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Gragnano F, Capolongo A, Micari A, Costa F, Garcia-Ruiz V, De Sio V, Terracciano F, Cesaro A, Moscarella E, Coletta S, Raucci P, Fimiani F, De Luca L, Gargiulo G, Andò G, Calabrò P. Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. J Clin Med 2023; 13:98. [PMID: 38202105 PMCID: PMC10780105 DOI: 10.3390/jcm13010098] [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: 11/08/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
The antithrombotic management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) poses numerous challenges. Triple antithrombotic therapy (TAT), which combines dual antiplatelet therapy (DAPT) with oral anticoagulation (OAC), provides anti-ischemic protection but increases the risk of bleeding. Therefore, TAT is generally limited to a short phase (1 week) after PCI, followed by aspirin withdrawal and continuation of 6-12 months of dual antithrombotic therapy (DAT), comprising OAC plus clopidogrel, followed by OAC alone. This pharmacological approach has been shown to mitigate bleeding risk while preserving adequate anti-ischemic efficacy. However, the decision-making process remains complex in elderly patients and those with co-morbidities, significantly influencing ischemic and bleeding risk. In this review, we discuss the available evidence in this area from randomized clinical trials and meta-analyses for post-procedural antithrombotic therapies in patients with non-valvular AF undergoing PCI.
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | | | - Vincenzo De Sio
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabrizia Terracciano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Silvio Coletta
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Pasquale Raucci
- Division of Health Technology Assessment, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, Azienda Ospedaliera di Rilievo Nazionale Dei Colli, “Vincenzo Monaldi”, CCMR Regione Campania, 80138 Naples, Italy;
| | - Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, 00152 Roma, Italy;
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
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Greco A, Laudani C, Rochira C, Capodanno D. Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective. Interv Cardiol 2023; 18:e05. [PMID: 37601736 PMCID: PMC10433110 DOI: 10.15420/icr.2021.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/20/2022] [Indexed: 08/22/2023] Open
Abstract
AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.
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Affiliation(s)
- Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Claudio Laudani
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Carla Rochira
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
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Garg A, Rout A, Farhan S, Waxman S, Giustino G, Tayal R, Abbott JD, Huber K, Angiolillo DJ, Rao SV. Dual antiplatelet therapy duration after percutaneous coronary intervention using drug eluting stents in high bleeding risk patients: A systematic review and meta-analysis. Am Heart J 2022; 250:1-10. [PMID: 35436504 DOI: 10.1016/j.ahj.2022.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Optimal dual antiplatelet therapy (DAPT) duration in patients at high bleeding risk (HBR) is not fully defined. We aimed to compare the safety and effectiveness of short-term DAPT (S-DAPT) with longer duration DAPT (L-DAPT) after percutaneous coronary intervention (PCI) with drug eluting stents (DES) in patients at HBR. METHODS We searched for studies comparing S-DAPT (≤3 months) followed by aspirin or P2Y 12 inhibitor monotherapy against L-DAPT (6-12 months) after PCI in HBR patients. Primary end points of interest were major bleeding and myocardial infarction (MI). Random-effects meta-analyses were performed to calculate odds ratios with 95% CIs. RESULTS Six randomized trials and 3 propensity-matched studies (n = 16,848) were included in the primary analysis. Compared with L-DAPT (n = 8,422), major bleeding was lower with S-DAPT (n = 8,426) [OR 0.68; 95% CI 0.51-0.89] whereas MI did not differ significantly between the 2 groups [1.16; 0.94-1.44]. There were no significant differences in risks of death, stroke or stent thrombosis (ST) between S-DAPT and L-DAPT groups. These findings were consistent when propensity-matched studies were analysed separately. Finally, there was a numerically higher, albeit statistically non-significant, ST in the S-DAPT arm of patients without an indication for OAC [1.98; 0.86-4.58]. CONCLUSIONS Among HBR patients undergoing current generation DES implantation, S-DAPT reduces bleeding without an increased risk of death or MI compared with L-DAPT. More research is needed to (1) evaluate risks of late ST after 1 to 3 months DAPT among patients with high ischemic and bleeding risks, (2) defining the SAPT of choice after 1 to 3 months DAPT.
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Affiliation(s)
- Aakash Garg
- Division of Cardiology, Brown University, Providence, RI.
| | - Amit Rout
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Serdar Farhan
- Division of Cardiology, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Sergio Waxman
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ
| | - Gennaro Giustino
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Raj Tayal
- Division of Cardiology, Valley Hospital, Ridgewood, NJ
| | | | - Kurt Huber
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Sunil V Rao
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
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Wang W, Huang Q, Pan D, Zheng W, Zheng S. The optimal duration of triple antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention: A network meta-analysis of randomized clinical trials. Int J Cardiol 2022; 357:33-38. [DOI: 10.1016/j.ijcard.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/15/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
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Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, Rao SV, Steg PG, Urban P, Valgimigli M, Windecker S, Angiolillo DJ. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:117-132. [PMID: 34426673 DOI: 10.1038/s41569-021-00598-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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Fanaroff AC, Lopes RD. The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Prog Cardiovasc Dis 2021; 69:11-17. [PMID: 34883097 DOI: 10.1016/j.pcad.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y12 inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y12 inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y12 inhibitor) for 6 to 12 months.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Renato D Lopes
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Durham, NC, United States of America.
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Galli M, Capodanno D, Andreotti F, Crea F, Angiolillo DJ. Safety and efficacy of P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary interventions. Expert Opin Drug Saf 2020; 20:9-21. [PMID: 33180563 DOI: 10.1080/14740338.2021.1850691] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI. Areas covered: P2Y12 inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y12 inhibitor monotherapy in patients undergoing PCI in different clinical settings. Expert opinion: P2Y12 inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y12 monotherapy regimen warrant further investigation.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy.,Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico," Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
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Capodanno D, Di Maio M, Greco A, Bhatt DL, Gibson CM, Goette A, Lopes RD, Mehran R, Vranckx P, Angiolillo DJ. Safety and Efficacy of Double Antithrombotic Therapy With Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e017212. [PMID: 32805186 PMCID: PMC7660808 DOI: 10.1161/jaha.120.017212] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/18/2020] [Indexed: 02/06/2023]
Abstract
Background The optimal antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention is a topic of debate. We aimed at defining the efficacy and safety of double antithrombotic therapy with single antiplatelet therapy (SAPT) plus a non-vitamin K antagonist oral anticoagulant (NOAC) against triple antithrombotic therapy with dual antiplatelet therapy (DAPT) added to a vitamin K antagonist (VKA), illustrating the pooled cumulative distribution of events, the ranking of different NOACs tested in NOAC+SAPT combination strategies, and the state of the current evidence in the field. Methods and Results Randomized controlled trials meeting the inclusion criteria were identified. The primary efficacy end point was the composite of trial-defined major adverse cardiac events. The primary safety end point was clinically significant bleeding. Secondary end points were the components of primary end points. Trial-level pairwise and Bayesian network meta-analyses, reconstructed Kaplan-Meier analyses, and trial sequential analysis were performed. Four randomized controlled trials (10 969 patients) were included. No differences were found in terms of major adverse cardiac events (hazard ratio [HR], 1.07; 95% CI, 0.94-1.22), and the NOAC+SAPT strategy showed a lower rate of clinically significant bleeding compared with VKA + DAPT (HR, 0.56; 95% CI, 0.39-0.80). These results were consistent in reconstructed Kaplan-Meier analyses. In the Bayesian network meta-analysis, different NOACs displayed diverse risk-benefit profiles. Trial sequential analyses suggest that the evidence for the similarity in major adverse cardiac events compared with VKA + DAPT and the bleeding risk reduction observed with NOAC+SAPT is likely to be conclusive. Conclusions NOAC+SAPT does not increase the risk of major adverse cardiac events and reduces the risk of bleeding compared with VKA + DAPT in AF patients undergoing percutaneous coronary intervention. Various NOACs may have different risk-benefit profiles in combination strategies. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020151089.
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Affiliation(s)
- Davide Capodanno
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
| | - Marco Di Maio
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
- Division of CardiologyDepartment of Translational Medical SciencesUniversity of Campania "Luigi Vanvitelli"NaplesItaly
| | - Antonio Greco
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
| | - Deepak L. Bhatt
- Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMA
| | - C. Michael Gibson
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Andreas Goette
- Atrial Fibrillation NetworkMunsterGermany
- Cardiology and Intensive Care MedicineSt Vincenz‐HospitalPaderbornGermany
- Working Group of Molecular ElectrophysiologyUniversity Hospital MagdeburgMagdeburgGermany
| | | | - Roxana Mehran
- Cardiovascular InstituteMount Sinai Medical CenterIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Pascal Vranckx
- Jessa ZiekenhuisFaculty of Medicine and Life Sciences at the Hasselt UniversityHasseltBelgium
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Lopes RD, Fanaroff AC. Dropping P2Y<sub>12</sub> inhibitors in patients with AF undergoing PCI? Not yet a SAFE bet. EUROINTERVENTION 2020; 16:e109-e111. [PMID: 32538790 DOI: 10.4244/eijv16i2a18] [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: 11/23/2022]
Affiliation(s)
- Renato D Lopes
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Durham, NC, USA
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