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De Luca G, Algowhary M, Uguz B, Oliveira DC, Ganyukov V, Zimbakov Z, Cercek M, Okkels Jensen L, Loh PH, Calmac L, Roura I Ferrer G, Quadros A, Milewski M, Scotto Di Uccio F, von Birgelen C, Versaci F, Ten Berg J, Casella G, Wong Sung Lung A, Kala P, Díez Gil JL, Carrillo X, Dirksen M, Becerra-Munoz VM, Kang-Yin Lee M, Juzar DA, de Moura Joaquim R, De Simone C, Milicic D, Davlouros P, Bakraceski N, Zilio F, Donazzan L, Kraaijeveld A, Galasso G, Arpad L, Marinucci L, Guiducci V, Menichelli M, Scoccia A, Yamac AH, Ugur Mert K, Flores Rios X, Kovarnik T, Kidawa M, Moreu J, Flavien V, Fabris E, Lozano Martínez-Luengas I, Boccalatte M, Bosa Ojeda F, Arellano-Serrano C, Caiazzo G, Cirrincione G, Kao HL, Sanchis Forés J, Vignali L, Pereira H, Manzo-Silbermann S, Ordoñez S, Arat Özkan A, Scheller B, Lehtola H, Teles R, Mantis C, Antti Y, Brum Silveira JA, Bessonov I, Zoni R, Savonitto S, Kochiadakis G, Alexopoulos D, Uribe CE, Kanakakis J, Faurie B, Gabrielli G, Gutierrez Barrios A, Bachini JP, Rocha A, Tam FCC, Rodriguez A, Lukito AA, Bellemain-Appaix A, Pessah G, Cortese G, Parodi G, Burgadha MA, Kedhi E, Lamelas P, Suryapranata H, Nardin M, Verdoia M. SARS-CoV-2 Positivity, Stent Thrombosis, and 30-day Mortality in STEMI Patients Undergoing Mechanical Reperfusion. Angiology 2023; 74:987-996. [PMID: 36222189 DOI: 10.1177/00033197221129351] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
SARS-Cov-2 has been suggested to promote thrombotic complications and higher mortality. The aim of the present study was to evaluate the impact of SARS-CoV-2 positivity on in-hospital outcome and 30-day mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) enrolled in the International Survey on Acute Coronary Syndromes ST-segment elevation Myocardial Infarction (ISACS-STEMI COVID-19 registry. The 109 SARS-CoV-2 positive patients were compared with 2005 SARS-CoV-2 negative patients. Positive patients were older (P = .002), less often active smokers (P = .002), and hypercholesterolemic (P = .006), they presented more often later than 12 h (P = .037), more often to the hub and were more often in cardiogenic shock (P = .02), or requiring rescue percutaneous coronary intervention after failed thrombolysis (P < .0001). Lower postprocedural Thrombolysis in Myocardial Infarction 3 flow (P = .029) and more thrombectomy (P = .046) were observed. SARS-CoV-2 was associated with a significantly higher in-hospital mortality (25.7 vs 7%, adjusted Odds Ratio (OR) [95% Confidence Interval] = 3.2 [1.71-5.99], P < .001) in-hospital definite in-stent thrombosis (6.4 vs 1.1%, adjusted Odds Ratio [95% CI] = 6.26 [2.41-16.25], P < .001) and 30-day mortality (34.4 vs 8.5%, adjusted Hazard Ratio [95% CI] = 2.16 [1.45-3.23], P < .001), confirming that SARS-CoV-2 positivity is associated with impaired reperfusion, with negative prognostic consequences.
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Affiliation(s)
- Giuseppe De Luca
- Division of Clinical and Experimental Cardiology, AOU Sassari, Sassari, Italy Division of Cardiology, Ospedale Nuovo Galeazzi, Milan, Italy
| | - Magdy Algowhary
- Division of Cardiology, Assiut University Heart Hospital, Assiut University, Asyut, Egypt
| | - Berat Uguz
- Division of Cardiology, Bursa City Hospital, Bursa, Turkey
| | - Dinaldo C Oliveira
- Pronto de Socorro Cardiologico Prof. Luis Tavares, Centro PROCAPE, Federal University of Pernambuco, Recife, Brasil
| | - Vladimir Ganyukov
- Department of Heart and Vascular Surgery, State Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Zan Zimbakov
- University Clinic for Cardiology, Medical Faculty, Ss' Cyril and Methodius University, Skopje, North Macedonia
| | - Miha Cercek
- Centre for Intensive Internal Medicine, University Medical Centre, Ljubljana, Slovenia
| | | | - Poay Huan Loh
- Department of Cardiology, National University Hospital, Singapore
| | | | - Gerard Roura I Ferrer
- Interventional Cardiology Unit, Heart Disease Institute. Hospital Universitari de Bellvitge, Spain
| | | | - Marek Milewski
- Division of Cardiology, Medical University of Silezia, Katowice, Poland
| | | | - Clemens von Birgelen
- Department of Cardiology, Medisch Spectrum Twente, Thoraxcentrum Twente, Enschede, The Netherlands
- Technical Medical Centre, Health Technologies and Services Research, University of Twente, Enschede, Netherlands
| | | | - Jurrien Ten Berg
- Division of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Gianni Casella
- Division of Cardiology, Ospedale Maggiore Bologna, Italy
| | | | - Petr Kala
- University Hospital Brno, Medical Faculty of Masaryk University Brno, Czech Republic
| | | | | | - Maurits Dirksen
- Division of Cardiology, Northwest Clinics Alkmaar, The Netherlands
| | | | - Michael Kang-Yin Lee
- Department of Cardiology, Queen Elizabeth Hospital, University of Hong Kong, Hong Kong
| | - Dafsah Arifa Juzar
- Department of Cardiology and Vascular Medicine, University of Indonesia National Cardiovascular Center "Harapan Kita", Jakarta
| | | | - Ciro De Simone
- Division of Cardiology, Clinica Villa Dei Fiori, Acerra, Italy
| | - Davor Milicic
- Department of Cardiology, University Hospital Centre, University of Zagreb, Zagreb, Croatia
| | - Periklis Davlouros
- Invasive Cardiology and Congenital Heart Disease, Patras University Hospital, Patras, Greece
| | | | - Filippo Zilio
- Division of Cardiology, Ospedale Santa Chiara di Trento, Italy
| | - Luca Donazzan
- Division of Cardiology, Ospedale "S. Maurizio", Bolzano, Italy
| | | | - Gennaro Galasso
- Division of Cardiology, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | - Lux Arpad
- Maastricht University Medical Center, Utrecht, Netherlands
| | - Lucia Marinucci
- Division of Cardiology, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | | | | | | | - Aylin Hatice Yamac
- Department of Cardiology, Hospital Bezmialem Vakıf University İstanbul, Istanbul, Turkey
| | - Kadir Ugur Mert
- Division of Cardiology, Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir, Turkey
| | | | | | - Michal Kidawa
- Central Hospital of Medical University of Lodz, Poland
| | - Josè Moreu
- Division of Cardiology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Vincent Flavien
- Division of Cardiology, Center Hospitalier Universitaire de Lille, Lille, France
| | - Enrico Fabris
- Azienda Ospedaliero - Universitaria Ospedali Riuniti Trieste, Italy
| | | | - Marco Boccalatte
- Division of Cardiology, Ospedale Santa Maria Delle Grazie, Pozzuoli, Italy
| | - Francisco Bosa Ojeda
- Division of Cardiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife
| | | | | | | | - Hsien-Li Kao
- Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital, Tapei, Taiwan
| | - Juan Sanchis Forés
- Division of Cardiology, Hospital Clinico Universitario de Valencia, Spain
| | - Luigi Vignali
- Interventional Cardiology Unit, Azienda Ospedaliera Sanitaria, Parma, Italy
| | - Helder Pereira
- Hospital Garcia de Orta, Cardiology Department, Pragal, Almada, Portugal
| | | | - Santiago Ordoñez
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Alev Arat Özkan
- Cardiology Institute, Instanbul University, Instanbul, Turkey
| | - Bruno Scheller
- Division of Cardiology, Clinical and Experimental Interventional Cardiology, University of Saarland, Germany
| | - Heidi Lehtola
- Division of Cardiology, Oulu University Hospital, Finland
| | - Rui Teles
- Division of Cardiology, Hospital de Santa Cruz, CHLO - Nova Medical School, CEDOC, Lisbon, Portugal
| | - Christos Mantis
- Division of Cardiology, Konstantopoulion Hospital, Athens, Greece
| | | | | | | | - Rodrigo Zoni
- Department of Teaching and Research, Instituto de Cardiología de Corrientes "Juana F. Cabral", Argentina
| | | | | | | | - Carlos E Uribe
- Carlos E Uribe, Division of Cardiology, Universidad UPB, Universidad CES, Medellin, Colombia
| | - John Kanakakis
- Division of Cardiology, Alexandra Hospital, Athens, Greece
| | - Benjamin Faurie
- Division of Cardiology, Groupe Hospitalier Mutualiste de Grenoble, France
| | - Gabriele Gabrielli
- Interventional Cardiology Unit, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | | | | | - Alex Rocha
- Department of Cardiology and Cardiovascular Interventions, Instituto Nacional de Cirugía Cardíaca, Montevideo, Uruguay
| | | | | | - Antonia Anna Lukito
- Cardiovascular Department Pelita Harapan University/Heart Center Siloam Lippo Village Hospital, Tangerang, Banten, Indonesia
| | | | - Gustavo Pessah
- Division of Cardiology, Hospiatl Cordoba, Cordoba, Argentina
| | | | - Guido Parodi
- Division of Cardiology, Ospedale di Lavagna, Italy
| | | | - Elvin Kedhi
- Division of Cardiology, Hopital Erasmus, Universitè Libre de Bruxelles, Belgium
| | | | - Harry Suryapranata
- Division of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matteo Nardin
- Department of Internal Medicine, Ospedale Riuniti, Brescia, Italy
| | - Monica Verdoia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Italy
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De Luca G, Algowhary M, Uguz B, Oliveira DC, Ganyukov V, Busljetik O, Cercek M, Jensen LO, Loh PH, Calmac L, Ferrer GRI, Quadros A, Milewski M, Scotto D’Uccio F, von Birgelen C, Versaci F, Ten Berg J, Casella G, Wong Sung Lung A, Kala P, Díez Gil JL, Carrillo X, Dirksen M, Becerra Munoz V, Lee MKY, Juzar DA, de Moura Joaquim R, Paladino R, Milicic D, Davlouros P, Bakraceski N, Zilio F, Donazzan L, Kraaijeveld A, Galasso G, Arpad L, Marinucci L, Guiducci V, Menichelli M, Scoccia A, Yamac AH, Ugur Mert K, Flores Rios X, Kovarnik T, Kidawa M, Moreu J, Flavien V, Fabris E, Martínez-Luengas IL, Boccalatte M, Bosa Ojeda F, Arellano-Serrano C, Caiazzo G, Cirrincione G, Kao HL, Sanchis Forés J, Vignali L, Pereira H, Manzo-Silberman S, Ordoñez S, Arat Özkan A, Scheller B, Lehitola H, Teles R, Mantis C, Antti Y, Brum Silveira JA, Zoni CR, Bessonov I, Uccello G, Kochiadakis G, Alexopulos D, Uribe CE, Kanakakis J, Faurie B, Gabrielli G, Gutierrez Barrios A, Bachini JP, Rocha A, Tam FCC, Rodriguez A, Lukito AA, Saint-Joy V, Pessah G, Tuccillo A, Ielasi A, Cortese G, Parodi G, Burgadha MA, Kedhi E, Lamelas P, Suryapranata H, Nardin M, Verdoia M. Age-Related Effects of COVID-19 Pandemic on Mechanical Reperfusion and 30-Day Mortality for STEMI: Results of the ISACS-STEMI COVID-19 Registry. J Clin Med 2023; 12:2116. [PMID: 36983119 PMCID: PMC10059932 DOI: 10.3390/jcm12062116] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND The constraints in the management of patients with ST-segment elevation myocardial infarction (STEMI) during the COVID-19 pandemic have been suggested to have severely impacted mortality levels. The aim of the current analysis is to evaluate the age-related effects of the COVID-19 pandemic on mechanical reperfusion and 30-day mortality for STEMI within the registry ISACS-STEMI COVID-19. METHODS This retrospective multicenter registry was performed in high-volume PPCI centers on four continents and included STEMI patients undergoing PPCI in March-June 2019 and 2020. Patients were divided according to age (< or ≥75 years). The main outcomes were the incidence and timing of PPCI, (ischemia time longer than 12 h and door-to-balloon longer than 30 min), and in-hospital or 30-day mortality. RESULTS We included 16,683 patients undergoing PPCI in 109 centers. In 2020, during the pandemic, there was a significant reduction in PPCI as compared to 2019 (IRR 0.843 (95%-CI: 0.825-0.861, p < 0.0001). We found a significant age-related reduction (7%, p = 0.015), with a larger effect on elderly than on younger patients. Furthermore, we observed significantly higher 30-day mortality during the pandemic period, especially among the elderly (13.6% vs. 17.9%, adjusted HR (95% CI) = 1.55 [1.24-1.93], p < 0.001) as compared to younger patients (4.8% vs. 5.7%; adjusted HR (95% CI) = 1.25 [1.05-1.49], p = 0.013), as a potential consequence of the significantly longer ischemia time observed during the pandemic. CONCLUSIONS The COVID-19 pandemic had a significant impact on the treatment of patients with STEMI, with a 16% reduction in PPCI procedures, with a larger reduction and a longer delay to treatment among elderly patients, which may have contributed to increase in-hospital and 30-day mortality during the pandemic.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, AOU Policlinico G Martino, 98124 Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
- Division of Cardiology, Galeazzi-Sant’Ambrogio Hospital, 20157 Milan, Italy
| | - Magdy Algowhary
- Division of Cardiology, Assiut University Heart Hospital, Assiut University, Asyut 71515, Egypt
| | - Berat Uguz
- Division of Cardiology, Bursa City Hospital, 16110 Bursa, Türkiye
| | - Dinaldo C. Oliveira
- Pronto de Socorro Cardiologico Prof. Luis Tavares, Centro PROCAPE, Federal University of Pernambuco, Recife 1235, Brazil
| | - Vladimir Ganyukov
- Department of Heart and Vascular Surgery, State Research Institute for Complex Issues of Cardiovascular Diseases, 653002 Kemerovo, Russia
| | - Oliver Busljetik
- University Clinic for Cardiology, Medical Faculty, Ss’ Cyril and Methodius University, 1000 Skopje, North Macedonia
| | - Miha Cercek
- Department of Cardiology, Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | | | - Poay Huan Loh
- Department of Cardiology, National University Hospital, Singapore 119074, Singapore
| | - Lucian Calmac
- Clinic Emergency Hospital of Bucharest, 010001 Bucharest, Romania
| | - Gerard Roura i Ferrer
- Interventional Cardiology Unit, Heart Disease Institute, Hospital Universitari de Bellvitge, 08016 Barcelona, Spain
| | - Alexandre Quadros
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre 90000-00, Brazil
| | - Marek Milewski
- Division of Cardiology, Medical University of Silezia, 40-002 Katowice, Poland
| | | | - Clemens von Birgelen
- Department of Cardiology, Medisch Spectrum Twente, Thoraxcentrum Twente, 7541 Enschede, The Netherlands
| | - Francesco Versaci
- Division of Cardiology, Ospedale Santa Maria Goretti Latina, 04100 Latina, Italy
| | - Jurrien Ten Berg
- Division of Cardiology, St Antonius Hospital, 3434 Nieuwegein, The Netherlands
| | - Gianni Casella
- Division of Cardiology, Ospedale Maggiore Bologna, 40100 Bologna, Italy
| | | | - Petr Kala
- University Hospital Brno, Medical Faculty of Masaryk University Brno, 60200 Bohunice, Czech Republic
| | | | | | - Maurits Dirksen
- Division of Cardiology, Northwest Clinics, 1811 Alkmaar, The Netherlands
| | | | - Michael Kang-yin Lee
- Department of Cardiology, Queen Elizabeth Hospital, University of Hong Kong, Hong Kong
| | - Dafsah Arifa Juzar
- Department of Cardiology and Vascular Medicine, University of Indonesia National Cardiovascular Center “Harapan Kita”, Jakarta 11402, Indonesia
| | | | - Roberto Paladino
- Division of Cardiology, Clinica Villa dei Fiori, 80011 Acerra, Italy
| | - Davor Milicic
- Department of Cardiology, University Hospital Centre, University of Zagreb, 10000 Zagreb, Croatia
| | - Periklis Davlouros
- Invasive Cardiology and Congenital Heart Disease, Patras University Hospital, 26221 Patras, Greece
| | | | - Filippo Zilio
- Division of Cardiology, Ospedale Santa Chiara di Trento, 38014 Trento, Italy
| | - Luca Donazzan
- Division of Cardiology, Ospedale ”S. Maurizio”, 39100 Bolzano, Italy
| | | | - Gennaro Galasso
- Division of Cardiology, Ospedale San Giovanni di Dio e Ruggid’Aragona, 84070 Salerno, Italy
| | - Lux Arpad
- Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands
| | - Lucia Marinucci
- Division of Cardiology, Azienda Ospedaliera “Ospedali Riuniti Marche Nord”, 61121 Pesaro, Italy
| | - Vincenzo Guiducci
- Division of Cardiology, AUSL-IRCCS Reggio Emilia, 42121 Reggio Emilia, Italy
| | | | | | - Aylin Hatice Yamac
- Department of Cardiology, Hospital Bezmialem Vakıf University, 34093 Istanbul, Türkiye
| | - Kadir Ugur Mert
- Division of Cardiology, Faculty of Medicine, Eskisehir Osmangazi University, 02640 Eskisehir, Türkiye
| | | | - Tomas Kovarnik
- University Hospital Prague, 12808 Prague, Czech Republic
| | - Michal Kidawa
- Central Hospital, Medical University of Lodz, 90-008 Lodz, Poland
| | - Josè Moreu
- Division of Cardiology, Complejo Hospitalario de Toledo, 45001 Toledo, Spain
| | - Vincent Flavien
- Division of Cardiology, Center Hospitalier Universitaire de Lille, 59000 Lille, France
| | - Enrico Fabris
- Azienda Ospedaliero, Universitaria Ospedali Riuniti Trieste, 34142 Trieste, Italy
| | | | - Marco Boccalatte
- Division of Cardiology, Ospedale Santa Maria delle Grazie, 80078 Pozzuoli, Italy
| | - Francisco Bosa Ojeda
- Division of Cardiology, Hospital Universitario de Canarias, 38001 Santa Cruz de Tenerife, Spain
| | | | - Gianluca Caiazzo
- Division of Cardiology, Ospedale “G Moscati”, 81031 Aversa, Italy
| | | | - Hsien-Li Kao
- Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital, 8865, Taipei 600, Taiwan
| | - Juan Sanchis Forés
- Division of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
| | - Luigi Vignali
- Interventional Cardiology Unit, Azienda Ospedaliera Sanitaria, 43121 Parma, Italy
| | - Helder Pereira
- Cardiology Department, Hospital Garcia de Orta, Pragal, 2805-267 Almada, Portugal
| | - Stephane Manzo-Silberman
- Division of Cardiology, CHU Lariboisière, AP-HP, Paris VII University, INSERM UMRS 942, 75010 Paris, France
| | - Santiago Ordoñez
- Instituto Cardiovascular de Buenos Aires, 6302, Buenos Aires C1428 CABA, Argentina
| | - Alev Arat Özkan
- Cardiology Institute, Instanbul University, 34000 Istanbul, Türkiye
| | - Bruno Scheller
- Division of Cardiology, Clinical and Experimental Interventional Cardiology, University of Saarland, 66421 Saarland, Germany
| | - Heidi Lehitola
- Division of Cardiology, Oulu University Hospital, 90220 Oulu, Finland
| | - Rui Teles
- Division of Cardiology, Hospital de Santa Cruz, CHLO-Nova Medical School, 1000 Lisbon, Portugal
| | - Christos Mantis
- Division of Cardiology, Kontantopoulion Hospital, 10431 Athens, Greece
| | - Ylitalo Antti
- Division of Cardiology, Heart Centre Turku, 20521 Turku, Finland
| | | | - Cesar Rodrigo Zoni
- Department of Teaching and Research, Instituto de Cardiología de Corrientes “Juana F. Cabral”, Corrientes W3400CDS, Argentina
| | - Ivan Bessonov
- Tyumen Cardiology Research Center, 625026 Tyumen, Russia
| | - Giuseppe Uccello
- Division of Cardiology, Ospedale “A. Manzoni”, 23900 Lecco, Italy
| | | | | | - Carlos E. Uribe
- Division of Cardiology, Universidad UPB-CES, Medellin 050001, Colombia
| | - John Kanakakis
- Division of Cardiology, Alexandra Hospital, 10431 Athens, Greece
| | - Benjamin Faurie
- Division of Cardiology, Groupe Hospitalier Mutualiste de Grenoble, 38000 Grenoble, France
| | | | | | | | - Alex Rocha
- Department of Cardiology and Cardiovascular Interventions, Instituto Nacional de Cirugía Cardíaca, Montevideo 11700, Uruguay
| | - Frankie C. C. Tam
- Department of Cardiology, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Alfredo Rodriguez
- Division of Cardiology, Otamendi Hospital, Buenos Aires 1001, Argentina
| | - Antonia Anna Lukito
- Heart Center Siloam Lippo Village Hospital, Cardiovascular Department Pelita Harapan University, Tangerang 15810, Indonesia
| | | | - Gustavo Pessah
- Division of Cardiology, Hospital Cordoba, Cordoba 5000, Argentina
| | - Andrea Tuccillo
- Division of Cardiology, Ospedale del Mare, 80147 Napoli, Italy
| | - Alfonso Ielasi
- Division of Cardiology, Galeazzi-Sant’Ambrogio Hospital, 20157 Milan, Italy
| | - Giuliana Cortese
- Department of Statistical Sciences, University of Padova, 35121 Padova, Italy
| | - Guido Parodi
- Cardiology, Azienda Ospedaliera Lavagna, 16033 Lavagna, Italy
| | | | - Elvin Kedhi
- Division of Cardiology, Hopital Erasmus, Universitè Libre de Bruxelles, 1050 Bruxelles, Belgium
| | - Pablo Lamelas
- Instituto Cardiovascular de Buenos Aires, 6302, Buenos Aires C1428 CABA, Argentina
| | - Harry Suryapranata
- Division of Cardiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands
| | - Matteo Nardin
- Department of Internal Medicine, Ospedale Riuniti, 25121 Brescia, Italy
| | - Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, ASL, 13900 Biella, Italy
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