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Ehrhardt MJ, Liu Q, Mulrooney DA, Rhea IB, Dixon SB, Lucas JT, Sapkota Y, Shelton K, Ness KK, Srivastava DK, McDonald A, Robison LL, Hudson MM, Yasui Y, Armstrong GT. Improved Cardiomyopathy Risk Prediction Using Global Longitudinal Strain and N-Terminal-Pro-B-Type Natriuretic Peptide in Survivors of Childhood Cancer Exposed to Cardiotoxic Therapy. J Clin Oncol 2024; 42:1265-1277. [PMID: 38207238 PMCID: PMC11095874 DOI: 10.1200/jco.23.01796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/27/2023] [Accepted: 10/26/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE To leverage baseline global longitudinal strain (GLS) and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) to identify childhood cancer survivors with a normal left ventricular ejection fraction (LVEF) at highest risk of future treatment-related cardiomyopathy. METHODS St Jude Lifetime Cohort participants ≥5 years from diagnosis, at increased risk for cardiomyopathy per the International Guideline Harmonization Group (IGHG), with an LVEF ≥50% on baseline echocardiography (n = 1,483) underwent measurement of GLS (n = 1,483) and NT-proBNP (n = 1,052; 71%). Multivariable Cox regression models estimated hazard ratios (HRs) and 95% CIs for postbaseline cardiomyopathy (modified Common Terminology Criteria for Adverse Events ≥grade 2) incidence in association with echocardiogram-based GLS (≥-18) and/or NT-proBNP (>age-sex-specific 97.5th percentiles). Prediction performance was assessed using AUC in models with and without GLS and NT-proBNP and compared using DeLong's test for IGHG moderate- and high-risk individuals treated with anthracyclines. RESULTS Among survivors (median age, 37.6; range, 10.2-70.4 years), 162 (11.1%) developed ≥grade 2 cardiomyopathy 5.1 (0.7-10.0) years from baseline assessment. The 5-year cumulative incidence of cardiomyopathy for survivors with and without abnormal GLS was, respectively, 7.3% (95% CI, 4.7 to 9.9) versus 4.4% (95% CI, 3.0 to 5.7) and abnormal NT-proBNP was 9.9% (95% CI, 5.8 to 14.1) versus 4.7% (95% CI, 3.2 to 6.2). Among survivors with a normal LVEF, abnormal baseline GLS and NT-proBNP identified anthracycline-exposed, IGHG-defined moderate-/high-risk survivors at a four-fold increased hazard of postbaseline cardiomyopathy (HR, 4.39 [95% CI, 2.46 to 7.83]; P < .001), increasing to a HR of 14.16 (95% CI, 6.45 to 31.08; P < .001) among survivors who received ≥250 mg/m2 of anthracyclines. Six years after baseline, AUCs for individual risk prediction were 0.70 for models with and 0.63 for models without GLS and NT-proBNP (P = .022). CONCLUSION GLS and NT-proBNP should be considered for improved identification of survivors at high risk for future cardiomyopathy.
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Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Daniel A. Mulrooney
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Isaac B. Rhea
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Stephanie B. Dixon
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - John T. Lucas
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Yadav Sapkota
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kyla Shelton
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Aaron McDonald
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
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Goldberg JF, Hyun G, Ness KK, Dixon SB, Towbin JA, Rhea IB, Ehrhardt MJ, Srivastava DK, Mulrooney DA, Hudson MM, Robison LL, Jefferies JL, Rohatgi A, Armstrong GT. Dyslipidemia and cardiovascular disease among childhood cancer survivors: a St. Jude Lifetime Cohort report. J Natl Cancer Inst 2024; 116:408-420. [PMID: 37952244 PMCID: PMC10919333 DOI: 10.1093/jnci/djad222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/27/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Childhood cancer survivors have increased risk of dyslipidemia and atherosclerotic cardiovascular disease (CVD). The aim of this study was to evaluate the prevalence and associated cardiovascular risks of specific lipid abnormalities among childhood cancer survivors. METHODS Comprehensive lipid panel measurements were obtained from 4115 5-year survivors, with 3406 (mean age at evaluation = 35.2 years, SD = 10.4 years) not having previous dyslipidemia diagnosis, as well as 624 age, sex, and race and ethnicity matched community controls. RESULTS Previously undiagnosed dyslipidemia with abnormal low-density lipoprotein (LDL) cholesterol (>160 mg/dL), non-high density lipoprotein (HDL) cholesterol (>190 mg/dL), HDL cholesterol (<40 mg/dL for men, <50 mg/dL for women), and triglycerides (>150 mg/dL) were identified in 4%, 6%, 30%, and 17%, respectively. Survivors without previous dyslipidemia diagnosis had higher LDL cholesterol and non-HDL cholesterol and lower HDL cholesterol than community controls. Cranial radiotherapy (relative risk [RR] = 2.2, 95% confidence interval [CI] = 1.6 to 3.0 for non-HDL cholesterol) and total body irradiation for hematopoietic cell transplantation (RR = 6.7, 95% CI = 3.5 to 13.0 for non-HDL cholesterol; RR = 9.9, 95% CI = 6.0 to 16.3 for triglycerides) were associated with greater risk of dyslipidemia. Diagnoses of low HDL cholesterol (hazard ratio [HR] = 2.9, 95% CI = 1.8 to 4.7) and elevated triglycerides (HR = 3.1, 95% CI = 1.9 to 5.1) were associated with increased risk for myocardial infarction, and diagnoses of high LDL cholesterol (HR = 2.2, 95% CI = 1.3 to 3.7), high non-HDL cholesterol (HR = 2.2, 95% CI = 1.3 to 3.7), low HDL cholesterol (HR = 3.9, 95% CI = 2.8 to 5.4), and elevated triglycerides (HR = 3.8, 95% CI = 2.7 to 5.5) were associated with increased risk for cardiomyopathy. CONCLUSIONS Previously undiagnosed dyslipidemia among childhood cancer survivors was associated with increased risk for myocardial infarction and cardiomyopathy. Comprehensive dyslipidemia evaluation and treatment are needed to reduce cardiovascular morbidity in this population.
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Affiliation(s)
- Jason F Goldberg
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Geehong Hyun
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Stephanie B Dixon
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jeffrey A Towbin
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac B Rhea
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Matthew J Ehrhardt
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Daniel A Mulrooney
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - John L Jefferies
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anand Rohatgi
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
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Hammoud RA, Mulrooney DA, Rhea IB, Yu C, Johnson JN, Chow EJ, Ehrhardt MJ, Hudson MM, Ness KK, Armstrong GT, Dixon SB. Modifiable Cardiometabolic Risk Factors in Survivors of Childhood Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2024; 6:16-32. [PMID: 38510292 PMCID: PMC10950443 DOI: 10.1016/j.jaccao.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 03/22/2024] Open
Abstract
The growing community of childhood cancer survivors faces a heavy burden of late onset morbidities and mortality, with cardiovascular diseases being the leading noncancer cause. In addition to demographics and cancer treatment exposures, which cannot be altered, cardiometabolic risk factors (obesity, hypertension, diabetes, and dyslipidemia) and frailty potentiate the risk of morbidity and mortality associated with chronic health conditions. Important opportunities exist to target these risk factors and improve late health outcomes for survivors. Unfortunately, limited evidence exists on the optimal methods to prevent, screen, and treat cardiometabolic risk factors among survivors, resulting in significant underdiagnosis and undertreatment. In this review, we discuss the prevalence of, risk factors for, current survivor-specific recommendations, and gaps in knowledge to mitigate potentially modifiable cardiometabolic risk factors and frailty among survivors of childhood cancer.
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Affiliation(s)
- Rawan A. Hammoud
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Isaac B. Rhea
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christine Yu
- Department of Pediatric Medicine, Division of Endocrinology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jason N. Johnson
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Eric J. Chow
- Fred Hutchinson Cancer Center, Seattle Children’s Hospital, University of Washington, Seattle, Washington, USA
| | - Matthew J. Ehrhardt
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Stephanie B. Dixon
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Palmer C, Mazur W, Truong VT, Nagueh SF, Fowler JA, Shelton K, Joshi VM, Ness KK, Srivastava DK, Robison LL, Hudson MM, Rhea IB, Jefferies JL, Armstrong GT. Prevalence of Diastolic Dysfunction in Adult Survivors of Childhood Cancer: A Report From SJLIFE Cohort. JACC CardioOncol 2023; 5:377-388. [PMID: 37397075 PMCID: PMC10308058 DOI: 10.1016/j.jaccao.2022.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 07/04/2023] Open
Abstract
Background The prevalence of diastolic dysfunction has not been systematically evaluated in a large population of survivors of childhood cancer using established guidelines and standards. Objectives This study sought to assess the prevalence and progression of diastolic dysfunction in adult survivors of childhood cancer exposed to cardiotoxic therapy. Methods Comprehensive, longitudinal echocardiographic examinations of adult survivors of childhood cancer ≥18 years of age and ≥10 years from diagnosis in SJLIFE (St. Jude Lifetime Cohort Study) were performed. Diastolic dysfunction was defined based on 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Results Among 3,342 survivors, the median (25th-75th percentiles [quartile (Q)1-Q3]) age at diagnosis was 8.1 years (Q1-Q3: 3.6-13.7 years), 30.1 years (Q1-Q3: 24.4-37.0 years) at the baseline echocardiography evaluation (Echo 1), and 36.6 years (Q1-Q3: 30.8-43.6 years) at the last follow-up echocardiography evaluation (1,435 survivors) (Echo 2). The proportion of diastolic dysfunction was 15.2% (95% CI: 14.0%-16.4%) at Echo 1 and 15.7% (95% CI: 13.9%-17.7%) at Echo 2, largely attributable to concurrent systolic dysfunction. Less than 5% of survivors with preserved ejection fraction had diastolic dysfunction (2.2% at Echo 1, 3.7% at Echo 2). Using global longitudinal strain assessment in adult survivors with preserved ejection fraction (defined with a cutpoint worse than -15.9%), the proportion of diastolic dysfunction increased to 9.2% at baseline and 9.0% at follow-up. Conclusions The prevalence of isolated diastolic dysfunction is low among adults who received cardiotoxic therapies for childhood cancer. The inclusion of left ventricular global longitudinal strain significantly increased the identification of diastolic dysfunction.
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Affiliation(s)
- Cassady Palmer
- Department of Cardiology, The Christ Hospital Health Network, Cincinnati, Ohio, USA
| | - Wojciech Mazur
- Department of Cardiology, The Christ Hospital Health Network, Cincinnati, Ohio, USA
| | - Vien T. Truong
- Department of Cardiology, The Christ Hospital Health Network, Cincinnati, Ohio, USA
| | - Sherif F. Nagueh
- Cardiology Department, Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - James A. Fowler
- Cardiopulmonary Services, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kyla Shelton
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Vijaya M. Joshi
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Isaac B. Rhea
- The Cardiovascular Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - John L. Jefferies
- The Cardiovascular Institute, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Lee DH, Hawk F, Seok K, Gliksman M, Emole J, Rhea IB, Viganego F, Welter-Frost A, Armanious M, Shah B, Chavez JC, Pinilla-Ibarz J, Schabath MB, Fradley M. Association between ibrutinib treatment and hypertension. Heart 2022; 108:445-450. [PMID: 34210750 PMCID: PMC9809112 DOI: 10.1136/heartjnl-2021-319110] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/03/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Ibrutinib is a tyrosine kinase inhibitor most commonly associated with atrial fibrillation. However, additional cardiotoxicities have been identified, including accelerated hypertension. The incidence and risk factors of new or worsening hypertension following ibrutinib treatment are not as well known. METHODS We conducted a retrospective study of 144 patients diagnosed with B cell malignancies treated with ibrutinib (n=93) versus conventional chemoimmunotherapy (n=51) and evaluated their effects on blood pressure at 1, 2, 3 and 6 months after treatment initiation. Descriptive statistics were used to compare baseline characteristics for each treatment group. Fisher's exact test was used to identify covariates significantly associated with the development of hypertension. Repeated measures analyses were conducted to analyse longitudinal blood pressure changes. RESULTS Both treatments had similar prevalence of baseline hypertension at 63.4% and 66.7%, respectively. There were no differences between treatments by age, sex and baseline cardiac comorbidities. Both systolic and diastolic blood pressure significantly increased over time with ibrutinib compared with baseline, whereas conventional chemoimmunotherapy was not associated with significant changes in blood pressure. Baseline hypertensive status did not affect the degree of blood pressure change over time. A significant increase in systolic blood pressure (defined as more than 10 mm Hg) was noted for ibrutinib (36.6%) compared with conventional chemoimmunotherapy (7.9%) at 1 month after treatment initiation. Despite being hypertensive at follow-up, 61.2% of patients who were treated with ibrutinib did not receive adequate blood pressure management (increase or addition of blood pressure medications). Within the ibrutinib group, of patients who developed more than 20 mm Hg increase in systolic blood pressure, only 52.9% had hypertension management changes. CONCLUSIONS Ibrutinib is associated with the development of hypertension and worsening of blood pressure. Cardiologists and oncologists must be aware of this cardiotoxicity to allow timely management of blood pressure elevations.
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Affiliation(s)
- Dae Hyun Lee
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Fahad Hawk
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Kieun Seok
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Matthew Gliksman
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Josephine Emole
- Department of Medical Oncology, Henry Ford Health System, Detroit, Michigan, USA
| | - Isaac B Rhea
- Cardio-Oncology Division, University of Tennessee Health Science Center Bookstore, Memphis, Tennessee, USA
| | - Federico Viganego
- Cardio-Oncology Program, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Allan Welter-Frost
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Merna Armanious
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Bijal Shah
- Malignant Hematology Program, Moffitt Cancer Center, Tampa, Florida, USA
| | - Juliio C Chavez
- Malignant Hematology Program, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Matthew B Schabath
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Michael Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Fradley MG, Ellenberg K, Alomar M, Swanson J, Kharod A, Nguyen ATH, Khodor S, Mishra S, Duong LM, Shah N, Armanious M, Rhea IB, Schabath MB, Kip KE. Patterns of Anticoagulation Use in Patients With Cancer With Atrial Fibrillation and/or Atrial Flutter. JACC CardioOncol 2020; 2:747-754. [PMID: 34396290 PMCID: PMC8352174 DOI: 10.1016/j.jaccao.2020.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Background Atrial fibrillation (AF) is a common cardiovascular complication affecting patients with cancer, but management strategies are not well established. Objectives The purpose of this retrospective cohort study was to evaluate cross-sectional patterns of anticoagulation (AC) use in patients with cancer with AF or atrial flutter (AFL) on the basis of their risk for stroke and bleeding. Methods Patients with cancer and electrocardiograms showing AF or AFL performed at Moffitt Cancer Center in either the inpatient or outpatient setting were included in this retrospective analysis. We described percentages of AC prescription by stroke and bleeding risk, as determined by individual CHA2DS2-VASc and HAS-BLED scores, respectively. Multivariable logistic regression evaluated clinical variables independently associated with anticoagulant prescription. Results The prevalence of electrocardiography-documented AF or AFL was 4.8% (n = 472). The mean CHA2DS2-VASc score was 2.8 ± 1.4. Among patients with CHA2DS2-VASc scores ≥2 and HAS-BLED scores <3, 44.3% did not receive AC, and of these, only 18.3% had platelet values <50,000/μl. In multivariable analysis, older age, hypertension, prior stroke, and history of venous thromboembolism were each directly associated with AC use, while current chemotherapy use, prior bleeding, renal disease, and thrombocytopenia were each inversely associated with AC use. Conclusions Nearly one-half of patients with cancer, the majority with normal platelet counts, had an elevated risk for stroke but did not receive AC. In addition to known predictors, current chemotherapy use was independently associated with a lower odds of AC use. This study highlights the need to improve the application of AF treatment algorithms to cancer populations.
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Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kerry Ellenberg
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Mohammed Alomar
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Justin Swanson
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Anant Kharod
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Anh Thy H Nguyen
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Sara Khodor
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Shreya Mishra
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Linh M Duong
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Nirav Shah
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Merna Armanious
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Isaac B Rhea
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kevin E Kip
- University of South Florida College of Public Health, Tampa, Florida, USA
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7
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Oliveira GH, Al-Kindi SG, Guha A, Dey AK, Rhea IB, deLima MJ. Cardiovascular risk assessment and management of patients undergoing hematopoietic cell transplantation. Bone Marrow Transplant 2020; 56:544-551. [PMID: 33130819 DOI: 10.1038/s41409-020-01080-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 09/18/2020] [Accepted: 09/29/2020] [Indexed: 01/07/2023]
Abstract
The purpose of this review is to provide a framework for the cardiovascular evaluation and management of patients undergoing hematopoietic cell transplantation (HCT). To accomplish this, we have performed an extensive literature review, critically analyzed the available evidence, and developed a set of recommendations to guide best practice. Herein, we discuss the cardiovascular risk profile of patients undergoing HCT along with putative mechanisms of HCT-induced cardiovascular injury. We then present an algorithm for cardiovascular testing and risk mitigation of potential recipients. Last, we address the management of the most prevalent cardiovascular conditions associated with HCT recipients.
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Affiliation(s)
- Guilherme H Oliveira
- Heart and Vascular Institute, University of South Florida, Tampa General Hospital and Moffitt Cancer Center, Tampa, FL, USA.
| | - Sadeer G Al-Kindi
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Avirup Guha
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Amit K Dey
- National Heart, Lung and Blood Institute, Bethesda, MD, USA
| | - Isaac B Rhea
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Marcos J deLima
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Stem Cell Transplant Program, Seidman Cancer Center, Cleveland, OH, USA
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8
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Rhea IB, Lyon AR, Fradley MG. Anticoagulation of Cardiovascular Conditions in the Cancer Patient: Review of Old and New Therapies. Curr Oncol Rep 2019; 21:45. [DOI: 10.1007/s11912-019-0797-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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10
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Rhea IB, Morris K, Sawada S, Feigenbaum H. Prevalence, etiology, and clinical implications of reduced longitudinal systolic strain in renal transplant candidates. Echocardiography 2016; 33:1676-1682. [PMID: 27543515 DOI: 10.1111/echo.13307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
AIMS Reduced global longitudinal systolic strain (GLS) is a common finding in end-stage renal disease (ESRD) patients with normal ejection fraction (EF), and GLS is a stronger predictor of mortality than EF. We sought to determine what factors may be responsible for the decreased strain in this population. METHODS AND RESULTS The study group was comprised of 139 renal transplant candidates with a normal EF who had echocardiography with assessment of GLS and basal longitudinal systolic strain (BLS). A GLS of less than -18 and a BLS less than -17 were defined as abnormal. Logistic regression was used to determine variables associated with abnormal GLS and BLS. Of the 139 patients, 49% had abnormal GLS and 70% had abnormal BLS. The univariate predictors of abnormal GLS (P<.05) were low-normal EF, increased interventricular septal thickness (IVS), diabetes, and dihydropyridine calcium channel blocker use. The univariate predictors of abnormal BLS (P<.05) were elevated systolic blood pressure, elevated diastolic blood pressure, elevated heart rate, decreased EF, increased IVS, increased left ventricular posterior wall thickness (LVPW), increased left ventricular mass index, regular dialysis, and clonidine use. On multivariate analysis, low-normal EF (P<.001), increased IVS (P=.024), and diabetes (P=.042) were independent predictors of abnormal GLS, while increased DBP (P=.018), increased LVPW (P=.001), and regular dialysis (P=.006) were independent predictors of abnormal BLS. CONCLUSIONS Clinical variables and co-findings beyond EF are associated with abnormal strain measurements and may partially explain the large incidence of abnormal strain in renal transplant candidates.
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Affiliation(s)
- Isaac B Rhea
- University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Stephen Sawada
- Krannert Institute of Cardiology, IU Health, Indianapolis, Indiana
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Rhea IB, Rehman S, Jarori U, Choudhry MW, Feigenbaum H, Sawada SG. Prognostic utility of blood pressure-adjusted global and basal systolic longitudinal strain. Echo Res Pract 2016; 3:17-24. [PMID: 27249810 PMCID: PMC5323871 DOI: 10.1530/erp-15-0037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/23/2016] [Indexed: 01/19/2023] Open
Abstract
Assessment of global longitudinal systolic strain (GLS) and longitudinal systolic strain of the basal segments (BLS) has shown prognostic value in cardiac disorders. However, strain is reduced with increased afterload. We assessed the prognostic value of GLS and BLS adjusted for afterload. GLS and BLS were determined in 272 subjects with normal ejection fraction and no known coronary disease, or significant valve disease. Systolic blood pressure (SP) and diastolic blood pressure (DP) obtained at the time of echocardiography were used to adjust GLS and BLS as follows: strain×SP (mmHg)/120 mmHg and strain×DP (mmHg)/80 mmHg. Patients were followed for cardiac events and mortality. The mean age was 53±15 years and 53% had hypertension. There were 19 cardiac events and 70 deaths over a mean follow-up of 26±14 months. Cox analysis showed that left ventricular mass index (P=0.001), BLS (P<0.001), and DP-adjusted BLS (P<0.001) were independent predictors of cardiac events. DP-adjusted BLS added incremental value (P<0.001) to the other two predictors and had an area under the curve of 0.838 for events. DP (P=0.001), age (P=0.001), ACE inhibitor use (P=0.017), and SP-adjusted BLS (P=0.012) were independent predictors of mortality. SP-adjusted BLS added incremental value (P=0.014) to the other independent predictors. In conclusion, DP-adjusted BLS and SP-adjusted BLS were independent predictors of cardiac events and mortality, respectively. Blood pressure-adjusted strain added incremental prognostic value to other predictors of outcome.
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Affiliation(s)
- Isaac B Rhea
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Shuja Rehman
- Tulane Heart and Vascular Institute, Tulane University, New Orleans, Louisiana, USA
| | - Upasana Jarori
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana, USA
| | | | - Harvey Feigenbaum
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana, USA
| | - Stephen G Sawada
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana, USA
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Rhea IB, Oliveira GH. Illuminating anthracycline cardiotoxicity: the renaissance of evidence-based onco-cardiology. J Thorac Dis 2015; 7:1111-2. [PMID: 26380724 DOI: 10.3978/j.issn.2072-1439.2015.07.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/09/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Isaac B Rhea
- Department of Medicine and Onco-Cardiology Program, Seidman Cancer Center and Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Guilherme H Oliveira
- Department of Medicine and Onco-Cardiology Program, Seidman Cancer Center and Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Rhea IB, Uppuluri S, Sawada S, Schneider BP, Feigenbaum H. Incremental Prognostic Value of Echocardiographic Strain and Its Association With Mortality in Cancer Patients. J Am Soc Echocardiogr 2015; 28:667-73. [DOI: 10.1016/j.echo.2015.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Indexed: 12/13/2022]
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Yu CC, Corr C, Shen C, Shelton R, Yadava M, Rhea IB, Straka S, Fishbein MC, Chen Z, Lin SF, Lopshire JC, Chen PS. Small conductance calcium-activated potassium current is important in transmural repolarization of failing human ventricles. Circ Arrhythm Electrophysiol 2015; 8:667-76. [PMID: 25908692 DOI: 10.1161/circep.114.002296] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 04/13/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND The transmural distribution of apamin-sensitive small conductance Ca(2+)-activated K(+) (SK) current (IKAS) in failing human ventricles remains unclear. METHODS AND RESULTS We optically mapped left ventricular wedge preparations from 12 failing native hearts and 2 rejected cardiac allografts explanted during transplant surgery. We determined transmural action potential duration (APD) before and after 100 nmol/L apamin administration in all wedges and after sequential administration of apamin, chromanol, and E4031 in 4 wedges. Apamin prolonged APD from 363 ms (95% confidence interval [CI], 341-385) to 409 (95% CI, 385-434; P<0.001) in all hearts, and reduced the transmural conduction velocity from 36 cm/s (95% CI, 30-42) to 32 cm/s (95% CI, 27-37; P=0.001) in 12 native failing hearts at 1000 ms pacing cycle length (PCL). The percent APD prolongation is negatively correlated with baseline APD and positively correlated with PCL. Only 1 wedge had M-cell islands. The percentages of APD prolongation in the last 4 hearts at 2000 ms PCL after apamin, chromanol, and E4031 were 9.1% (95% CI, 3.9-14.2), 17.3% (95% CI, 3.1-31.5), and 35.9% (95% CI, 15.7-56.1), respectively. Immunohistochemical staining of subtype 2 of SK protein showed increased expression in intercalated discs of myocytes. CONCLUSIONS SK current is important in the transmural repolarization in failing human ventricles. The magnitude of IKAS is positively correlated with the PCL, but negatively correlated with APD when PCL is fixed. There is abundant subtype 2 of SK protein in the intercalated discs of myocytes.
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Affiliation(s)
- Chih-Chieh Yu
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Christopher Corr
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Changyu Shen
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Richard Shelton
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Mrinal Yadava
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Isaac B Rhea
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Susan Straka
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Michael C Fishbein
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Zhenhui Chen
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Shien-Fong Lin
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - John C Lopshire
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.)
| | - Peng-Sheng Chen
- From the Department of Medicine, Division of Cardiology, Krannert Institute of Cardiology (C.-C.Y., C.C., R.S., M.Y., I.B.R., S.S., Z.C., S.-F.L., J.C.L., P.-S.C.) and Department of Biostatistics (C.S.), Indiana University School of Medicine, Indianapolis; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (C.-C.Y.); Fairbanks School of Public Health, School of Medicine, Indiana University, Indianapolis (C.S.); Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles (M.C.F.); Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan (S.-F.L.); and Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN (J.C.L.).
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