothelial dysfunction that primarily affect women, and their potential implications for disease management. Advanced imaging technologies, such as magnetic resonance imaging and positron-emission tomography, enable the detection and increased understanding of microvascular dysfunction in various diseases. Therapies that improve endothelial function, such as those used in PAH, may also be associated with benefits across the full spectrum of microvascular dysfunction. A shared pathology across multiple organ systems highlights the need for a collaborative, multidisciplinary approach among medical subspecialty practitioners who care for women with small-vessel disease. Such an approach may lead to accelerated research in diseases that affect women and their quality of life.
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Affiliation(s)
- Hena Patel
- Department of Cardiology, Rush Medical College, Rush University, Chicago, Illinois
| | - Neelum T Aggarwal
- Department of Neurological Sciences, Rush Alzheimer's Disease Center, Rush Medical College, Rush University, Chicago, Illinois
| | - Anupama Rao
- Department of Cardiology, Rush Medical College, Rush University, Chicago, Illinois
| | | | - Rupa M Sanghani
- Department of Cardiology, Rush Medical College, Rush University, Chicago, Illinois
| | - Mary Byrnes
- Clinical Nursing, Rush Medical College, Rush University, Chicago, Illinois
| | - Dinesh Kalra
- Department of Cardiology, Rush Medical College, Rush University, Chicago, Illinois
| | - Leigh Dairaghi
- Rush Medical College, Rush University, Chicago, Illinois
| | - Lynne Braun
- Rush College of Nursing and Medicine, Rush University, Chicago, Illinois
| | - Sherine Gabriel
- Department of Rheumatology, Rush Medical College, Rush University, Chicago, Illinois
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Quesada O, AlBadri A, Wei J, Shufelt C, Mehta PK, Maughan J, Suppogu N, Aldiwani H, Cook-Wiens G, Nelson MD, Sharif B, Handberg EM, Anderson RD, Petersen J, Berman DS, Thomson LEJ, Pepine CJ, Merz CNB. Design, methodology and baseline characteristics of the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD). Am Heart J 2020; 220:224-236. [PMID: 31884245 DOI: 10.1016/j.ahj.2019.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/30/2019] [Indexed: 12/16/2022]
Abstract
A significant number of women with signs and symptoms of ischemia with no obstructive coronary artery disease (INOCA) have coronary vascular dysfunction detected by invasive coronary reactivity testing (CRT). However, the noninvasive assessment of coronary vascular dysfunction has been limited. METHODS The Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) was a prospective study of women with suspected INOCA aimed to investigate whether (1) cardiac magnetic resonance imaging (CMRI) abnormalities in left ventricular morphology and function and myocardial perfusion predict CRT measured coronary microvascular dysfunction, (2) these persistent CMRI abnormalities at 1-year follow-up predict persistent symptoms of ischemia, and (3) these CMRI abnormalities predict cardiovascular outcomes. By design, a sample size of 375 women undergoing clinically indicated invasive coronary angiography for suspected INOCA was projected to complete baseline CMRI, a priori subgroup of 200 clinically indicated CRTs, and a priori subgroup of 200 repeat 1-year follow-up CMRIs. RESULTS A total of 437 women enrolled between 2008 and 2015, 374 completed baseline CMRI, 279 completed CRT, and 214 completed 1-year follow-up CMRI. Mean age was 55± 11 years, 93% had 20%-50% coronary stenosis, and 7% had <20% stenosis by angiography. CONCLUSIONS The WISE-CVD study investigates the utility of noninvasive CMRI to predict coronary vascular dysfunction in comparison to invasive CRT, and the prognostic value of CMRI abnormalities for persistent symptoms of ischemia and cardiovascular outcomes in women with INOCA. WISE-CVD will provide new understanding of a noninvasive imaging modality for future clinical trials.
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Affiliation(s)
- Odayme Quesada
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Ahmed AlBadri
- Emory Women's Heart Center & Emory Clinical Cardiovascular Research Institute, Atlanta, GA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Puja K Mehta
- Emory Women's Heart Center & Emory Clinical Cardiovascular Research Institute, Atlanta, GA
| | - Jenna Maughan
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Nissi Suppogu
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Haider Aldiwani
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Galen Cook-Wiens
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael D Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Behzad Sharif
- Mark S. Taper Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eileen M Handberg
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL
| | - R David Anderson
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL
| | - John Petersen
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL
| | - Daniel S Berman
- Mark S. Taper Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise E J Thomson
- Mark S. Taper Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Carl J Pepine
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA.
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7
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Thomson LEJ, Wei J, Agarwal M, Haft-Baradaran A, Shufelt C, Mehta PK, Gill EB, Johnson BD, Kenkre T, Handberg EM, Li D, Sharif B, Berman DS, Petersen JW, Pepine CJ, Bairey Merz CN. Cardiac magnetic resonance myocardial perfusion reserve index is reduced in women with coronary microvascular dysfunction. A National Heart, Lung, and Blood Institute-sponsored study from the Women's Ischemia Syndrome Evaluation. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002481. [PMID: 25801710 DOI: 10.1161/circimaging.114.002481] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women with signs and symptoms of ischemia and no obstructive coronary artery disease often have coronary microvascular dysfunction (CMD), diagnosed by invasive coronary reactivity testing (CRT). Although traditional noninvasive stress imaging is often normal in CMD, cardiac MRI may be able to detect CMD in this population. METHODS AND RESULTS Vasodilator stress cardiac MRI was performed in 118 women with suspected CMD who had undergone CRT and 21 asymptomatic reference subjects. Semi-quantitative evaluation of the first-pass perfusion images was completed to determine myocardial perfusion reserve index (MPRI). The relationship between CRT findings and MPRI was examined by Pearson correlations, logistic regression, and sensitivity/specificity. Symptomatic women had lower mean pharmacological stress MPRI compared with reference subjects (1.71±0.43 versus 2.23±0.37; P<0.0001). Lower MPRI was predictive of ≥1 abnormal CRT variables (odds ratio =0.78 [0.70, 0.88], P<0.0001, c-statistic 0.78 [0.68, 0.88]). An MPRI threshold of 1.84 predicted CRT abnormality with sensitivity 73% and specificity 74%. CONCLUSIONS Noninvasive cardiac MRI MPRI can detect CMD defined by invasive CRT. Further work is aimed to optimize the noninvasive identification and management of CMD patients. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00832702.
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Affiliation(s)
- Louise E J Thomson
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.).
| | - Janet Wei
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Megha Agarwal
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Afsaneh Haft-Baradaran
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Chrisandra Shufelt
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Puja K Mehta
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Edward B Gill
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - B Delia Johnson
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Tanya Kenkre
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Eileen M Handberg
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Debiao Li
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Behzad Sharif
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Daniel S Berman
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - John W Petersen
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - Carl J Pepine
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
| | - C Noel Bairey Merz
- From the Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (L.E.J.T., J.W., M.A., A.H.-B., C.S., P.K.M., E.B.G., D.S.B., C.N.B.M.); School of Public Health, University of Pittsburgh, PA (B.D.J., T.K.); Division of Cardiology, University of Florida, Gainesville (E.M.H., J.W.P., C.J.P.); and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (D.L., B.S.)
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