1
|
Theofilis P, Oikonomou E, Sagris M, Papageorgiou N, Tsioufis K, Tousoulis D. Novel Concepts in the Management of Angina in Coronary Artery Disease. Curr Pharm Des 2023; 29:1825-1834. [PMID: 37183474 DOI: 10.2174/1381612829666230512152153] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 05/16/2023]
Abstract
Coronary artery disease remains a condition with high prevalence and detrimental effects on the quality of life of affected individuals. Its most frequent manifestation, stable angina pectoris, may be challenging to manage despite the available antianginal pharmacotherapy and adequate risk factor control, especially in subjects not amenable to revascularization. In the direction of refractory angina pectoris, several approaches have been developed over the years with varying degrees of success. Among the most recognized techniques in managing angina is enhanced external counterpulsation, which utilizes mechanical compression of the lower extremities to increase blood flow to the heart. Moving to coronary sinus reduction, it leads to an increase in coronary sinus backward pressure, ultimately augmenting myocardial blood flow redistribution to ischemic regions and ameliorating chronic angina. Clinical trial results of the above-mentioned techniques have been encouraging but are based on small sample sizes to justify their widespread application. Other interventional approaches, such as transmyocardial laser revascularization, extracorporeal shockwave myocardial revascularization, and spinal cord stimulation, have been met with either controversial or negative results, and their use is not recommended. Lastly, angiogenic therapy with targeted intramyocardial vascular endothelial growth factor injection or CD34+ cell therapy may be beneficial and warrants further investigation. In this review, we summarize the current knowledge in the field of angina management, highlighting the potential and the gaps in the existing evidence that ought to be addressed in future larger-scale, randomized studies before these techniques can be safely adapted in the clinical practice of patients with refractory angina pectoris.
Collapse
Affiliation(s)
- Panagiotis Theofilis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Cardiology Department, "Sotiria" Chest Diseases Hospital, University of Athens Medical School, Athens, Greece
| | - Marios Sagris
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - Konstantinos Tsioufis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| |
Collapse
|
2
|
Vervaat FE, van der Gaag A, Teeuwen K, van Suijlekom H, Wijnbergen I. Neuromodulation in patients with refractory angina pectoris: a review. Eur Heart J Open 2022; 3:oeac083. [PMID: 36632476 PMCID: PMC9825802 DOI: 10.1093/ehjopen/oeac083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/18/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
The number of patients with coronary artery disease (CAD) who have persisting angina pectoris despite optimal medical treatment known as refractory angina pectoris (RAP) is growing. Current estimates indicate that 5-10% of patients with stable CAD have RAP. In absolute numbers, there are 50 000-100 000 new cases of RAP each year in the USA and 30 000-50 000 new cases each year in Europe. The term RAP was formulated in 2002. RAP is defined as a chronic disease (more than 3 months) characterized by diffuse CAD in the presence of proven ischaemia which is not amendable to a combination of medical therapy, angioplasty, or coronary bypass surgery. There are currently few treatment options for patients with RAP. One such last-resort treatment option is spinal cord stimulation (SCS) with a Class of recommendation IIB, level of evidence B in the 2019 European Society of Cardiology guidelines for the diagnosis and management of chronic coronary syndromes. The aim of this review is to give an overview of neuromodulation as treatment modality for patients with RAP. A comprehensive overview is given on the history, proposed mechanism of action, safety, efficacy, and current use of SCS.
Collapse
Affiliation(s)
| | - Antal van der Gaag
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Koen Teeuwen
- Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - Hans van Suijlekom
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, the Netherlands
| | | |
Collapse
|
3
|
Wu E, Mårtensson J, Desta L, Broström A. Adverse events and their management during enhanced external counterpulsation treatment in patients with refractory angina pectoris: observations from a routine clinical practice. Eur J Cardiovasc Nurs 2021; 21:152-160. [PMID: 34002207 DOI: 10.1093/eurjcn/zvab040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/28/2022]
Abstract
AIMS Enhanced external counterpulsation (EECP) is a non-invasive treatment (35 one-hour sessions) for patients with refractory angina pectoris (RAP). To avoid interruption of treatment, more knowledge is needed about potential adverse events (AE) of EECP and their appropriate management. To describe occurrence of AE and clinical actions related to EECP treatment in patients with RAP and compare the distribution of AE between responders and non-responders to treatment. METHODS AND RESULTS A retrospective study was conducted by reviewing medical records of 119 patients with RAP who had undergone one EECP treatment and a 6-min-walk test pre- and post-treatment. Sociodemographic, medical, and clinical data related to EECP were collected from patients' medical records. An increased walking distance by 10% post-treatment, measured by 6-min-walk test, was considered a responder. The treatment completion rate was high, and the occurrence of AE was low. Adverse events occurred more often in the beginning and gradually decreased towards the end of EECP treatment. The AE were either device related (e.g. muscle pain/soreness) or non-device related (e.g. bradycardia). Medical (e.g. medication adjustments) and/or nursing (e.g. extra padding around the calves, wound dressing) actions were used. The AE distribution did not differ between responders (n = 49, 41.2%) and non-responders. Skin lesion/blister occurred mostly in responders and paraesthesia occurred mostly in non-responders. CONCLUSION Enhanced external counterpulsation appears to be a safe and well-tolerated treatment option in patients with RAP. However, nurses should be attentive and flexible to meet their patients' needs to prevent AE and early termination of treatment.
Collapse
Affiliation(s)
- Eline Wu
- Heart and Vascular Theme, Karolinska University Hospital, Karolinska University Hospital, Hälsovägen, SE 141 86 Stockholm, Sweden, SE-141 86 Stockholm, Sweden
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Jan Mårtensson
- Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Liyew Desta
- Heart and Vascular Theme, Karolinska University Hospital, Karolinska University Hospital, Hälsovägen, SE 141 86 Stockholm, Sweden, SE-141 86 Stockholm, Sweden
- Division of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anders Broström
- Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
| |
Collapse
|
4
|
Corre J, Douard H, Ronchard T. Cardiac rehabilitation with intermittent myocardial ischaemia as a new therapeutic option in refractory angina? ESC Heart Fail 2021; 8:2316-2319. [PMID: 33792203 PMCID: PMC8120403 DOI: 10.1002/ehf2.13335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 12/17/2022] Open
Abstract
A 72-year-old man daily suffered from a refractory angina consecutive to a diffuse coronary artery disease despite optimal medical management. Revascularization could not be performed because of a severe thrombopenia. He was referred to our outpatient cardiac rehabilitation programme where he was candidate for 20 sessions, three times a week, of high-intensity aerobic interval training involving brief episodes of regressive myocardial ischaemia. After 7 weeks, exercise capacity (+28.5%), VO2 peak (35.7%), and ischaemic threshold increased while clinical status and quality of life improved. No adverse effect was reported. Aerobic interval training with myocardial ischaemia might be a therapeutic alternative in refractory angina.
Collapse
Affiliation(s)
- Jerome Corre
- Hôpital cardiologique Haut-Lévêque, Bordeaux University Hospital, Avenue de Magellan, Pessac, 33600, France.,Department of Cardiology, Felix Guyon Hospital, La Reunion University Hospital, Saint-Denis, Réunion, France
| | - Herve Douard
- Hôpital cardiologique Haut-Lévêque, Bordeaux University Hospital, Avenue de Magellan, Pessac, 33600, France
| | - Thibault Ronchard
- Department of Cardiology, Felix Guyon Hospital, La Reunion University Hospital, Saint-Denis, Réunion, France
| |
Collapse
|
5
|
Abstract
The article discusses pharmacologic and interventional therapeutic options for patients with refractory angina. Refractory angina refers to long-lasting symptoms (≥3 months) due to established reversible ischemia in the presence of obstructive coronary artery disease, which cannot be controlled by escalating medical therapy with second-line and third-line pharmacologic agents, bypass grafting, or stenting. Due to an aging population, increased number of comorbidities, and advances in coronary artery disease treatment, incidence of refractory angina is growing. Although the number of therapeutic options is increasing, there is a lack of randomized clinical trials that could help create recommendations for this group of patients.
Collapse
Affiliation(s)
- Marcin Makowski
- Department of Interventional Cardiology, Medical University of Lodz, Central Clinical Hospital, ul. Pomorska 251, Lodz 92-213, Poland.
| | | | - Marzenna Zielińska
- Department of Interventional Cardiology, Medical University of Lodz, Central Clinical Hospital, ul. Pomorska 251, Lodz 92-213, Poland
| |
Collapse
|
6
|
Vervaat FE, van der Gaag A, van Suijlekom H, Botman CJ, Teeuwen K, Wijnbergen I. Improvement in quality of life and angina pectoris: 1-year follow-up of patients with refractory angina pectoris and spinal cord stimulation. Neth Heart J 2020; 28:478-84. [PMID: 32430654 DOI: 10.1007/s12471-020-01422-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aims Spinal cord stimulation (SCS) is a treatment for patients with refractory angina pectoris (RAP) who remain symptomatic despite optimal medical therapy and without revascularisation options. Previous studies have shown that SCS improves the quality of life in this patient group and reduces the severity of the angina pectoris. The aim of this prospective, single-arm observational study is to show this effect in a single-centre cohort using a multidisciplinary team approach to the selection process, with a follow-up period of 1 year. Methods and results Between July 2010 and March 2017, 87 patients with RAP referred to our centre received SCS. The Seattle Angina Questionnaire (SAQ) and RAND 36-Item Health Survey (RAND-36) were completed at baseline, prior to implantation, and 1 year post-implantation. After 1 year of follow-up there was a statistically significant decrease in the frequency of angina pectoris attacks from more than 4 times a day to 1–2 times a week (p < 0.001). The SAQ showed statistically significant improvement in four of the five dimensions: physical limitation (p < 0.001), angina frequency (p < 0.001), angina stability (p < 0.001) and quality of life (p < 0.001). The RAND-36 showed statistically significant improvement in all nine dimensions: physical functioning (p = 0.001), role/physical (p < 0.001), social functioning (p = 0.03), role/emotional (p < 0.05), bodily pain (p < 0.001), general health (p < 0.001), vitality (p < 0.001), mental health (p = 0.02) and health change (p < 0.001). Conclusion This study showed a significant improvement in quality of life and reduction of angina pectoris severity after 1 year of follow-up in patients treated with SCS for RAP. Electronic supplementary material The online version of this article (10.1007/s12471-020-01422-0) contains supplementary material, which is available to authorized users.
Collapse
|
7
|
Ceccon CL, Duque AS, Gowdak LH, Mathias W Jr, Chiang HP, Sbano JCN, Lima MF, Machado Cesar LA, Cruz CBBV, Dourado PMM, Meneghetti C, Tsutsui JM. Shock-Wave Therapy Improves Myocardial Blood Flow Reserve in Patients with Refractory Angina: Evaluation by Real-Time Myocardial Perfusion Echocardiography. J Am Soc Echocardiogr 2019; 32:1075-85. [PMID: 31235421 DOI: 10.1016/j.echo.2019.04.420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/31/2019] [Accepted: 04/09/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Cardiac shock-wave therapy (CSWT) has been demonstrated as an option for the treatment of patients with refractory angina (RA), promoting immediate vasodilatory effects and, in the long-term, neoangiogenic effects that would be responsible for reducing the myocardial ischemic load. The aim of this study was to determine the effects of CSWT on myocardial blood flow reserve (MBFR) assessed by quantitative real-time myocardial perfusion echocardiography in patients with RA. METHODS Fifteen patients (mean age 61.5 ± 12.8 years) with RA who underwent CSWT during nine sessions, over 3 months of treatment, were prospectively studied. A total of 32 myocardial segments with ischemia were treated, while another 31 did not receive therapy because of technical limitations. Myocardial perfusion was evaluated at rest and after dipyridamole stress (0.84 mg/kg) before and 6 months after CSWT, using quantitative real-time myocardial perfusion echocardiography. Clinical effects were evaluated using Canadian Cardiovascular Society grading of angina and the Seattle Angina Questionnaire. RESULTS The ischemic segments treated with CSWT had increased MBFR (from 1.33 ± 0.22 to 1.74 ± 0.29, P < .001), a benefit that was not observed in untreated ischemic segments (1.51 ± 0.29 vs 1.54 ± 0.28, P = .47). Patients demonstrated increased global MBFR (from 1.78 ± 0.54 to 1.89 ± 0.49, P = .017). Semiquantitative single-photon emission computed tomographic analysis of the treated ischemic segments revealed a score reduction from 2.10 ± 0.87 to 1.68 ± 1.19 (P = .024). There was improvement in Canadian Cardiovascular Society score (from 3.20 ± 0.56 to 1.93 ± 0.70, P < .05) and in Seattle Angina Questionnaire score (from 42.3 ± 12.99 to 71.2 ± 14.29, P < .05). No major cardiovascular events were recorded during follow-up. CONCLUSIONS CSWT improved MBFR in ischemic segments, as demonstrated by quantitative real-time myocardial perfusion echocardiography. These results suggest that CSWT has the potential to increase myocardial blood flow, with an impact on symptoms and quality of life in patients with RA.
Collapse
|
8
|
Kikuchi Y, Ito K, Shindo T, Hao K, Shiroto T, Matsumoto Y, Takahashi J, Matsubara T, Yamada A, Ozaki Y, Hiroe M, Misumi K, Ota H, Takanami K, Hiraide T, Takase K, Tanji F, Tomata Y, Tsuji I, Shimokawa H. A multicenter trial of extracorporeal cardiac shock wave therapy for refractory angina pectoris: report of the highly advanced medical treatment in Japan. Heart Vessels 2018; 34:104-113. [PMID: 29942978 DOI: 10.1007/s00380-018-1215-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 03/16/2018] [Accepted: 06/22/2018] [Indexed: 01/09/2023]
Abstract
We have previously demonstrated that cardiac shock wave therapy (CSWT) effectively improves myocardial ischemia through coronary neovascularization both in a porcine model of chronic myocardial ischemia and in patients with refractory angina pectoris (AP). In this study, we further addressed the efficacy and safety of CSWT in a single-arm multicenter study approved as a highly advanced medical treatment by the Japanese Ministry of Health, Labour and Welfare. Fifty patients with refractory AP [mean age 70.9 ± 12.6 (SD) years, M/F 38/12] without the indications of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were enrolled in 4 institutes in Japan. Ischemic myocardial regions in the left ventricle (LV) were identified by drug-induced stress myocardial perfusion imaging (MPI). Shock waves (200 shots/spot at 0.09 mJ/mm2) were applied to 40-60 spots in the ischemic myocardium 3 times in the first week. The patients were followed up for 3 months thereafter. Forty-one patients underwent CSWT and completed the follow-up at 3 months. CSWT markedly improved weekly nitroglycerin use [from 3.5 (IQR 2 to 6) to 0 (IQR 0 to 1)] and the symptoms [Canadian Cardiovascular Society functional class score, from 2 (IQR 2 to 3) to 1 (IQR 1 to 2)] (both P < 0.001). CSWT also significantly improved 6-min walking distance (from 384 ± 91 to 435 ± 122 m, P < 0.05). There were no significant changes in LV ejection fraction evaluated by echocardiography and LV stroke volume evaluated by cardiac magnetic resonance imaging (from 56.3 ± 14.7 to 58.8 ± 12.8%, P = 0.10, and from 52.3 ± 17.4 to 55.6 ± 15.7 mL, P = 0.15, respectively). Percent myocardium ischemia assessed by drug-induced stress MPI tended to be improved only in the treated segments (from 16.0 ± 11.1 to 12.1 ± 16.2%, P = 0.06), although no change was noted in the whole LV. No procedural complications or adverse effects related to the CSWT were noted. These results of the multicenter trial further indicate that CSWT is a useful and safe non-invasive strategy for patients with refractory AP with no options of PCI or CABG.
Collapse
Affiliation(s)
- Yoku Kikuchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenta Ito
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyotaka Hao
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takao Matsubara
- Department of Cardiovascular Medicine, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Akira Yamada
- Department of Cardiovascular Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Yukio Ozaki
- Department of Cardiovascular Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Michiaki Hiroe
- Department of Cardiovascular Medicine, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Kazuo Misumi
- Department of Cardiovascular Medicine, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Hideki Ota
- Department of Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kentaro Takanami
- Department of Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomomichi Hiraide
- Department of Radiology, Miyagi Cardiovascular and Respiratory Center, Kurihara, Japan
| | - Kei Takase
- Department of Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiya Tanji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Yasutake Tomata
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| |
Collapse
|
9
|
Slikkerveer J, de Boer K, Robbers LFHJ, van Rossum AC, Kamp O. Evaluation of extracorporeal shock wave therapy for refractory angina pectoris with quantitative analysis using cardiac magnetic resonance imaging: a short communication. Neth Heart J 2016; 24:319-25. [PMID: 27059621 PMCID: PMC4840110 DOI: 10.1007/s12471-016-0825-7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Aims There is a continuing search for new treatment options in patients who suffer from refractory angina pectoris to improve quality of life. Several studies have recently demonstrated promising results by stimulating angiogenesis using extracorporeal shockwave therapy in these patients. The purpose of this study is to quantitatively analyse the effect of extracorporeal shockwave therapy on myocardial perfusion in patients with refractory angina pectoris. Methods We included 15 patients with NYHA class 3–4 of whom 8 patients underwent baseline and follow-up cardiac magnetic resonance imaging (CMR). All patients received 9 shockwave treatments of their ischaemic zone over a period of 3 months. Results Quantitative analysis of myocardial perfusion using CMR revealed no significant improvement of myocardial perfusion after treatment (0.80 ± 0.22 vs 0.76 ± 0.31; p = 0.42). However, the total group of 15 patients did experience a significant improvement in NYHA class (p = 0.034) and reduction of nitroglycerin use (p = 0.012). Conclusion Although treatment with extracorporeal shockwave was associated with an improvement in NYHA class, we could not observe an improvement in myocardial ischaemic zone and perfusion with CMR. To unravel the exact mechanisms of shockwave treatment, more in vitro and animal studies as well as larger (placebo-controlled) studies are required.
Collapse
Affiliation(s)
- J Slikkerveer
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands.
- Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands.
| | - K de Boer
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
| | - L F H J Robbers
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
- Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - A C van Rossum
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
| | - O Kamp
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
| |
Collapse
|