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1. Diagnostic Yield of Comprehensive Coronary Function Testing in Patients with Angina and Unobstructed Coronary Arteries: Endotype Characterisation and Clinical Implications

Author: Johanna McChord, Astrid Hubert, Raffi Bekeredjian, Peter Ong, and Andreas Seitz
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Background: Coronary functional disorders (CFD) are significant contributors to angina with non-obstructed coronary arteries (ANOCA). Various endotypes, such as epicardial or microvascular spasm and/or coronary microvascular dysfunction (CMD), have been identified. Previous studies have shown a high prevalence of CFD in ANOCA cases, but often lacked comprehensive coronary functional testing (CFT), which ideally includes coronary spasm provocation testing and CMD assessment. This study aims to investigate the prevalence of CFD and to characterise endotypes in ANOCA patients using comprehensive CFT. Methods: A total of 89 consecutive ANOCA patients (mean age 64, 69% women) who underwent comprehensive CFT were enrolled. CFT comprised acetylcholine (ACh) spasm provocation testing and assessment of coronary flow reserve (CFR) and hyperaemic microvascular resistance using Doppler technique. Results: CFT identified at least one coronary vasomotion disorder in 91% of patients with ANOCA. Among them, microvascular spasm was the most common endotype (61%), followed by CMD (43%). Only 9% of patients had isolated CMD with the remaining CMD patients also showing coronary spasm. Low CFR was mainly associated with high resting coronary flow rather than impaired hyperaemic flow (R −0.60, p
Published: 2024
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2. Bridging the Gender Gap in Cardiovascular Medicine: Addressing Drug Intolerances and Personalized Care for Women with Angina/Ischemia with Non-Obstructive Coronary Artery Disease

Author: Johanna McChord and Peter Ong
Subjects: gender medicine, sex-based differences, non-obstructive coronary artery disease, ANOCA, INOCA, coronary microvascular dysfunction, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Gender medicine has increasingly underscored the necessity of addressing sex-based differences in disease prevalence and management, particularly within cardiovascular conditions and drug intolerance. Women often present cardiovascular diseases distinctively from men, with a higher prevalence of non-obstructive coronary artery disease and varied ischemic manifestations, such as coronary microvascular dysfunction and epicardial or microvascular coronary spasm. This disparity is further exacerbated by elevated drug intolerance rates among women, influenced by hormonal, genetic, and psychosocial factors. The 2024 ESC guidelines for managing chronic coronary syndromes stress the need for personalized approaches to treat angina and ischemia with non-obstructive coronary artery disease (ANOCA/INOCA), recommending a combination of antianginal medications. Despite standard treatments, up to 40% of ANOCA/INOCA patients experience refractory angina, necessitating a multifaceted approach that often involves multiple antianginal drugs, which can increase the likelihood of drug intolerances. Future research should focus on including women in drug studies and addressing sex-specific differences, while healthcare providers must be equipped to manage gender-specific drug intolerances. Enhanced awareness, individualized treatment strategies, and gender-sensitive healthcare policies are crucial for improving outcomes and bridging the gender gap in cardiovascular medicine.
Published: 2024
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3. The Evolution of Coronary Artery Spasm: How the Pendulum Has Swung

Author: John F Beltrame, Peter Ong, and Filippo Crea
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Published: 2023
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4. Drug repurposing—a promising approach for patients with angina but non-obstructive coronary artery disease (ANOCA)

Author: Johanna McChord, Valeria Martínez Pereyra, Sarah Froebel, Raffi Bekeredjian, Matthias Schwab, and Peter Ong
Subjects: drug repurposing, sGC stimulators, ET-1 receptor blockers, refractory angina, ANOCA, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: In today’s era of individualized precision medicine drug repurposing represents a promising approach to offer patients fast access to novel treatments. Apart from drug repurposing in cancer treatments, cardiovascular pharmacology is another attractive field for this approach. Patients with angina pectoris without obstructive coronary artery disease (ANOCA) report refractory angina despite standard medications in up to 40% of cases. Drug repurposing also appears to be an auspicious option for this indication. From a pathophysiological point of view ANOCA patients frequently suffer from vasomotor disorders such as coronary spasm and/or impaired microvascular vasodilatation. Consequently, we carefully screened the literature and identified two potential therapeutic targets: the blockade of the endothelin-1 (ET-1) receptor and the stimulation of soluble guanylate cyclase (sGC). Genetically increased endothelin expression results in elevated levels of ET-1, justifying ET-1 receptor blockers as drug candidates to treat coronary spasm. sGC stimulators may be beneficial as they stimulate the NO-sGC-cGMP pathway leading to GMP-mediated vasodilatation.
Published: 2023
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5. Coronary Spasm: Ethnic and Sex Differences

Author: Peter Ong, Astrid Hubert, Maike Schwidder, and John F Beltrame
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Coronary spasm (CS), which may occur at the epicardial (focal or diffuse spasm) and/or microvascular (microvascular spasm) level, is a well-established cause of myocardial ischaemia, in particular in patients with anginal chest pain despite unobstructed coronary arteries. The diagnosis of CS can be confirmed during coronary angiography by an additional provocation test with vasoactive substances such as acetylcholine. Due to partially inconsistent data from large clinical studies, especially between Asian and white CS patients, ethnic differences concerning the prevalence and angiographic patterns of CS seem to exist. Furthermore, several studies in patients with coronary vasomotor disorders pointed towards differences among male and female CS patients. This article gives an overview of ethnic- and sex-related differences in patients with CS.
Published: 2023
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6. Usefulness of wearable electrocardiography devices in patients experiencing paroxysmal cardiac-related symptoms: A case series of the 'CardioSecur' system

Author: Johanna McChord, Cathrin Theis, Sarah Fröbel, Andreas Seitz, Udo Sechtem, Raffi Bekeredjian, and Peter Ong
Subjects: Mobile ECG, Wearable ECG, Telemedicine, Artificial intelligence-enhanced ECG, Coronary vasomotion disorder, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Background: Electrocardiograms (ECGs) recorded with wearable devices and additional smartphone apps play an increasing role in cardiology. Case summaries: We present two cases in which it was possible to record an ECG during cardiac-related symptoms using the patients' smartphones. Previous standard resting and 24-hour ECGs had revealed no pathologies. In one case, AV nodal reentry tachycardia was detected and treated accordingly. In the second case, ischemic ECG changes were recorded in a young woman without cardiovascular risk factors during a chest pain episode. Suspecting a coronary vasomotion disorder, an invasive diagnostic procedure was performed. The acetylcholine spasm provocation test revealed coronary microvascular spasm and appropriate therapy was initiated. Discussion: Smartphone-based ECG systems which can be used by the patient independently while experiencing cardiac-related symptoms are a modern diagnostic tool. Considering the use of these systems is beneficial for early diagnosis and appropriate treatment for paroxysmal arrhythmias and coronary vasomotion disorders.
Published: 2023
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7. Successful TAVI Despite Sudden Low Output and Ventricular Fibrillation in a Patient with Cardiac Amyloidosis

Author: Peter Ong, Stephan Hill, Dominik Bierbaum, Nathalie Geiger, Christian Wunder, Ulrich Franke, Samir Ahad, and Raffi Bekeredjian
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Management of patients with cardiac amyloidosis and concomitant high-grade aortic stenosis is challenging. Here, we report the case of a 79-year-old man with transcatheter aortic valve implantation (TAVI) complicated by low cardiac output during release of a Medtronic Evolut R 34 mm valve. After initiation of mechanical circulatory support, the TAVI valve was successfully implanted despite ongoing ventricular fibrillation. The ventricular fibrillation was successfully treated with injection of potassium into the aorta, with subsequent defibrillation and ventricular pacing. Moreover, pharmacological management of transient severe LV dysfunction and high-grade mitral regurgitation finally led to a favourable course.
Published: 2023
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8. Meta-analysis and systematic review of coronary vasospasm in ANOCA patients: Prevalence, clinical features and prognosis

Author: Janneke Woudstra, Caitlin E. M. Vink, Diantha J. M. Schipaanboord, Etto C. Eringa, Hester M. den Ruijter, Rutger G. T. Feenstra, Coen K. M. Boerhout, Marcel A. M. Beijk, Guus A. de Waard, Peter Ong, Andreas Seitz, Udo Sechtem, Jan J. Piek, Tim P. van de Hoef, and Yolande Appelman
Subjects: coronary vasospasm, ANOCA, acetylcholine provocation test, sex, microcirculation, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: BackgroundCoronary artery spasm (CAS), encompassing epicardial and microvascular spasm, is increasingly recognized as cause of angina in patients with non-obstructive coronary artery disease (ANOCA). However, various spasm provocation testing protocols and diagnostic criteria are used, making diagnosis and characterization of these patients difficult and interpretation of study results cumbersome. This review provides a structured overview of the prevalence, characterization and prognosis of CAS worldwide in men and women.MethodsA systematic review identifying studies describing ANOCA patients with CAS was performed. Multiple outcomes (prevalence, clinical features, and prognosis) were assessed. Data, except for prognosis were pooled and analysed using random effects meta-analysis models.ResultsTwenty-five publications (N = 14.554) were included (58.2 years; 44.2% women). Percentages of epicardial constriction to define epicardial spasm ranged from >50% to >90%. Epicardial spasm was prevalent in 43% (range 16–73%), with a higher prevalence in Asian vs. Western World population (52% vs. 33%, p = 0.014). Microvascular spasm was prevalent in 25% (range 7–39%). Men were more likely to have epicardial spasm (61%), women were more likely to have microvascular spasm (64%). Recurrent angina is frequently reported during follow-up ranging from 10 to 53%.ConclusionCAS is highly prevalent in ANOCA patients, where men more often have epicardial spasm, women more often have microvascular spasm. A higher prevalence of epicardial spasm is demonstrated in the Asian population compared to the Western World. The prevalence of CAS is high, emphasizing the use of unambiguous study protocols and diagnostic criteria and highlights the importance of routine evaluation of CAS in men and women with ANOCA.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272100.
Published: 2023
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9. CMR findings in patients referred for suspected myocarditis following mRNA-based COVID vaccination compared with pre-COVID myocarditis referrals: A single-centre observational study

Author: Andreas Seitz, Claire Rogers, Georgios Moutzoukis, Lisa Oberli, Peter Ong, Raffi Bekeredjian, and Heiko Mahrholdt
Subjects: Myocarditis, COVID, Vaccination, mRNA, Cardiac magnetic resonance, Mapping, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Background: Vaccination is considered the key to overcome the COVID pandemic. For the first time mRNA-based vaccinations are used in humans. Case series suggested an increased risk of myocarditis after vaccination. This study sought to describe CMR findings in patients with suspected mRNA-vaccine associated myocarditis. Methods: A total of 33 consecutive patients referred for CMR work-up of suspected myocarditis associated with mRNA-based vaccination were included. A historical cohort of 135 consecutive patients referred for suspected myocarditis in the pre-COVID era served as control group. All patients underwent multi-parametric CMR including CINE and late gadolinium enhancement (LGE) imaging as well as parametric T1/T2 mapping of the left ventricular myocardium. Results: Patients referred for suspected vaccination-related myocarditis were more often female (55 % vs 32 %, p = 0.015) and demonstrated smaller LV dimensions as well as a better LV function compared to patients of the control group. CMR revealed a lower prevalence of non-ischemic LGE in patients with suspected vaccination-myocarditis (6 % vs 22 %, p = 0.04). However, among patients without LGE we observed a higher prevalence of an abnormal T1/T2 mapping result in patients with suspected vaccination-myocarditis compared to the control group (45 % vs 18 %, p = 0.010). Conclusion: In this small single-centre study, compared to myocarditis referrals in the pre-COVID era, patients currently referred for CMR work-up of suspected mRNA-vaccination-associated myocarditis demonstrated lower prevalence of LGE but higher prevalence of abnormal T1/T2 mapping. These hypothesis-generating observations may point towards a rather subtle myocardial damage and support the routine use of T1/T2 mapping in this indication.
Published: 2022
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10. Prognostic association of plasma NT-proBNP levels in patients with microvascular angina -A report from the international cohort study by COVADIS

Author: Akira Suda, Jun Takahashi, Maike Schwidder, Peter Ong, Daniel Ang, Colin Berry, Paolo G. Camici, Filippo Crea, Juan Carlos Kaski, Carl Pepine, Ornella Rimoldi, Udo Sechtem, Satoshi Yasuda, John F. Beltrame, C. Noel Bairey Merz, and Hiroaki Shimokawa
Subjects: Microvascular angina, Brain natriuretic peptides, NT-proBNP, Prognosis, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: BackgroudThe aim of this study was to assess the prognostic association of plasma levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) with clinical outcomes of patients with microvascular angina (MVA). Methods: In this international prospective cohort study of MVA by the Coronary Vasomotor Disorders International Study (COVADIS) group, we examined the association between plasma NT-proBNP levels and the incidence of major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina. Results: We examined a total of 226 MVA patients (M/F 66/160, 61.9 ± 10.2 [SD] yrs.) with both plasma NT-proBNP levels and echocardiography data available at the time of enrolment. The median level of NT-proBNP level was 94 pg/ml, while mean left ventricular ejection fraction was 69.2 ± 10.9 % and E/e’ 10.7 ± 5.2. During follow-up period of a median of 365 days (IQR 365–482), 29 MACEs occurred. Receiver-operating characteristics curve analysis identified plasma NT-proBNP level of 78 pg/ml as the optimal cut-off value. Multivariable logistic regression analysis revealed that plasma NT-proBNP level ≥ 78 pg/ml significantly correlated with the incidence of MACE (odds ratio (OR) [95 % confidence interval (CI)] 3.11[1.14–8.49], P = 0.001). Accordingly, Kaplan-Meier survival analysis showed a significantly worse prognosis in the group with NT-proBNP ≥ 78 (log-rank test, P
Published: 2022
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11. European Society of Cardiology Highlights: Late-breaking Science MINOCA/ANOCA

Author: Peter Ong and Andreas Seitz
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Published: 2022
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12. Structural or Functional Coronary Artery Disease? Acetylcholine Testing Reveals Epicardial Spasm After Multiple Myocardial RevascularizationsNovel Teaching Points

Author: Sarah Froebel, PhD, Johanna McChord, MD, Valeria Martínez-Pereyra, MSc, Raffi Bekeredjian, MD, and Peter Ong, MD
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Published: 2021
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13. Repurposing Riociguat for Treatment of Refractory Angina Resulting From Coronary Spasm

Author: Valeria Martínez Pereyra, MS, Andreas Seitz, MD, Astrid Hubert, PhD, Sascha Beck, MS, Ute Hofmann, PhD, Matthias Schwab, MD, Raffi Bekeredjian, MD, Udo Sechtem, MD, and Peter Ong, MD
Subjects: acetylcholine testing, coronary artery spasm, drug repurposing, individual treatment trial, microvascular dysfunction, riociguat, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Coronary spasm is a frequent cause of angina despite unobstructed coronary arteries, and symptom control with recommended drugs is limited. We report the case of a 77-year-old woman who had refractory angina despite conventional antianginal treatment. Repurposing riociguat, a soluble guanylate cyclase stimulator, resulted in improvement of symptoms and prevention of spasm. (Level of Difficulty: Intermediate.)
Published: 2021
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14. Prevention of epicardial coronary artery spasm with intracoronary nitroglycerine during acetylcholine testing in a female patient with resting angina—implications for optimal pharmacological management

Author: Valeria Martínez Pereyra, Andreas Seitz, Udo Sechtem, and Peter Ong
Subjects: acetylcholine testing, angina pectoris, coronary artery spasm, nitrogylcerin, rechallenge, Medicine, Medicine (General), R5-920
Abstract: Abstract We here present the case of a 55‐year old woman who presented with recurrent angina at rest followed by presyncopal attacks and nausea to our clinic. Her only cardiovascular risk factor was arterial hypertension. High‐sensitive troponin T was 3 pg/ml (n
Published: 2022
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15. Definitions and Epidemiology of Coronary Functional Abnormalities

Author: Andreas Seitz, Johanna McChord, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Coronary functional abnormalities are frequent causes of angina pectoris, particularly in patients with unobstructed coronary arteries. There is a spectrum of endotypes of functional coronary abnormalities with different mechanisms of pathology including enhanced vasoconstriction (i.e. coronary artery spasm) or impaired vasodilatation, such as impaired coronary flow reserve or increased microvascular resistance. These vasomotor abnormalities can affect various compartments of the coronary circulation such as the epicardial conduit arteries and/or the coronary microcirculation. Unequivocal categorisation and nomenclature of the broad spectrum of disease endotypes is crucial both in clinical practice as well as in clinical trials. This article describes the definitions of coronary functional abnormalities with currently accepted cut-off values, as well as diagnostic methods to identify and distinguish endotypes. The authors also provide a summary of contemporary data on the prevalence of the different endotypes of coronary functional abnormalities and their coexistence.
Published: 2021
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16. Insights to advance our management of myocardial ischemia: From obstructive epicardial disease to functional coronary alterations

Author: C. Noel Bairey Merz, John F. Beltrame, Colin Berry, William E. Boden, Paolo G. Camici, Filippo Crea, Judith S. Hochman, Juan Carlos Kaski, Patrick T. O'Gara, Peter Ong, Carl J. Pepine, Hiroaki Shimokawa, Udo Sechtem, and Gregg W. Stone
Subjects: Coronary artery disease, Coronary microvascular dysfunction, Microvascular angina, Myocardial ischemia with no obstructive CAD (INOCA), Vasospastic angina, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Study objective: The Coronary Vasomotor Disorders International Study Group (COVADIS) invited leading experts to address strategies to enhance our clinical understanding of INOCA with an emphasis on the management of coronary vasomotor disorders. Design: Under-recognition of coronary vasomotor disorders, distinguishing different presentations of angina due to vasospasm and/or abnormal microvascular vasodilatation, developing invasive/non-invasive testing and treatment protocols, integrating diagnostic protocols into cardiologists' workflow and trials to inform guideline development were identified as key knowledge gaps and will be briefly addressed in this Viewpoint article. Setting: Virtual international meeting. Participants: Leading international experts in ischemic heart disease with no obstructive coronary artery disease. Interventions: None. Main outcome measures: None. Results: Topics discussed include: 1. Obstructive epicardial disease, functional vasospasm and microvascular disorders; 2. Under-recognition of coronary vasomotor disorders in clinical practice; 3. Complexity of coronary vasomotor disorders; 4. Understanding different presentations - vasospastic disease and microvascular angina; 5. Invasive/noninvasive testing and treatment protocols for vasospasm and microvascular angina assessment; 6. Treatment challenges; 7. Integrating diagnostic protocols into cardiologists' workflow; 8. The path forward to advance our approach to managing myocardial ischemia. Conclusions: Obstructive epicardial disease, functional vasospasm and microvascular disorders often co-exist and contribute to myocardial ischemia. Under-recognition, the complexity of coronary vasomotor disorders, understanding different presentations, testing and treatment protocols, treatment challenges, and integrating diagnostic protocols into cardiologists' workflow all contribute to the path forward to advance our management of myocardial ischemia for improved patient outcomes.
Published: 2021
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17. Coronary Microvascular Spasm as the Underlying Cause of the Angiographic Slow Flow Phenomenon

Author: Valeria Martínez Pereyra, MSc, Andreas Seitz, MD, Astrid Hubert, PhD, Heiko Mahrholdt, MD, Raffi Bekeredjian, MD, Udo Sechtem, MD, and Peter Ong, MD
Subjects: coronary flow, coronary microvascular spasm, coronary vasomotor disorders, microvascular dysfunction, slow coronary flow, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Slow coronary flow is frequently seen during angiography in patients with angina and unobstructed coronary arteries. However, the pathophysiology of this finding remains largely unclear. We report a case of a 52-year-old woman with slow coronary flow caused by acetylcholine-induced microvascular spasm, as confirmed by intracoronary flow measurements. (Level of Difficulty: Beginner.)
Published: 2020
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18. Invasive Diagnosis of Coronary Functional Disorders Causing Angina Pectoris

Author: Sascha Beck, Valeria Martínez Pereyra, Andreas Seitz, Johanna McChord, Astrid Hubert, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Coronary vasomotion disorders represent a frequent cause of angina and/or dyspnoea in patients with non-obstructed coronary arteries. The highly sophisticated interplay of vasodilatation and vasoconstriction can be assessed in an interventional diagnostic procedure. Established parameters characterising adequate vasodilatation are coronary blood flow at rest, and, after drug-induced vasodilation, coronary flow reserve, and microvascular resistance (hyperaemic microvascular resistance, index of microcirculatory resistance). An increased vasoconstrictive potential is diagnosed by provocation testing with acetylcholine or ergonovine. This enables a diagnosis of coronary epicardial and/or microvascular spasm. Ischaemia associated with microvascular spasm can be confirmed by ischaemic ECG changes and the measurement of lactate concentrations in the coronary sinus. Although interventional diagnostic procedures are helpful for determining the mechanism of the angina, which may be the key to successful medical treatment, they are still neither widely accepted nor applied in many medical centres. This article summarises currently well-established invasive methods for the diagnosis of coronary functional disorders causing angina pectoris.
Published: 2021
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19. Optimal Prognostication of Patients with Coronary Stenoses in the Pre- and Post-PCI setting: Comments on TARGET FFR and DEFINE-FLOW Trials Presented at TCT Connect 2020

Author: Andreas Seitz, Stefan Baumann, Udo Sechtem, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: The body of evidence for the use of coronary physiology assessments to guide percutaneous coronary intervention (PCI) has been growing continuously in recent decades. Two studies presented during TCT Connect 2020 added insights into the prognostic value of coronary physiology measurements in pre- and post-PCI settings. The first study, TARGET FFR, assessed whether a post-PCI fractional flow reserve (FFR)-guided incremental optimisation strategy (PIOS) was superior to angiography-guided PCI. The second study, DEFINE-FLOW, assessed the course of stenoses with fractional and coronary flow reserve (FFR+/CFR−) discordance when treated medically. This article summarises the main results from the TARGET FFR and the DEFINE-FLOW trials and puts them into the context of the existing literature.
Published: 2021
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20. Coronary microvascular dysfunction in patients with mild-to-moderate aortic stenosis – Insights from intracoronary acetylcholine testing

Author: Valeria Martínez Pereyra, Andreas Seitz, Heiko Mahrholdt, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Subjects: Aortic stenosis, Coronary microvascular dysfunction, Coronary microvascular spasm, Coronary vasomotion, Acetylcholine testing, Shortness of breath, Diseases of the circulatory (Cardiovascular) system, RC666-701
Published: 2020
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21. International prospective cohort study of microvascular angina – Rationale and design

Author: Akira Suda, Jun Takahashi, John F. Beltrame, Colin Berry, Paolo G. Camici, Filippo Crea, Javier Escaned, Tom Ford, Juan Carlos Kaski, Takahiko Kiyooka, Puja K. Metha, Peter Ong, Yukio Ozaki, Carl Pepine, Ornella Rimoldi, Basmah Safdar, Udo Sechtem, Kenichi Tsujita, Eric Yii, C. Noel Bairey Merz, and Hiroaki Shimokawa
Subjects: Coronary microvascular dysfunction, Microvascular angina, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Background: Patients with signs and symptoms of myocardial ischemia and non-obstructive coronary artery disease (CAD) frequently have coronary functional abnormalities, including coronary microvascular dysfunction. Those with the latter are grouped under the term “microvascular angina” (MVA). Although diagnostic criteria exist for MVA, as recently proposed by our COVADIS (COronary VAsomotor Disorders International Study) group and the condition has been increasingly recognized in clinical practice, the clinical characteristics and long-term prognosis of MVA patients in the current era remain to be fully elucidated. Aims: In the present study, we aimed to prospectively assess the clinical characteristics and long-term prognosis of MVA subjects in the current era in an international, multicenter, observational, and prospective registry study. Methods: A total of 15 medical centers across 7 countries (USA, UK, Germany, Spain, Italy, Australia, and Japan) enrolled subjects fulfilling the COVADIS diagnostic criteria for MVA as follows; (1) signs and/or symptoms of myocardial ischemia, (2) absence of obstructive CAD, and (3) objective evidence of myocardial ischemia and/or coronary microvascular dysfunction. The primary endpoint was the composite of major cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, hospitalization due to heart failure or unstable angina. Between July 2015 and December 2018, a total of 706 subjects with MVA (M/F 256/450, 61.1 ± 11.8 [SD] yrs.) were registered. Subjects will be followed for at least 1 year. Summary: The present study will provide important information regarding the clinical characteristics, management, and long-term prognosis of MVA patients in the current era.
Published: 2020
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22. Predictors of Mortality in Patients With Biopsy‐Proven Viral Myocarditis: 10‐Year Outcome Data

Author: Simon Greulich, Andreas Seitz, Karin A. L. Müller, Stefan Grün, Peter Ong, Nawid Ebadi, Klaus Peter Kreisselmeier, Peter Seizer, Raffi Bekeredjian, Carolin Zwadlo, Christoph Gräni, Karin Klingel, Meinrad Gawaz, Udo Sechtem, and Heiko Mahrholdt
Subjects: biopsy, cardiovascular magnetic resonance, late gadolinium enhancement, mortality, myocarditis, viral, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Background There is scarce data about the long‐term mortality as well as the prognostic value of cardiovascular magnetic resonance and late gadolinium enhancement (LGE) in patients with biopsy‐proven viral myocarditis. We sought to investigate: (1) mortality and (2) prognostic value of LGEcardiovascular magnetic resonance (location, pattern, extent, and distribution) in a >10‐year follow‐up in patients with biopsy‐proven myocarditis. Methods and Results Two‐hundred three consecutive patients with biopsy‐proven viral myocarditis and cardiovascular magnetic resonance were enrolled; 183 patients were eligible for standardized follow‐up. The median follow‐up was 10.1 years. End points were all‐cause death, cardiac death, and sudden cardiac death (SCD). We found substantial long‐term mortality in patients with biopsy‐proven myocarditis (39.3% all cause, 27.3% cardiac, and 10.9% SCD); 101 patients (55.2%) demonstrated LGE. The presence of LGE was associated with a more than a doubled risk of death (hazard ratio [HR], 2.40; 95% CI], 1.30–4.43), escalating to a HR of 3.00 (95% CI, 1.41–6.42) for cardiac death, and a HR of 14.79 (95% CI, 1.95–112.00) for SCD; all P≤0.009. Specifically, midwall, (antero‐) septal LGE, and extent of LGE were highly associated with death, all P
Published: 2020
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23. Coronary Artery Spasm: The Interplay Between Endothelial Dysfunction and Vascular Smooth Muscle Cell Hyperreactivity

Author: Astrid Hubert, Andreas Seitz, Valeria Martínez Pereyra, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: Patients with angina pectoris, the cardinal symptom of myocardial ischaemia, yet without significant flow-limiting epicardial artery stenosis represent a diagnostic and therapeutic challenge. Coronary artery spasm (CAS) is an established cause for anginal chest pain in patients with angiographically unobstructed coronary arteries. CAS may occur at the epicardial level and/or in the microvasculature. Although the underlying pathophysiological mechanisms of CAS are still largely unclear, endothelial dysfunction and vascular smooth muscle cell (VSMC) hyperreactivity seem to be involved as major players, although their contribution to induce CAS is still seen as controversial. This article will look at the role and possible mechanistic interplay between an impaired endothelial and VSMC function in the pathogenesis of CAS.
Published: 2020
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24. Does Coronary Microvascular Spasm Exist? Objective Evidence from Intracoronary Doppler Flow Measurements During Acetylcholine Testing

Author: Fabian Guenther, Andreas Seitz, Valeria Martínez Pereyra, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: A 43-year-old woman with recurrent atypical angina underwent invasive coronary angiography including intracoronary Doppler blood flow assessment and coronary spasm provocation testing. While obstructive epicardial disease could be ruled-out angiographically, the patient experienced reproduction of her angina symptoms after intracoronary administration of acetylcholine (100 µg) during spasm provocation testing. Simultaneously, the ECG showed new-onset ST-segment depression in the absence of epicardial spasm. In addition, coronary flow velocity was significantly reduced after acetylcholine compared to the baseline condition. Following intracoronary administration of nitroglycerine (200 µg), the patient’s symptoms as well as the ECG changes and coronary flow reduction were reversed. Considering the ongoing challenges in appropriate evaluation of the pathophysiological mechanisms of coronary microvascular dysfunction, simultaneous intracoronary Doppler flow measurement during spasm testing – as shown in this case – may provide objective evidence for microvascular spasm in addition to the standardized diagnostic criteria, especially if they are ambiguous.
Published: 2020
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25. Giant Aneurysm of a Coronary-Pulmonary Artery Fistula: A Rare Cause of a Diastolic Murmur

Author: Andreas Seitz, Sophie Schäfer, Maik Backes, Heiko Mahrholdt, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract: A coronary-pulmonary artery fistula with giant aneurysmal dilatation is an extremely rare clinical constellation. The natural course of this disease and the incidence of complications are unknown. Hence, optimal treatment, particularly in asymptomatic patients, is still a matter of debate. Here we report a case of a 71-year-old asymptomatic woman with a diastolic murmur. Comprehensive cardiovascular assessments including cardiac computed tomography and invasive coronary angiography revealed a coronary-pulmonary artery fistula with giant aneurysmal dilatation. The patient was managed conservatively and has now been followed up for 5 years without any events.
Published: 2019
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26. Persisting Angina after Successful Surgical Removal of a Large Coronary Artery Aneurysm Attached to the Proximal Portion of the Left Circumflex Artery: Role of Coronary Artery Spasm

Author: Udo Sechtem, Peter Ong, Adrian Ursulescu, Anastasios Athanasiadis, and Bahar Sayin
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Published: 2018
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27. Occlusive Spasm of the Left Anterior Descending Artery and First Diagonal Branch After Implantation of Everolimus Eluting Stents Without Re-stenosis in a Female Patient with Resting Angina

Author: Giancarlo Pirozzolo, Anastasios Athanasiadis, Udo Sechtem, and Peter Ong
Subjects: Diseases of the circulatory (Cardiovascular) system, RC666-701
Published: 2017
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28. Evaluating the Impact of Drug Dispensing Systems on the Safety and Efficiency in a Singapore Outpatient Pharmacy

Author: Peter Ong Yong Sheng, Chen Li Li, Wong Jane Ai, Yeyen Gunawan, Goh Wei Jiang, Tan Mui Chai, and Lee Soo Boon
Subjects: automation, robot, machine, automated drug picking, pharmacy automation, Pharmacy and materia medica, RS1-441
Abstract: Purpose: Automation of pharmacy workflow can reduce medication errors as well as improve efficiency of the medication picking, packing and labeling process. Since September 2012, two drug dispensing systems (DDS) began operations in the Singapore General Hospital Specialist Outpatient Clinic Pharmacy. This study sought to evaluate the impact of the DDS on safety and efficiency in the pharmacy. Methods: The primary outcome was the rate of prevented dispensing incidents contributed by DDS or manual picking of medications defined as the number of prevented dispensing incidents per 1000 medications picked. The secondary outcome was the productivity of each full time equivalent (FTE) when assigned to either the DDS or manual picking stations. Data pertaining to the primary and secondary outcomes between January and December 2013 were collected and analyzed. The rate of prevented dispensing incidents was expressed in median (interquartile range) and compared using Mann-Whitney U test. Other continuous variables were expressed in mean ± standard deviation and compared using independent samples t-test. Results: An average of 59494 medications was picked every month in the pharmacy. DDS accounted for 21.1 percent while manual picking accounted for 78.9 percent of all the medications picked. The median rate of prevented dispensing incidents per month committed by manual picking (2.73) was significantly higher than the DDS (0.00). DDS had greater productivity with each FTE in the DDS having an average of 6175 picks per month which was significantly higher than each FTE in the manual picking stations which had an average of 4867 picks per month. Conclusion: Installation of DDS in an outpatient pharmacy improved safety of the pharmacy workflow by automating the medication picking, packing and labeling process and minimizing human errors. Efficiency of the medication picking, packing and labeling process was also improved by the DDS as there were continuous efforts to boost their productivity as well as being more reliable and better able to handle fluctuations in patient load. Type: Original Research
Published: 2014
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29. Use of pharmacology in the diagnosis and management of vasomotor and microcirculation disorders

Author: Johanna McChord and Peter Ong
Subjects: Cardiology and Cardiovascular Medicine
Published: 2023
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30. Klinische und prozedurale Charakteristika von Patienten mit akutem Koronarsyndrom während der COVID-19-Pandemie 2020 im Vergleich zu einer Kontrollgruppe aus 2019

Author: Peter Ong, Stefanie Schäfer, Louisa Karagülle-Dörrenhaus, Clara Rau, Sarah Fröbel, Sebastian Spaich, and Raffi Bekeredjian
Subjects: General Medicine
Abstract: Zusammenfassung Hintergrund Während der COVID-19-Pandemie wurden ärztliche Behandlungen abgesagt und notfallmäßige Behandlungen aus Angst vor einer Ansteckung mit Sars-CoV-2 hinausgezögert. Letzteres betraf auch Patienten mit akutem Koronarsyndrom. Eine detaillierte Beschreibung dieser Patienten in Bezug auf das Management im Herzkatheterlabor ist bislang aber noch nicht erfolgt. Methoden Retrospektive Querschnittsstudie mit Erfassung aller Patienten, die wegen eines akuten Koronarsyndroms (STEMI, NSTEMI, instabile Angina) einer Herzkatheteruntersuchung vom 01.03.2019–30.06.2019 (Gruppe A) sowie vom 01.03.2020–30.06.2020 (Gruppe B) unterzogen wurden. Demografische Faktoren, kardiovaskuläre Risikofaktoren sowie prozedurale Daten (z.B. Ausmaß der KHK, klinische Diagnose, Revaskularisationsstrategie und -ergebnis, Einsatz eines Herzunterstützungssystems, Door-to-Needle-Time, In-hospital-Mortalität) wurden verglichen. Ergebnisse 469 Patienten wurden in die Studie eingeschlossen (Gruppe A 239, Gruppe B 230 Patienten, mittleres Alter 69 Jahre, 71% männlich). Verglichen mit Gruppe A zeigten sich bei Gruppe B weniger Patienten mit STEMI und instabiler Angina pectoris (p=0,033), dafür mehr Patienten mit NSTEMI (p=0,047). Patienten in der Gruppe B hatten seltener eine koronare Eingefäßerkrankung (p=0,001), dafür wiesen diese häufiger eine koronare Dreigefäßerkrankung als in der Gruppe A auf (p=0,052). Schlussfolgerung Trotz vergleichbarer Gesamtzahlen wurden Patienten mit akutem Koronarsyndrom während der COVID-19-Pandemie im Vergleich zu einer Kontrollgruppe häufiger mit NSTEMI aufgenommen und hatten ein größeres Ausmaß der KHK.
Published: 2022
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31. Epicardial atherosclerosis and coronary tortuosity in patients with acetylcholine-induced coronary spasm

Author: Johanna, McChord, Robert, Gollwitzer, Andreas, Seitz, Udo, Sechtem, Raffi, Bekeredjian, and Peter, Ong
Subjects: Humans, Female, General Medicine, Cardiology and Cardiovascular Medicine, Acetylcholine
Abstract: Angina pectoris in the absence of relevant epicardial stenoses is frequently caused by coronary spasm. This mechanism of angina is common yet underdiagnosed in daily clinical practice. The pathophysiology of coronary spasm is complex, multifactorial, and not completely understood. The purpose of this study was to analyze the relationship between macroscopic coronary morphologies and coronary spasm.Epicardial atherosclerosis, coronary vessel tortuosity, coronary aneurysms, and myocardial bridges were analyzed angiographically in 610 patients and a potential association with the result of an intracoronary acetylcholine (ACh) provocation test was investigated.The comparison showed that angiographic morphologic variations in the coronary arteries are related to the occurrence of coronary spasm. We observed a strong association between the presence of epicardial atherosclerosis and epicardial spasm [87 patients of 179 with epicardial spasm had epicardial atherosclerosis (49%) vs. 45 patients of 172 with microvascular spasm (26%) vs. 89 patients of 259 with negative/inconclusive ACh test (36%); P0.005]. Moreover, we found a higher frequency of coronary tortuosity in patients with microvascular spasm [99 patients of 172 with microvascular spasm had at least moderate coronary tortuosity (58%) vs. 76 patients of 179 with epicardial spasm (43%) vs. 126 patients of 259 with negative/inconclusive ACh test (49%); P = 0.017]. Multivariable analysis revealed epicardial atherosclerosis (50% stenosis) on coronary angiography as a predictor for epicardial spasm (OR, 2.096; 95% CI, 1.467-2.995; P0.0005). Female sex (OR, 5.469; 95% CI, 3.433-8.713; P0.0005), and exertional angina (OR, 2.411; 95% CI, 1.597-3.639; P0.0005) were predictors of microvascular spasm in multivariable analysis.In angina patients with no obstructive coronary artery disease, epicardial atherosclerosis is associated with ACh-induced epicardial coronary spasm. Moreover, coronary microvascular spasm is more prevalent in female patients and those with exertional angina. Our results provide insights into the relationship between coronary morphology and coronary vasomotor function.
Published: 2022
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32. Management des chronischen Koronarsyndroms

Author: Udo Sechtem, Andreas Seitz, Peter Ong, and Raffi Bekeredjian
Subjects: Cardiology and Cardiovascular Medicine
Published: 2022
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33. Epicardial and microvascular coronary artery spasm in biopsy-proven viral myocarditis

Author: Andreas, Seitz, Valeria, Martínez Pereyra, Astrid, Hubert, Karin, Klingel, Raffi, Bekeredjian, Udo, Sechtem, and Peter, Ong
Subjects: Adult, Male, Chest Pain, Spasm, Biopsy, Coronary Vasospasm, Stroke Volume, Middle Aged, Coronary Angiography, Coronary Vessels, Acetylcholine, Ventricular Function, Left, Myocarditis, Young Adult, Virus Diseases, Humans, Female, Cardiology and Cardiovascular Medicine, Aged
Abstract: Coronary spasm has been suggested to be the underlying mechanism of chest pain in patients with myocarditis and unobstructed coronary arteries. Here we sought to investigate a potential association between virus type and coronary spasm endotype in patients with biopsy-proven viral myocarditis.A total of 618 consecutive patients with unobstructed coronary arteries who underwent endomyocardial biopsy between 2008 and 2018 were screened. Viral myocarditis defined as (immuno-)histological evidence of myocardial inflammation and proof of viral genome by PCR was confirmed in 114 patients. Of these, 34 patients had undergone additional intracoronary acetylcholine (ACh) testing and served as the final study cohort.Patients in this study were 51 ± 27 years old, 41% were female and mean left ventricular ejection fraction was 58 ± 23%. Most frequently, virus DNA was detected by PCR from parvovirus B19 (PVB19, 59%) and human herpesvirus 6 (HHV6, 26%). ACh testing revealed epicardial spasm in 10 patients (29%) and microvascular spasm in 11 patients (32%). The rate of coronary spasm was higher in patients with PVB19-associated myocarditis compared to those with HHV6-associated myocarditis (80% vs. 33%, p = 0.031). In particular, there was a higher prevalence of microvascular spasm in patients with PVB19 compared to HHV6 infection (45% vs. 0%, p = 0.018).Coronary spasm is a frequent finding in patients with biopsy-proven viral myocarditis supporting the hypothesis that coronary spasm may contribute to chest pain in these patients. We observed a particular association of microvascular spasm with PVB19 infection.
Published: 2022
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34. Characterization and implications of intracoronary hemodynamic assessment during coronary spasm provocation testing

Author: Andreas Seitz, Valeria Martínez Pereyra, Sarah Froebel, Astrid Hubert, Johanna McChord, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Subjects: General Medicine, Cardiology and Cardiovascular Medicine
Published: 2023
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35. Management of patients with ST-segment myocardial infarction and multivessel disease: what are the options in 2022?

Author: Peter, Ong, Valeria, Martínez Pereyra, Udo, Sechtem, and Raffi, Bekeredjian
Subjects: Percutaneous Coronary Intervention, Treatment Outcome, Myocardial Infarction, Humans, ST Elevation Myocardial Infarction, Coronary Artery Disease, General Medicine, Cardiology and Cardiovascular Medicine
Abstract: Multivessel coronary disease is a frequent finding in patients with STEMI. However, choosing the optimal treatment strategy for these patients can be challenging. The benefit of complete versus culprit-vessel-only revascularization demonstrated by several studies led to a change in the current 2018 ESC/EACTS revascularization guidelines recommending treatment of nonculprit lesions before hospital discharge. This article summarizes current data in this area, looks at remaining knowledge gaps and gives an outlook regarding ongoing trials. The latter will provide further robust evidence for the optimal management of patients with STEMI and multivessel disease.
Published: 2022
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36. Therapieoptionen bei Patienten mit Angina pectoris infolge koronarer Vasomotionsstörungen

Author: Corinna Kroll, Astrid Hubert, Sarah Fröbel, Andreas Seitz, Johanna McChord, Raffi Bekeredjian, Udo Sechtem, and Peter Ong
Published: 2022
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37. Principles and pitfalls in coronary vasomotor function testing

Author: Robbert J. de Winter, Peter Ong, Laura Bukkems, Patty Teeuwisse, Marcel A.M. Beijk, Udo Sechtem, Rutger Feenstra, Tim van der Hoef, Andreas Seitz, Coen Boerhout, Jan J. Piek, Valérie E. Stegehuis, Cardiology, Graduate School, ACS - Amsterdam Cardiovascular Sciences, Pharmacy, Other Research, ACS - Atherosclerosis & ischemic syndromes, ACS - Microcirculation, ACS - Heart failure & arrhythmias, and VU University medical center
Subjects: Endotype, medicine.medical_specialty, stable angina, adjunctive pharmacotherapy, Functional testing, Coronary Artery Disease, Coronary Angiography, Angina Pectoris, Coronary artery disease, Angina, Clinical Research, Humans, Medicine, Intensive care medicine, Protocol (science), Vasomotor function, integumentary system, ACS/NSTE-ACS, business.industry, Heart, medicine.disease, Coronary Vessels, miscellaneous, Discontinuation, Vasomotor System, cardiovascular system, Thermodilution technique, Cardiology and Cardiovascular Medicine, business, circulatory and respiratory physiology
Abstract: BACKGROUND Coronary vasomotor dysfunction can be diagnosed in a large proportion of patients with angina in the presence of non-obstructive coronary artery disease (ANOCA) using comprehensive protocols for coronary vasomotor function testing. Although consensus on diagnostic criteria for endotypes of coronary vasomotor dysfunction have been published, consensus on a standardised study testing protocol is lacking. AIMS In this review we provide an overview of the variations in coronary vasomotor function testing used and discuss the practical principles and pitfalls of coronary vasomotor function testing. METHODS For the purpose of this review we assessed study protocols that evaluate coronary vasomotor response as reported in the literature. We compared these protocols regarding a number of procedural aspects and chose six examples to highlight the differences and uniqueness. RESULTS Currently, numerous protocols co-exist and vary in vascular domains tested, the manner to test these domains (e.g. pre-procedural discontinuation of medication, provocative agent, solution, infusion time, and target artery) and techniques used for measurements (e.g. doppler vs thermodilution technique). CONCLUSIONS This lack of consensus on a uniform functional testing protocol hampers both a broader clinical acceptance of the concepts of coronary vasomotor dysfunction, and the widespread adoption of such testing protocols in current clinical practice. Furthermore, the endotype of coronary vasomotor dysfunction might differ between the few specialised centres that perform coronary vasomotor function testing as a result of the use of different protocols. In this review we provide an overview of the variations in coronary vasomotor function testing used and discuss the practical principles and pitfalls of coronary vasomotor function testing.
Published: 2022
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38. Ist die weibliche koronare Mikrovaskulatur anders?

Author: Udo Sechtem, Andreas Seitz, Johanna McChord, and Peter Ong
Subjects: General Medicine
Abstract: ZusammenfassungViele Frauen mit Angina pectoris haben keine stenosierende koronare Herzerkrankung. Oft liegen der Symptomatik koronare Funktionsstörungen zugrunde, die wiederum häufig die koronare Mikrovaskulatur betreffen. Zu unterscheiden ist zwischen mikrovaskulären Störungen der Vasodilatation bzw. der Vasokonstriktion, wobei letztere häufiger sind. Die genaue Diagnose erfordert in aller Regel invasive Funktionstests mit Applikation von Adenosin bzw. Acetylcholin. Die Testergebnisse erlauben die Einteilung in Endotypen, die wiederum die Basis für eine angepasste und daher erfolgreiche medikamentöse Therapie sind. Es wurde spekuliert, dass die weibliche Mikrovaskulatur anders aufgebaut sein bzw. anders funktionieren könne als die männliche. Wahrscheinlich ist der wesentliche Unterschied aber die schnellere und daher frühere Entwicklung epikardialer stenosierender Läsionen bei Männern, bei denen dann nicht weiter nach dem Zustand der Mikrovaskulatur geschaut wird. Dafür spricht die hohe Zahl von Patienten, die auch nach Koronarintervention weiter Angina pectoris haben.
Published: 2022
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39. Is Sciencific evidence but in the eye of the beholder?

Author: Udo Sechtem, Andreas Seitz, and Peter Ong
Subjects: Cardiology and Cardiovascular Medicine
Published: 2023
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40. Acetylcholine Rechallenge

Author: Andreas Seitz, Rutger G.T. Feenstra, Regina E. Konst, Valeria Martínez Pereyra, Sascha Beck, Marcel A.M. Beijk, Tim P. van de Hoef, Niels van Royen, Raffi Bekeredjian, Udo Sechtem, Peter Damman, Jan J. Piek, and Peter Ong
Subjects: Cardiology and Cardiovascular Medicine
Published: 2022
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41. Coronary artery spasm and impaired myocardial perfusion in patients with ANOCA: Predictors from a multimodality study using stress CMR and acetylcholine testing

Author: Heiko Mahrholdt, Astrid Hubert, Peter Ong, Valeria Martínez Pereyra, Udo Sechtem, Giancarlo Pirozzolo, Andreas Seitz, Raffi Bekeredjian, and Fabian Guenther
Subjects: Spasm, medicine.medical_specialty, Vasodilator Agents, Coronary Angiography, Angina, Coronary circulation, Percutaneous Coronary Intervention, Coronary Circulation, Internal medicine, otorhinolaryngologic diseases, medicine, Humans, cardiovascular diseases, Myocardial infarction, Ejection fraction, business.industry, medicine.disease, Coronary Vessels, Acetylcholine, nervous system diseases, Perfusion, body regions, Coronary arteries, stomatognathic diseases, medicine.anatomical_structure, Conventional PCI, Cardiology, Female, Cardiology and Cardiovascular Medicine, business, Artery
Abstract: Background Functional coronary disorders such as coronary spasm and microvascular dysfunction (including microvascular spasm and impaired microvascular dilatation) are frequent findings among patients with angina and non-obstructed coronary arteries (ANOCA). In this study, we investigated a potential association of coronary spasm and myocardial perfusion abnormalities as well as predictors of such functional coronary disorders in ANOCA patients using a multimodality diagnostic strategy including adenosine stress CMR and intracoronary acetylcholine testing. Methods We enrolled 129 patients with ANOCA who underwent acetylcholine testing and adenosine stress perfusion CMR. Patients were allocated to 3 groups according to their spasm testing result with regard to standardized COVADIS criteria: 1) epicardial spasm, 2) microvascular spasm, and 3) no spasm. The myocardial perfusion reserve index (MPRI) was semiquantitatively determined from adenosine stress perfusion CMR. Multivariate regression analyses were performed to identify predictors of coronary functional disorders. Results Patients with epicardial spasm had lower MPRI than patients without, whereas MPRI was preserved in patients with microvascular spasm. Multivariate analyses revealed age, previous myocardial infarction, LVEF and epicardial spasm as independent predictors of diminished MPRI, whereas previous PCI was associated with epicardial spasm, and female sex was a strong predictor of microvascular spasm. Conclusions Our results demonstrate coexistence of different functional coronary disorder endotypes involving the macro- and microvascular level of the coronary circulation in patients with ANOCA. We demonstrate that epicardial spasm is associated with diminished myocardial perfusion reserve and report further predictors of coronary functional disorders.
Published: 2021
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42. Coronary computed tomographic angiography as gatekeeper for new-onset stable angina

Author: C. K. M. Boerhout, G. A. Somsen, Jan J. Piek, L. Hofstra, Peter Ong, Rutger Feenstra, Marcel A.M. Beijk, T. P. van de Hoef, and Yolande Appelman
Subjects: education.field_of_study, medicine.medical_specialty, business.industry, Functional testing, Population, Chronic coronary syndromes, Coronary computed tomographic angiography, medicine.disease, Stable angina, Coronary artery disease, New onset, Computed tomographic angiography, Angina, Nonobstructive coronary artery disease, Internal medicine, Opinion Paper, Cardiology, Medicine, In patient, Cardiology and Cardiovascular Medicine, business, education, Gatekeeper
Abstract: Patients with new-onset stable angina constitute a substantial part of the population seen by cardiologists. Currently, the diagnostic workup of these patients depends on the pre-test probability of having obstructive coronary artery disease. It consists of either functional testing for myocardial ischaemia or anatomical testing by using coronary computed tomographic angiography (CCTA) or invasive coronary angiography. In case the pre-test probability is > 5%, the current guidelines for the management of chronic coronary syndromes do not state a clear preference for one of the noninvasive techniques. However, based on the recently published cost-effectiveness analysis of the PROMISE trial and considering the diagnostic yield in patients with angina and nonobstructive coronary artery disease, we argue a more prominent role for CCTA as a gatekeeper for patients with new-onset stable angina.
Published: 2021
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43. Invasive Assessments For Coronary Vasomotor Disorders: Current State of the Art Methods Collection

Author: Andreas Seitz, Colin Berry, and Peter Ong
Subjects: General Immunology and Microbiology, General Chemical Engineering, General Neuroscience, General Biochemistry, Genetics and Molecular Biology
Published: 2023
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44. Reference values for intracoronary Doppler flow velocity-derived hyperaemic microvascular resistance index

Author: Rutger G T, Feenstra, Andreas, Seitz, Coen K M, Boerhout, Robbert J, de Winter, Peter, Ong, Marcel A M, Beijk, Jan J, Piek, Udo, Sechtem, Tim P, van de Hoef, Cardiology, VU University medical center, Graduate School, ACS - Atherosclerosis & ischemic syndromes, ACS - Amsterdam Cardiovascular Sciences, and ACS - Microcirculation
Subjects: Microcirculation, Hyperemia, Angina, Coronary Angiography, Hyperaemic microvascular resistance, Coronary Vessels, Angina Pectoris, Coronary Circulation, Humans, Vascular Resistance, Coronary vasomotor dysfunction, Non-obstructive coronary artery disease, Cardiology and Cardiovascular Medicine, Blood Flow Velocity, Reference value
Abstract: Background: Invasive assessments of microvascular function are rapidly becoming an integral part of physiological assessment in chronic coronary syndromes. Objective: We aimed to establish a reference range for Doppler flow velocity-derived hyperaemic microvascular resistance index (HMR) in a cohort of angina with no significant epicardial coronary obstruction (ANOCA) patients with no structural pathophysiological alterations in the coronary circulation. Methods: The reference population consisted of ANOCA patients undergoing invasive coronary vasomotor function assessment who had a coronary flow reserve (CFR) >2.5, and had either (1) tested negatively for spasm provocation (n = 12) or (2) tested positively with only angina at rest (n = 29). A reference range for HMR was established using a non-parametric method and correlations with clinical characteristics were determined using a spearman rank correlation analysis. Results: In 41 patients median HMR amounted to 1.6 mmHg/cm/s [Q1, Q3: 1.3, 2.2 mmHg/cm/s]. The reference range for HMR that is applicable to 95% of the population was 0.8 mmHg/cm/s (90% CI: 0.8–1.0 mmHg/cm/s) to 2.7 mmHg/cm/s (90% CI: 2.6–2.7 mmHg/cm/s). No significant correlations were found between HMR and clinical characteristics. Conclusion: In this reference population undergoing invasive coronary vasomotor function testing, the 90% confidence interval of the HMR upper limit of normal ranges from 2.6 to 2.7 mmHg/cm/s. A > 2.5 mmHg/cm/s HMR threshold can be used to identify abnormal microvascular resistance in daily clinical practice.
Published: 2023
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45. [Clinical and procedural characteristics of patients with acute coronary syndrome during the COVID-19 pandemic 2020 compared to a control group from 2019]

Author: Peter, Ong, Stefanie, Schäfer, Louisa, Karagülle-Dörrenhaus, Clara, Rau, Sarah, Fröbel, Sebastian, Spaich, and Raffi, Bekeredjian
Abstract: During the COVID-19 pandemic medical treatments including emergencies were often delayed, in part because of fear of an infection with Sars-CoV-2. Even patients with an acute coronary syndrome (ACS) were affected by these circumstances. In the present study we provide a systematic comparison of patients with ACS during the COVID-19 pandemic compared to a control group.This is a retrospective cross-sectional study including all patients admitted with an ACS (STEMI, NSTEMI, unstable angina) undergoing coronary angiography between March 2019 and June 2019 (group A) and between March 2020 and June 2020 (group B). Demographic factors, cardiovascular risk factors and procedural data (extent of coronary disease, clinical diagnose, revascularisation strategy and outcome, use of mechanical support devices, door-to-needle time and in-hospital mortality) were compared.469 patients were included in the present study (239 patients in group A and 230 in group B, mean age 69 years, 71% male). Compared to group A there were fewer patients with STEMI and unstable angina (p=0,033) but more patients with NSTEMI (p=0,047) in group B. Patients in group B had less often single vessel disease (p=0,001) but in contrast more often triple vessel disease compared to group A (p=0,052).Despite overall comparable numbers of ACS patients those admitted during the COVID-19 pandemic were more frequently diagnosed with NSTEMI and had a larger extent of coronary disease compared to a control group.Während der COVID-19-Pandemie wurden ärztliche Behandlungen abgesagt und notfallmäßige Behandlungen aus Angst vor einer Ansteckung mit Sars-CoV-2 hinausgezögert. Letzteres betraf auch Patienten mit akutem Koronarsyndrom. Eine detaillierte Beschreibung dieser Patienten in Bezug auf das Management im Herzkatheterlabor ist bislang aber noch nicht erfolgt.Retrospektive Querschnittsstudie mit Erfassung aller Patienten, die wegen eines akuten Koronarsyndroms (STEMI, NSTEMI, instabile Angina) einer Herzkatheteruntersuchung vom 01.03.2019–30.06.2019 (Gruppe A) sowie vom 01.03.2020–30.06.2020 (Gruppe B) unterzogen wurden. Demografische Faktoren, kardiovaskuläre Risikofaktoren sowie prozedurale Daten (z.B. Ausmaß der KHK, klinische Diagnose, Revaskularisationsstrategie und -ergebnis, Einsatz eines Herzunterstützungssystems, Door-to-Needle-Time, In-hospital-Mortalität) wurden verglichen.469 Patienten wurden in die Studie eingeschlossen (Gruppe A 239, Gruppe B 230 Patienten, mittleres Alter 69 Jahre, 71% männlich). Verglichen mit Gruppe A zeigten sich bei Gruppe B weniger Patienten mit STEMI und instabiler Angina pectoris (p=0,033), dafür mehr Patienten mit NSTEMI (p=0,047). Patienten in der Gruppe B hatten seltener eine koronare Eingefäßerkrankung (p=0,001), dafür wiesen diese häufiger eine koronare Dreigefäßerkrankung als in der Gruppe A auf (p=0,052).Trotz vergleichbarer Gesamtzahlen wurden Patienten mit akutem Koronarsyndrom während der COVID-19-Pandemie im Vergleich zu einer Kontrollgruppe häufiger mit NSTEMI aufgenommen und hatten ein größeres Ausmaß der KHK.
Published: 2022

46. Initial Invasive or Conservative Strategy for Stable Coronary Disease

Author: Maron D. J., Hochman J. S., Reynolds H. R., Bangalore S., O'Brien S. M., Boden W. E., Chaitman B. R., Senior R., Lopez-Sendon J., Alexander K. P., Lopes R. D., Shaw L. J., Berger J. S., Newman J. D., Sidhu M. S., Goodman S. G., Ruzyllo W., Gosselin G., Maggioni A. P., White H. D., Bhargava B., Min J. K., John Mancini G. B., Berman D. S., Picard M. H., Kwong R. Y., Ali Z. A., Mark D. B., Spertus J. A., Krishnan M. N., Elghamaz A., Moorthy N., Hueb W. A., Demkow M., Mavromatis K., Bockeria O., Peteiro J., Miller T. D., Szwed H., Doerr R., Keltai M., Selvanayagam J. B., Gabriel Steg P., Held C., Kohsaka S., Mavromichalis S., Kirby R., Jeffries N. O., Harrell F. E., Rockhold F. W., Broderick S., Bruce Ferguson T., Williams D. O., Harrington R. A., Stone G. W., Rosenberg Y, ISCHEMIA Research Group: Joseph Ricci, A Tello Montoliu, A I Robero Aniorte, Abbey Mulder, Abhay A Laddu, Abhinav Goyal, Abhishek Dubey, Abhishek Goyal, Abigail Knighton, Abraham Oomman, Adam J Jaskowiak, Adam Kolodziej, Adam Witkowski, Adnan Hameed, Adriana Anesini, Afshan Hussain, Agne Juceviciene, Agne Urboniene, Agnes Jakal, Agnieszka Szramowska, Ahmad Khairuddin, Ahmed Abdel-Latif, Ahmed Adel, Ahmed Aljzeeri, Ahmed Kamal, Ahmed Talaat, Aimee Mann, Aira Contreras, Ajit Kumar, V K Kumar, Akemi Furukawa, Akshay Bagai, Akvile Smigelskaite, Alain Furber, Alain Rheault, Alaine Melanie Loehr, Alan Rosen, Albert Varga, Albertina Qelaj, Alberto Barioli, Aldo Russo, Alec Moorman, Alejandro Gisbert, Aleksandra Fratczak, Aleksandras Laucevicius, Alena Kuleshova, Alessandro Sionis, Alexander A Sirker, Alexander M Chernyavskiy, Alexandra Craft, Alexandra Vazquez, Alexandre Ciappina Hueb, Alexandre S Colafranseschi, Alexandre Schaan de Quadros, Alexandre Tognon, Ali Alghamdi, Alice Manica Muller, Aline Nogueira Rabaça, Aline Peixoto Deiro, Alison Hallam, Allegra Stone, Allison Schley, Almudena Castro, Alvaro Rabelo Ales, Amanda Germann, Amanda O'Malley, Amar Uxa, Amarachi Ojajuni, Amarino C Oliveira Jr, Amber B Hull, Ambuj Roy, Amer Zarka, Amir Janmohamed, Ammani Brown, Ammy Malinay, Amparo Martinez Monzonis, Amy J Richards, Amy Iskandrian, Amy Ollinger, Ana D Djordjevic-Dikic, Ana Fernández Martínez, Ana Gomes Almeida, Ana Paula Batista, Ana Rita Francisco, Ana S Mladenovic, Ana Santana, Anam Siddiqui, Anastasia M Kuzmina-Krutetskaya, Andras Vertes, Andre S Sousa, Andre Gabriel, André Schmidt, Andrea M Lundeen, Andrea Bartykowszki, Andrea Lorimer, Andrea Mortara, Andrea Pascual, Andreia Coelho, Andreia Rocha, Andrés García-Rincón, Andrew G Howarth, Andrew J Moriarty, Andrew Docherty, Andrew Starovoytov, Andrew Zurick, Andrzej Łabyk, Andrzej Swiatkowski, Andy Lam, Anelise Kawakami, Angela Hoye, Angela Kim, Angelique Smit, Angelo Nobre, Anil V Shah, Anja Ljubez, Anjali Anand, Ankush Sachdeva, Ann Greenberg, Ann Luyten, Ann Ostrander, Anna Di Donato, Anna Cichocka-Radwan, Anna Fojt, Anna Plachcinska, Anna Proietti, Anna Teresinska, Anne Marie Webb, Anne Cartwright, Anne Heath, Anne Mackin, Anong Amaritakomol, Anong Chaiyasri, Anoop Chauhan, Anoop Mathew, Anthony Gemignani, Anto Luigi Andres, Antonia Vega, Antonietta Hansen, Antonino Ginel Iglesias, Antonio Carlos Carvalho, Antonio Di Chiara, Antonio Serra Peñaranda, Antonio Carvalho, Antonio Colombo, Antonio Fiarresga, Anupama Rao, Aquiles Valdespino-Estrada, Araceli Boan, Areef Ishani, Ariel Diaz, Arijit Ghosh, Arintaya Prommintikul, Arline Roberts, Arnold H Seto, Arnold P Good, Arshed Quyyumi, Arthur J Labovitz, Arthur Kerner, Arturo S Campos-Santaolalla, Arunima Misra, Ashok Mukherjee, Ashok Seth, Ashraf Seedhom, Asim N Cheema, Asker Ahmed, Atul Mathur, Atul Verma, Audrey W Leong, Axel Åkerblom, Axelle Fuentes, Aynun Naher, Badhma Valaiyapathi, Baljeet Kaur, Bandula Guruge, Barbara Brzezińska, Barbara Nardi, Bartosz Czarniak, Bebek Singh, Begoña Igual, Bela Merkely, Belen Cid Alvarez, Benjamin J Spooner, Benjamin J W Chow, Benjamin Cheong, Benoy N Shah, Bernard de Bruyne, Bernardas Valecka, Bernhard Jäger, Beth A Archer, Beth Abramson, Beth Jorgenson, Bethany Harvey, Betsy O'Neal, Bev Atkinson, Bev Bozek, Bevin Lang, Bijulal Sasidharan, Bin Yang, Bin Zhang, Binoy Mannekkattukudy Kurian, Bjoern Goebel, Bob Hu, Bogdan A Popescu, Bogdan Crnokrak, Bolin Zhu, Bonnie J Kirby, Brandi D Zimbelman, Brandy Starks, Branko D Beleslin, Brenda Hart, Brian P Shapiro, Brian McCandless, Brianna Wisniewski, Brigham R Smith, Brooks Mirrer, Bruce McManus, Bruce Rutkin, Bruna Edilena Paulino, Bruna Maria Ascoli, Bryn Smith, Byron J Allen, C Michael Gibson, C Noel Bairey Merz, Calin Pop, Cameron Hague, Camila Thais de Ormundo, Candace Gopaul, Candice P Edillo, Carísi A Polanczyk, Carita Krannila, Carla Vicente, Carl-Éric Gagné, Carlo Briguori, Carlos Peña Gil, Carlos Alvarez, Carly Ohmart, Carmen C Beladan, Carmen Ginghina, Carol M Kartje, Caroline Alsweiler, Caroline Brown, Caroline Callison, Caroline Pinheiro, Caroline Rodgers, Caroline Spindler, Carolyn Corbett, Carrie Drum, Casey Riedberger, Catherine Bone, Catherine Fleming, Catherine Gordon, Catherine Jahrsdorfer, Catherine Lemay, Catherine Weick, Cathrine Patten, Cecilia Goletto, Cezary Kepka, Chandini Suvarna, Chang Xu, Chantale Mercure, Charle A Viljoen, Charlene Wiyarand, Charles Jia-Yin Hou, Charles Y Lui, Charles Cannan, Charles Cornet, Charlotte Pirro, Chataroon Rimsukcharoenchai, Chen Wang, Cheng-Ting Tsai, Chen-Yen Chien, Cheryl A Allardyce, Chester M Hedgepeth, Chetan Patel, Chiara Attanasio, Chih-Hsuan Yen, Chi-Ming Chow, Ching Min Er, Ching-Ching Ong, Cholenahally Nanjappa Manjunath, Chris Beck, Chris Buller, Christel Vassaliere, Christian Hamm, Christiano Caldeira, Christie Ballantyne, Christina Björklund, Christine R Hinton, Christine Bergeron, Christine Masson, Christine Roraff, Christine Shelley, Christophe Laure, Christophe Thuaire, Christopher Kinsey, Christopher McFarren, Christopher Spizzieri, Christopher Travill, Chun-Chieh Liu, Chung-Lieh Hung, Chunguang Li, Chun-Ho Yun, Chunli Xia, Ciarra Heard, Cidney Schultz, Clare Venn-Edmonds, Claudia P Hochberg, Claudia Wegmayr, Claudia Cortés, Claudia Escobar, Cláudia Freixo, Claudio T Mesquita, Clemens T Kadalie, Colin Berry, Constance Philander, Corine Thobois, Costantino Costantini, Courtney Page, Craig Atkinson, Craig Barr, Craig Paterson, Cristina Bare, Cynthia Baumann, Cynthia Burman, Dalisa Espinosa, Damien Collison, Dan Deleanu, Dan Elian, Dan Gao, Dana Oliver, Daniel P Vezina, Daniel O'Rourke, Daniele Komar, Danielle Schade, Darrel P Francis, Dastan Malaev, David A Bull, David E Winchester, David P Faxon, David Booth, David Cohen, David DeMets, David Foo, David Schlichting, David Taggart, David Waters, David Wohns, Davis Vo, Dawid Teodorczyk, Dawn Shelstad, Dawn Turnbull, Dayuan Li, Dean Kereiakes, Deborah O'Neill, Deborah Yip, Debra K Johnson, Debra Dees, Deepak L Bhatt, Deepika Gopal, Deepti Kumar, Deirdre Mattina, Deirdre Murphy, Delano R Small, Delsa K Rose, Dengke Jiang, Denis Carl Phaneuf, Denise Braganza, Denise Fine, Derek Cyr, Desiree Tobin, Diana Cukali, Diana Parra, Diane Camara, Diane Minshall Liu, Diego Adrián Vences, Diego Franca de Cunha, Dimitrios Stournaras, Dipti Patel, Dongze Li, Donna Exley, Dorit Grahl, Dragana Stanojevic, Duarte Cacela, Dwayne S G Conway, E Pinar Bermudez, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Edoardo Verna, Eduardo Hernandez-Rangel, Edward D Nicol, Edward O McFalls, Edward T Martin, Edyta Kaczmarska, Ekaterina I Lubinskaya, Elena A Demchenko, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise L Hannemann, Elise van Dongen, Elissa Restelli Piloto, Eliza Kaplan, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizabeth Congdon, Elizabeth Ferguson, Elizaveta V Zbyshevskaya, Ellen Magedanz, Ellie Fridell, Ellis W Lader, Elvin Kedhi, Emanuela Racca, Emilie Tachot, Emily DeRosa, Encarnación Alonso-Álvarez, Eric Nicollet, Eric Peterson, Erick Alexánderson Rosas, Erick Donato Morales, Erin Orvis, Ermina Moga, Estelle Montpetit, Estevao Figueiredo, Eugene Passamani, Eugenia Nikolsky, Eunice Yeoh, Evgeniy I Kretov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, F Marin Ortuño, Fabio R Farias, Fabio Fimiani, Fabrizio Rolfo, Fa-Chang Yu, Fadi Hage, Fadi Matar, Fahim Haider Jafary, Fang Feng, Fang Liu, Fatima Ranjbaran, Fatima Rodriguez, Fausto J Pinto, Fauzia Rashid, Federica Ramani, Fei Wang, Fernanda Igansi, Filipa Silva, Filippo Ottani, Fiona Haines, Firas Al Solaiman, Flávia Egydio, Flavio Lyra, Florian Egger, Fran Farquharson, Frances Laube, Francesc Carreras Costa, Francesca de Micco, Francesca Bianchini, Francesca Pezzetta, Francesca Pietrucci, Francesco Orso, Francesco Pisano, Francis Burt, Francisca Patuleia Figueiras, Francisco Fernandez-Aviles, Francois Pierre Mongeon, Frans Van de Werf, Franziska Guenther, Fraser N Witherow, Fred Mohr, Frederico Dall'Orto, Fumiyuki Otsuka, G De La Morena, G Karthikeyan, Gabor Dekany, Gabor Kerecsen, Gabriel Galeote, Gabriel Grossmann, Gabriel Vorobiof, Gabriela Sanchez de Souza, Gabriela Guzman, Gabriela Zeballos, Gabriele Gabrielli, Gabriele Jakl-Kotauschek, Gail A Shammas, Gail Brandt, Gang Chen, Gary E Lane, Gary J Luckasen, Gautam Sharma, Gelmina Mikolaitiene, Gennie Yee, Georg Nickenig, George E Revtyak, George J Juang, Gerald Fletcher, Gerald Leonard, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Geza Fontos, Ghada Mikhail, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Giles Roditi, Gilles Barone-Rochette, Girish Mishra, Giuseppe Tarantini, Glenda Wong, Glenn S Hamroff, Glenn Rayos, Gong Cheng, Gonzalo Barge-Caballero, Goran Davidović, Goran Stankovic, Gordana Stevanovic, Grace Jingyan Wang, Grace M Young, Graceanne Wayser, Graciela Scaro, Graham S Hillis, Graham Wong, Grazyna Anna Szulczyk, Gregor Simonis, Gregory Kumkumian, Gretchen Ann Peichel, Grzegorz Gajos, Gudrun Steinmaurer, Guilherme G Rucatti, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillem Pons Lladó, Gunnar Frostfelt, Gurpreet S Wander, Gurpreet Gulati, Gustavo Pucci, Hafidz Abd Hadi, Haibo Zhang, Haitao Wang, Halina Marciniak, Han Chen, Hanan Kerr, Hani Najm, Hanna Douglas, Hannah Phillips, Hao Dai, Haojian Dong, Haqeel Jamil, Harikrishnan Sivadasanpillai, Harry Suryapranata, Hassan Reda, Hayley Pomeroy, Heather Barrentine, Heather Golden, Heather Hurlburt, Heidi Wilson, Helen C Tucker, Helene Abergel, Hemalata Siddaram, Hermine Osseni, Herwig Schuchlenz, Hesong Zeng, Hicham Skali, Hilda Solomon, Hollie Horton, Holly Hetrick, Holly Little, Holly Park, Hongjie Chi, Hossam Mahrous, Howard A Levite, Hristo Pejkov, Huajun Li, Hugo Bloise-Adames, Hugo Marques, Hui Zhong, Hui-Min Zhang, Humayrah Hashim, Hung-I Yeh, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ihab Hamzeh, Ikraam Hassan, Ikuko Ueda, Ileana L Pina, Ilona Tamasauskiene, Ilse Bouwhuis, Imran Arif, Ina Wenzelburger, Inês Zimbarra Cabrita, Ines Rodrigues, Inga H Robbins, Inga Soveri, Ingela Schnittger, Iqbal Karimullah, Ira M Dauber, Iram Rehman, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Irni Yusnida, Isabel Estela Carvajal, Isabella C Palazzo, Isabelle Hogan, Isabelle Roy, Ishba Syed, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, J David Knight, Jacek Kusmierek, Jackie M White, Jackie Chow, Jacob Udell, Jacqueline E Tamis-Holland, Jacqueline Fannon, Jacquelyn A Quin, Jacquelyn Do, Jaekyeong Heo, Jakub Maksym, James E Davies, James H O'Keefe Jr, James J Jang, James Cha, James Harrison, James Hirsch, James Stafford, James Tatoulis, Jamie Rankin, Jan Henzel, Jan Orga, Jana Tancredi, Janaina Oliveira, Jane Burton, Jane Eckstein, Jane Marucci, Janet P Knight, Janet Blount, Janet Halliday, Janetta Kourzenkova, Janitha Raj, Jan-Malte Sinning, Jaqueline Pozzibon, Jaroslaw Drozdz, Jaroslaw Karwowski, Jason D Glover, Jason Loh Kwok, Jason T Call, Jason Linefsky, Jassira Gomes, Jati Anumpa, Javier J Garcia, Javier Courtis, Jay Meisner, K Jayakumar, Jayne Scales, Jean E Denaro, Jean Michel Juliard, Jean Ho, Jeanette K Stansborough, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeet Thambyrajah, Jeff Leimberger, Jeffery A Breall, Jeffrey A Kohn, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Blume, Jeffrey Kanters, Jeffrey Lorin, Jeffrey Moses, Jelena J Stepanovic, Jelena Celutkiene, Jelena Djokic, Jelena Stojkovic, Jenne M Jose, Jenne Manchery, Jennifer A Mull, Jennifer H Czerniak, Jennifer L Stanford, Jennifer Gillis, Jennifer Horst, Jennifer Isaacs, Jennifer Langdon, Jennifer Thomson, Jennifer Tomfohr, Jennifer White, Jen-Yuan Kuo, Jeremy Rautureau, Jerome Fleg, Jessica Berg, Jessica Rodriguez, Jessica Waldron, Jhina Patro, Jia Li, Jiajia Mao, Jiamin Liu, Jian'an Wang, Jianhua Li, Jianxin Zhang, Jie Qi, Jihyun Lyo, Jill Marcus, Jim Blankenship, Jing Zhang, Jingjing Liu, Jing-Yao Fan, Jiun-Yi Li, Jiwan Pradhan, Jiyan Chen, J M Rivera Caravaca, Jo Evans, Joan Garcia Picart, Joan Hecht, Joanna Jaroch, Joanna Zalewska, Joanne Kelly, Joanne Taaffe, João Reynaldo Abbud, João V Vitola, Joaquín V Peñafiel, Jocelyne Benatar, Jody Bindeman, Joe Sabik, Joel Klitch, Johann Christopher, Johannes Aspberg, John D Friedman, John F Beltrame, John F Heitner, John Joseph Graham, John R Davies, John Doan, John Kotter, John Kurian, John Mukai, John Pownall, Jolanta Sobolewska, Jon Kobashigawa, Jonathan L Goldberg, Jonathan W Bazeley, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Leipsic, Jonean Thorsen, Jorge F Trejo Gutierrez, Jorge Escobedo, Jorik Timmer, José A Ortega-Ramírez, José Antonio Marin-Neto, Jose D Salas, Jose Enrique Castillo, Jose Francisco Saraiva, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Vieira, José M Flores-Palacios, Jose Ramon Gonzalez, Jose Seijas Amigo, Jose Fragata, Josep Maria Padró, Josheph F X McGarvey Jr, Joseph Hannan, Joseph Sacco, Joseph Sweeny, Joseph Wiesel, Josephine D Abraham, Joshua P Loh, Joy Burkhardt, Joyce R White, Joyce Riestenberg-Smith, Judit Sebo, Judith L Meadows, Judith Wright, Judy Mae Foltz, Judy Hung, Judy Otis, Juergen Stumpf, Jui-Peng Tsai, Julia S Dionne, Julia de Aveiro Morata, Julie Bunke, Julie Morrow, Julio César Figal, Jun Fujita, Jun Jiang, Junhua Li, Junqing Yang, Juntima Euathrongchit, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Kai Eggers, Kamalakar Surineni, Kanae Hirase, T R Kapilamoorthy, Karen Calfas, Karen Gratrix, Karen Hallett, Karen Hultberg, Karen Nugent, Karen Petrosyan, Karen Swan, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karsten Lenk, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Kate Pointon, Kate Robb, Katherine Martin, Kathleen Claes, Kathryn Carruthers, Kathy E Siegel, Katia Drouin, Katie Fowler-Lehman, Kavita Rawat, Kay Rowe, Keiichi Fukuda, Keith A A Fox, Ken Mahaffey, Kendra Unterbrink, Kenneth Giedd, Kerrie Van Loo, Kerry Lee, Kerstin Bonin, Kevin R Bainey, Kevin T Harley, Kevin Anstrom, Kevin Chan, Kevin Croce, Kevin Landolfo, Kevin Marzo, Keyur Patel, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khaled Ziada, Khaula Baloch, Khrystyna Kushniriuk, Kian-Keong Poh, Kim F Ireland, Kim Holland, Kimberly Ann Byrne, Kimberly E Halverson, Kimberly Elmore, Kimberly Miller-Cox, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kotiboinna Preethi, Kozhaya Sokhon, Krissada Meemuk, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristina Wippler, Kristine Arges, Kristine Teoh, Krystal Etherington, Krystyna Łoboz-Grudzień, Krzysztof W Reczuch, Krzysztof Bury, Krzysztof Drzymalski, Krzysztof Kukuła, Kuo-Tzu Sung, Kurt Huber, Ladda Douangvila, Lance Sullenberger, Larissa Miranda Trama, Laszlone Matics, Laura Drew, Laura Flint, Laura Keinaite, Laura Sarti, Laurel Kolakaluri, Lawrence M Phillips, Lawrence Friedman, Lawrence Phillips, Lazar Velicki, Leah Howell, Leandro C Maranan, Leanne Cox, Ledjalem Daba, Lei Zhang, Lekshmi Dharmarajan, Leo Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Leszek Sokalski, Li Hai Yan, Li Li, Lia Nijmeijer, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilia Schiavi, Lilian Mazza Barbosa, Lillian L Khor, Lina Felix-Stern, Linda L Hall, Linda M Hollenweger, Linda Arcand, Linda Davidson-Ray, Linda Schwarz, Lindsey N Sikora, Lingping Chi, Lino Patricio, Liping Zhang, Lisa Chaytor, Lisa Hatch, Lisa McCloy, Lisa Wong, Liselotte Persson, Lixin Jiang, Liz Low, Ljiljana Pupic, Loïc Bière, Lorenzo Monti, Lori Christensen, Lori Pritchard, Loriane Black, Lori-Ann Desimone, Lori-Ann Larmand, Lorraine McGregor, Louise Morby, Louise Thomson, Luc Harvey, Luciana de Pádua Baptista, Lucilla Garcia, Ludivine Eliahou, Ludmila Helmer, Luis F Smidt, Luis Bernanrdes, Luis Guzman, Luiz A Carvalho, Luyang Xiong, Lynette L Teo, Lynn M Neeson, Lynne Winstanley, M Barbara Srichai-Parsia, M Quintana Giner, M Sowjanya Reddy, M Valdés Chávarri, M Grazia Rossi, Maarten Simoons, Maayan Konigstein, Maciej Lesiak, Maciej Olsowka, Mafalda Selas, Magalie Corfias, Magdalena Madero Rovalo, Magdalena Łanocha, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdalena Rantinella, Magdy Abdelhamid, Magnolia Jimenez, Mahboob Alam, Mahevamma Mylarappa, Mahfouz El Shahawy, Mahmoud Mohamed, Mahmud Al-Bustami, Majo X Joseph, Malgorzata Frach, Małgorzta Celińska-Spodar, Malte Helm, Manas Chacko, Mandy Murphy, Manitha Vinod, Manjula Rani, Manu Dhawan, Manuela Mombelli, Marcel Weber, Marcello Galvani, Marcelo Jamus Rodrigues, Marcia F Dubin, Marcia F Werner Bayer, Marcin Szkopiak, Marco Antonio Monsalve, Marco Bizzaro Santos, Marco Magnoni, Marco Marini, Marco Sicuro, Marco Zenati, Marcos Valério Coimbra Resende, Marek Roik, Margalit Bentzvi, Margaret Gilsenan, Margaret Iraola, Margot C Quinn, Maria A Alfonso, Maria Antonieta Pereira Moraes, María Dolores Martínez-Ruíz, María Fernanda Canales, Maria Inês Caetano, Maria P Corral, Maria Pérez García, Maria Victoria Actis, Maria Aguirre, Maria Andreasson, Maria Aprile, Maria Colton, Maria Eugenia Martin, Maria Lasala, Maria Lorenzo, Maria Posada, Maria Shier, Maria Thottam, Mariana V Furtado, Mariana Yumi Okada, Marianna D A Dracoulakis, Marianne De Andrade, Mariano Rubio, Marie Essermark, Marielle Scherrer-Crosbie, Marija T Petrovic, Marija Zdravkovic, Marilyn Black, Marina Garcia, Mario J Garcia, Mariola Szulik, Marisa Orgera, Mark A de Belder, Mark Harbinson, Mark Hyun, Mark Peterson, Mark Xavier, Marlowe Mosley, Marta Capinha, Marta Marcinkiewicz-Siemion, Marta Swiderek, Martha Meyer, Martina Ceseri, Martina Tricoli, Marvin Kronenberg, Mary Williams, Mary Ann Champagne, Mary Colleen Rogge, Mary R Soltau, Mary Streif, Massimo Villella, Massoud Leesar, Matei Claudia, Mateusz Solecki, Matías Nicolás Mungo, Matthew Wall Jr, Matthew Budoff, Matthew Jezior, Matthew Luckie, Matthias Friedrich, Mauren P Haeffner, Maximilian Tscharre, Max-Paul Winter, Mayana Almeida, Mayil S Krishnam, Mayuri Patel, Meenakshi Mishra, Megan Manocchia, Meghana Kakade, Melanie J Munro, Melissa D Chaplin, Melissa LeFevre, Mervyn Andiapen, Michael A Gibson, Michael B Rubens, Michael C Turner, Michael D Shapiro, Michael W Lee, Michael Berlowitz, Michael Davidson, Michael Mack, Michael McDaniel, Michael Mumma, Michal Wlodarczyk, Michel G Khouri, Michel S Slama, Michele Rawlins, Michelle M Bonner, Michelle M Seib, Michelle Chang, Michelle Crowder, Michelle Dixon, Michelle Mayon, Michelle McEvoy, Michelle Yee, Miguel M Fernandes, Miguel Nobre Menezes, Miguel Souto Bayarri, Miguel Barrero, Mikhail T Torosoff, Milan R Dobric, Milan Dobric, Milica Nikola Dekleva, Milind Avdhoot Gadkari, Millie Gomez, Min Tun Kyaw, Miriam Brooks, Miroslav Stevo Martinovic, Mitchel B Lustre, Mohammad Tariq Vakani, Mohammad El-Hajjar, Mohammed Al-Amoodi, Mohammed Hussain, Mohammed Saleem, Moisés Blanco-Calvo, Moisés Jiménez-Santos, Mona Bhatia, Monica Rosca, Monika Laukyte, Montserrat Gracida Blanca, Montserrat Vila Perales, Mouaz H Al-Mallah, Moysés de Oliveira Filho, Mpiko Ntsekhe, Muhamed Saric, Mulei Chen, Myriam Brousseau, Myrthes Emy Takiuti, Nada Cemerlic-Adjic, Nadia Asif, Nadia Gakou, Nafisa Hussain, Nana O Katamadze, Nancy L Clapp, Nancy Aedy, Nandita Nataraj, Nanette K Wenger, Naomi Uchida, Nasrul Ismail, Natalia S Oliveira, Natalia de Carvalho Maffei, Natalie Spitzer, Natasha C Putnam, Naved Aslam, Neamat Mowafy, Neeraj Pandit, Neeraj Parakh, Nevena Garcevic, Ngaire Meadows, Nhi N Tran, Nicholas Danchin, Nicki Lakeman, Nicola Johnston, Nicolas W Shammas, Nicole Saint Vrestil, Nicole Deming, Nier Zhong, Niket Patel, Nikola N Boskovic, Nikolaos Karogiannis, Nikos Werner, Nina Johnston, Ning Zhang, Ning Zhou, Niree Hindoyan, Nirmal Kumar, Nitika Chadha, Nitish Naik, Nodira Aripova, Noloyiso Mtana, Nona A Eskelson, Noor Syamira 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Paula García-González, Paulo Cury Rezende, Paulo Ricardo Caramori, Pavel S Kozlov, Pedro Canas Silva, Pedro Gabriel Melo Barros E Silva, Pedro Píccaro de Oliveira, Pedro Carvalho, Pedro Modas, Pedro Rio, Peeyush Jain, Peiyu He, Peter A McCullough, Peter H Stone, Peter M Pollak, Peter Douglass, Peter Henriksen, Peter OKane, Peter Ong, Philip Jones, Philip Rogal, Philippe Généreux, Philippe Menasche, Philippe Rheault, Phoebe Goold, Pierre Gervais, Pierre Michaud, Pilar Calvillo, Ping Chai, Piotr Jakubowski, Piotr Pruszczyk, Piotr Slomka, Piyamitr Sritara, Poay-Huan Loh, Poonam Sonawane, Pouneh Samadi, Pragnesh P Parikh, Prakash Deedwania, Pranav M Patel, Praneeth Polamuri, Pratiksha Sharma, Precilia Vasquez, Preeti Kamath, Prince Thomas, Priyadarshani Arambam, Puja K Mehta, Purvez Grant, Pushpa Naik, Qi Zhong, Qian Zhao, Qiang Zhou, Qianqian Yuan, Qin Yu, Qingxian Li, Qiulan Xie, Qiutang Zeng, R J Vindhya, R James Gerlach, Rachel King, Rada Vučić, Radmila Lyubarova, Radoslaw Pracon, 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Bermudez, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Edoardo Verna, Eduardo Hernandez-Rangel, Edward D Nicol, Edward O McFalls, Edward T Martin, Edyta Kaczmarska, Ekaterina I Lubinskaya, Elena A Demchenko, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise L Hannemann, Elise van Dongen, Elissa Restelli Piloto, Eliza Kaplan, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizabeth Congdon, Elizabeth Ferguson, Elizaveta V Zbyshevskaya, Ellen Magedanz, Ellie Fridell, Ellis W Lader, Elvin Kedhi, Emanuela Racca, Emilie Tachot, Emily DeRosa, Encarnación Alonso-Álvarez, Eric Nicollet, Eric Peterson, Erick Alexánderson Rosas, Erick Donato Morales, Erin Orvis, Ermina Moga, Estelle Montpetit, Estevao Figueiredo, Eugene Passamani, Eugenia Nikolsky, Eunice Yeoh, Evgeniy I Kretov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, F Marin Ortuño, Fabio R Farias, Fabio Fimiani, Fabrizio Rolfo, Fa-Chang Yu, Fadi Hage, Fadi Matar, Fahim Haider 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Hayley Pomeroy, Heather Barrentine, Heather Golden, Heather Hurlburt, Heidi Wilson, Helen C Tucker, Helene Abergel, Hemalata Siddaram, Hermine Osseni, Herwig Schuchlenz, Hesong Zeng, Hicham Skali, Hilda Solomon, Hollie Horton, Holly Hetrick, Holly Little, Holly Park, Hongjie Chi, Hossam Mahrous, Howard A Levite, Hristo Pejkov, Huajun Li, Hugo Bloise-Adames, Hugo Marques, Hui Zhong, Hui-Min Zhang, Humayrah Hashim, Hung-I Yeh, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ihab Hamzeh, Ikraam Hassan, Ikuko Ueda, Ileana L Pina, Ilona Tamasauskiene, Ilse Bouwhuis, Imran Arif, Ina Wenzelburger, Inês Zimbarra Cabrita, Ines Rodrigues, Inga H Robbins, Inga Soveri, Ingela Schnittger, Iqbal Karimullah, Ira M Dauber, Iram Rehman, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Irni Yusnida, Isabel Estela Carvajal, Isabella C Palazzo, Isabelle Hogan, Isabelle Roy, Ishba Syed, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, J David Knight, Jacek Kusmierek, Jackie M White, Jackie Chow, Jacob Udell, Jacqueline E Tamis-Holland, Jacqueline Fannon, Jacquelyn A Quin, Jacquelyn Do, Jaekyeong Heo, Jakub Maksym, James E Davies, James H O'Keefe Jr, James J Jang, James Cha, James Harrison, James Hirsch, James Stafford, James Tatoulis, Jamie Rankin, Jan Henzel, Jan Orga, Jana Tancredi, Janaina Oliveira, Jane Burton, Jane Eckstein, Jane Marucci, Janet P Knight, Janet Blount, Janet Halliday, Janetta Kourzenkova, Janitha Raj, Jan-Malte Sinning, Jaqueline Pozzibon, Jaroslaw Drozdz, Jaroslaw Karwowski, Jason D Glover, Jason Loh Kwok, Jason T Call, Jason Linefsky, Jassira Gomes, Jati Anumpa, Javier J Garcia, Javier Courtis, Jay Meisner, K Jayakumar, Jayne Scales, Jean E Denaro, Jean Michel Juliard, Jean Ho, Jeanette K Stansborough, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeet Thambyrajah, Jeff Leimberger, Jeffery A Breall, Jeffrey A Kohn, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Blume, 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John Doan, John Kotter, John Kurian, John Mukai, John Pownall, Jolanta Sobolewska, Jon Kobashigawa, Jonathan L Goldberg, Jonathan W Bazeley, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Leipsic, Jonean Thorsen, Jorge F Trejo Gutierrez, Jorge Escobedo, Jorik Timmer, José A Ortega-Ramírez, José Antonio Marin-Neto, Jose D Salas, Jose Enrique Castillo, Jose Francisco Saraiva, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Vieira, José M Flores-Palacios, Jose Ramon Gonzalez, Jose Seijas Amigo, Jose Fragata, Josep Maria Padró, Josheph F X McGarvey Jr, Joseph Hannan, Joseph Sacco, Joseph Sweeny, Joseph Wiesel, Josephine D Abraham, Joshua P Loh, Joy Burkhardt, Joyce R White, Joyce Riestenberg-Smith, Judit Sebo, Judith L Meadows, Judith Wright, Judy Mae Foltz, Judy Hung, Judy Otis, Juergen Stumpf, Jui-Peng Tsai, Julia S Dionne, Julia de Aveiro Morata, Julie Bunke, Julie Morrow, Julio César Figal, Jun Fujita, Jun Jiang, Junhua Li, Junqing Yang, Juntima Euathrongchit, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Kai Eggers, Kamalakar Surineni, Kanae Hirase, T R Kapilamoorthy, Karen Calfas, Karen Gratrix, Karen Hallett, Karen Hultberg, Karen Nugent, Karen Petrosyan, Karen Swan, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karsten Lenk, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Kate Pointon, Kate Robb, Katherine Martin, Kathleen Claes, Kathryn Carruthers, Kathy E Siegel, Katia Drouin, Katie Fowler-Lehman, Kavita Rawat, Kay Rowe, Keiichi Fukuda, Keith A A Fox, Ken Mahaffey, Kendra Unterbrink, Kenneth Giedd, Kerrie Van Loo, Kerry Lee, Kerstin Bonin, Kevin R Bainey, Kevin T Harley, Kevin Anstrom, Kevin Chan, Kevin Croce, Kevin Landolfo, Kevin Marzo, Keyur Patel, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khaled Ziada, Khaula Baloch, Khrystyna Kushniriuk, Kian-Keong Poh, Kim F Ireland, Kim Holland, Kimberly Ann Byrne, Kimberly E Halverson, Kimberly Elmore, Kimberly Miller-Cox, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kotiboinna Preethi, Kozhaya Sokhon, Krissada Meemuk, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristina Wippler, Kristine Arges, Kristine Teoh, Krystal Etherington, Krystyna Łoboz-Grudzień, Krzysztof W Reczuch, Krzysztof Bury, Krzysztof Drzymalski, Krzysztof Kukuła, Kuo-Tzu Sung, Kurt Huber, Ladda Douangvila, Lance Sullenberger, Larissa Miranda Trama, Laszlone Matics, Laura Drew, Laura Flint, Laura Keinaite, Laura Sarti, Laurel Kolakaluri, Lawrence M Phillips, Lawrence Friedman, Lawrence Phillips, Lazar Velicki, Leah Howell, Leandro C Maranan, Leanne Cox, Ledjalem Daba, Lei Zhang, Lekshmi Dharmarajan, Leo Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Leszek Sokalski, Li Hai Yan, Li Li, Lia Nijmeijer, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilia Schiavi, Lilian Mazza Barbosa, Lillian L Khor, Lina Felix-Stern, Linda L Hall, Linda M Hollenweger, Linda Arcand, Linda Davidson-Ray, Linda Schwarz, Lindsey N Sikora, Lingping Chi, Lino Patricio, Liping Zhang, Lisa Chaytor, Lisa Hatch, Lisa McCloy, Lisa Wong, Liselotte Persson, Lixin Jiang, Liz Low, Ljiljana Pupic, Loïc Bière, Lorenzo Monti, Lori Christensen, Lori Pritchard, Loriane Black, Lori-Ann Desimone, Lori-Ann Larmand, Lorraine McGregor, Louise Morby, Louise Thomson, Luc Harvey, Luciana de Pádua Baptista, Lucilla Garcia, Ludivine Eliahou, Ludmila Helmer, Luis F Smidt, Luis Bernanrdes, Luis Guzman, Luiz A Carvalho, Luyang Xiong, Lynette L Teo, Lynn M Neeson, Lynne Winstanley, M Barbara Srichai-Parsia, M Quintana Giner, M Sowjanya Reddy, M Valdés Chávarri, M Grazia Rossi, Maarten Simoons, Maayan Konigstein, Maciej Lesiak, Maciej Olsowka, Mafalda Selas, Magalie Corfias, Magdalena Madero Rovalo, Magdalena Łanocha, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdalena Rantinella, Magdy Abdelhamid, Magnolia Jimenez, Mahboob Alam, Mahevamma Mylarappa, Mahfouz El Shahawy, Mahmoud Mohamed, Mahmud Al-Bustami, Majo X Joseph, Malgorzata Frach, Małgorzta Celińska-Spodar, Malte Helm, Manas Chacko, Mandy Murphy, Manitha Vinod, Manjula Rani, Manu Dhawan, Manuela Mombelli, Marcel Weber, Marcello Galvani, Marcelo Jamus Rodrigues, Marcia F Dubin, Marcia F Werner Bayer, Marcin Szkopiak, Marco Antonio Monsalve, Marco Bizzaro Santos, Marco Magnoni, Marco Marini, Marco Sicuro, Marco Zenati, Marcos Valério Coimbra Resende, Marek Roik, Margalit Bentzvi, Margaret Gilsenan, Margaret Iraola, Margot C Quinn, Maria A Alfonso, Maria Antonieta Pereira Moraes, María Dolores Martínez-Ruíz, María Fernanda Canales, Maria Inês Caetano, Maria P Corral, Maria Pérez García, Maria Victoria Actis, Maria Aguirre, Maria Andreasson, Maria Aprile, Maria Colton, Maria Eugenia Martin, Maria Lasala, Maria Lorenzo, Maria Posada, Maria Shier, Maria Thottam, Mariana V Furtado, Mariana Yumi Okada, Marianna D A Dracoulakis, Marianne De Andrade, Mariano Rubio, Marie Essermark, Marielle Scherrer-Crosbie, Marija T Petrovic, Marija Zdravkovic, Marilyn Black, Marina Garcia, Mario J Garcia, Mariola Szulik, Marisa Orgera, Mark A de Belder, Mark Harbinson, Mark Hyun, Mark Peterson, Mark Xavier, Marlowe Mosley, Marta Capinha, Marta Marcinkiewicz-Siemion, Marta Swiderek, Martha Meyer, Martina Ceseri, Martina Tricoli, Marvin Kronenberg, Mary Williams, Mary Ann Champagne, Mary Colleen Rogge, Mary R Soltau, Mary Streif, Massimo Villella, Massoud Leesar, Matei Claudia, Mateusz Solecki, Matías Nicolás Mungo, Matthew Wall Jr, Matthew Budoff, Matthew Jezior, Matthew Luckie, Matthias Friedrich, Mauren P Haeffner, Maximilian Tscharre, Max-Paul Winter, Mayana Almeida, Mayil S Krishnam, Mayuri Patel, Meenakshi Mishra, Megan Manocchia, Meghana Kakade, Melanie J Munro, Melissa D Chaplin, Melissa LeFevre, Mervyn Andiapen, Michael A Gibson, Michael B Rubens, Michael C Turner, Michael D Shapiro, Michael W Lee, Michael Berlowitz, Michael Davidson, Michael Mack, Michael McDaniel, Michael Mumma, Michal Wlodarczyk, Michel G Khouri, Michel S Slama, Michele Rawlins, Michelle M Bonner, Michelle M Seib, Michelle Chang, Michelle Crowder, Michelle Dixon, Michelle Mayon, Michelle McEvoy, Michelle Yee, Miguel M Fernandes, Miguel Nobre Menezes, Miguel Souto Bayarri, Miguel Barrero, Mikhail T Torosoff, Milan R Dobric, Milan Dobric, Milica Nikola Dekleva, Milind Avdhoot Gadkari, Millie Gomez, Min Tun Kyaw, Miriam Brooks, Miroslav Stevo Martinovic, Mitchel B Lustre, Mohammad Tariq Vakani, Mohammad El-Hajjar, Mohammed Al-Amoodi, Mohammed Hussain, Mohammed Saleem, Moisés Blanco-Calvo, Moisés Jiménez-Santos, Mona Bhatia, Monica Rosca, Monika Laukyte, Montserrat Gracida Blanca, Montserrat Vila Perales, Mouaz H Al-Mallah, Moysés de Oliveira Filho, Mpiko Ntsekhe, Muhamed Saric, Mulei Chen, Myriam Brousseau, Myrthes Emy Takiuti, Nada Cemerlic-Adjic, Nadia Asif, Nadia Gakou, Nafisa Hussain, Nana O Katamadze, Nancy L Clapp, Nancy Aedy, Nandita Nataraj, Nanette K Wenger, Naomi Uchida, Nasrul Ismail, Natalia S Oliveira, Natalia de Carvalho Maffei, Natalie Spitzer, Natasha C Putnam, Naved Aslam, Neamat Mowafy, Neeraj Pandit, Neeraj Parakh, Nevena Garcevic, Ngaire Meadows, Nhi N Tran, Nicholas Danchin, Nicki Lakeman, Nicola Johnston, Nicolas W Shammas, Nicole Saint Vrestil, Nicole Deming, Nier Zhong, Niket Patel, Nikola N Boskovic, Nikolaos Karogiannis, Nikos Werner, Nina Johnston, Ning Zhang, Ning Zhou, Niree Hindoyan, Nirmal Kumar, Nitika Chadha, Nitish Naik, Nodira Aripova, Noloyiso Mtana, Nona A Eskelson, Noor Syamira Mokhtar, Noppon Taksaudom, Nor Asiah Basri, Nora Marchelletta, Norma Hogg, Nungshi Jungla, Nuno Ferreira, Oksana A Lubyanaya, Olga B Nikolaeva, Olga Cañavate, Olga Sobrino, Olga Walesiak, Olga Walter, Olga Zdończyk, Olivia J Lim, Olivia Anaya, Olivia Mancilla, Olivier Dubourg, Olugbenga Bello, Omar Almousalli, Omar Thompson, Oni Olurinde, Or Harel, Osama Raheem, Oscar Méndiz, Óscar Prada-Delgado, Oz Shapira, P Christian Schulze, Pachara Panpunuan, Pal Maurovich-Horvat, Pallav Garg, Paloma Moraga, Pam Singh, Pamela Julian, Pamela Ouyang, Pamela Sigel, Pamela Woodard, Panpan Zhou, Paola Emanuela Poggio, Paola Smanio, Paolo Calabro, Paramjit Jeetley, Pascal Goube, Patricia K Nguyen, Patricia Alarie, Patricia Arakelian, Patricia Arsenault, Patricia Blaise, Patricia Brito, Patricia Cowper, Patricia Endsley, Patricia Mieses, Patrick B Alexander, Patrick Donnelly, Patrick Wilmot, Patrycja Lebioda, Paul C Gordon, Paul Der Mesropian, Paul Galiwango, Paul Hauptman, Paul Kennedy, Paula Beardsley, Paula García-González, Paulo Cury Rezende, Paulo Ricardo Caramori, Pavel S Kozlov, Pedro Canas Silva, Pedro Gabriel Melo Barros E Silva, Pedro Píccaro de Oliveira, Pedro Carvalho, Pedro Modas, Pedro Rio, Peeyush Jain, Peiyu He, Peter A McCullough, Peter H Stone, Peter M Pollak, Peter Douglass, Peter Henriksen, Peter OKane, Peter Ong, Philip Jones, Philip Rogal, Philippe Généreux, Philippe Menasche, Philippe Rheault, Phoebe Goold, Pierre Gervais, Pierre Michaud, Pilar Calvillo, Ping Chai, Piotr Jakubowski, Piotr Pruszczyk, Piotr Slomka, Piyamitr Sritara, Poay-Huan Loh, Poonam Sonawane, Pouneh Samadi, Pragnesh P Parikh, Prakash Deedwania, Pranav M Patel, Praneeth Polamuri, Pratiksha Sharma, Precilia Vasquez, Preeti Kamath, Prince Thomas, Priyadarshani Arambam, Puja K Mehta, Purvez Grant, Pushpa Naik, Qi Zhong, Qian Zhao, Qiang Zhou, Qianqian Yuan, Qin Yu, Qingxian Li, Qiulan Xie, Qiutang Zeng, R J Vindhya, R James Gerlach, Rachel King, Rada Vučić, Radmila Lyubarova, Radoslaw Pracon, Raewyn Fisher, Rafael Beyar, Rafael Diaz, Rafael Selgas, Raffaele Bugiardini, Raffaele Fanelli, Raisa Kavalakkat, V S Rajalekshmi, Rajat S Barua, Rajeev Menon, Rajesh Gopalan Nair, Rajesh Francis, Rajiv Narang, Rakesh Yadav, Ralph Alan Huston, T Ramakrishnan, Ramesh de Silva, Rami El Mahmoud, Ramiro Carvalho, Ramon de Jesús-Pérez, Ramona Stevens, Ran Leng, Ranjan Kachru, Ranjit Kumar Nath, Raquel Sanchez, Raven R Dwyer, Raven Lee, Ray Wyman, Raymond C Wong, Raymond W Little, Raymundo Ocaranza Sanchez, Rebecca J Wimmer, Rebecca Bariciano, Rebecca Otis, Rebekah R Herrmann, Reem Yunis, Reinette Hampson, Renato Abdala Karam, Renee C Hessian, Renee Kaneshiro, Reshma Ravindran, Reto Andreas Gamma, Reyna Bhandari, Reza Arsanjani, Ricardo L Lopes, Ricardo Mendes Oliveira, Ricardo Costa, Richa Bhatt, Richard F Davies, Richard H J Trimlett, Richard Goldweit, Rik Hermanides, Rine Nakanishi, Rinu R Sidh, Risha Patel, Rita Coram, Rizwan A Siddiqui, Rob S Beanlands, Robert J Hamburger, Robert K Riezebos, Robert M Donnino, Robert Bojar, Robert Chilton, Robert Guyton, Robert Henderson, Robert Kornberg, Robert Leber, Robert Mao, Robert Stenberg, Roberta P Santos, Roberto René Favaloro, Roberto Amati, Rodolfo G S D Lima, Rodrigo J Cerci, Rogerio Tumelero, Rohit Tandon, Roma Tewari, Romalisa Miranda-Peats, Ron Wald, Ronald A Mastouri, Ronald G Morford, Ronald G Schwartz, Ronald P Pedalino, Rongrong Hu, Ronnell A Hansen, Ronny A Cohen, Rory Hachamovitch, Rosa Homem, Rosa Sandonato, Rosane Laimer, Rosann Gans, Roxanne Yost, Roy Mathew, Rubén Baleón-Espinosa, Ruben Ramos, Rubine Gevorgyan, Rui Ferreira, Rui Jing, Ruth Pérez-Fernández, S K Dwivedi, S Ramakrishnan, Saadat Khan, Sabahat Bokhari, Sabu Thomas, Sadath Lubna, Sajeeda Parveen Khan, Sajeev Chakanalil Govindan, Saket Girotra, Saleem Kassam, Sallie Canada, Salvador Cruz-Flores, Samaa Mohamed, Samantha Ly, Sameh El Kaffas, Samia Massalha, Sampoornima Setty, Samuel Nwosu, Sandeep Seth, Sandeep Singh, Sander R Niehe, Sandra M Rivest, Sandra S Zier, Sandra Ahoud, Sandy Carr, Sanjay Ganapathi, Sanjay Shetty, Sanjeev Sharma, Santa Jimenez, Santhosh Satheesh, Santiago A Garcia, Sara Fernandez, Sara Karlsson, Sara Salkind, Sara Temiyasathit, Sarah Medina Rodriguez, Sarah Beaudry, Sarah Hadjih, Sarah Williams, Sarah Zahrani, Sarju Ralhan, Sasa Hinic, Sasko Kedev, Satinder Singh, Satoshi Yasuda, Satvic Cholenahally Manjunath, Sau Lee, Scott M Kaczkowski, Scott Kinlay, Sean W Hayes, Sebastian Sobczak, Senait Asier, Sergey A Sayganov, Seth I Sokol, Shaheen Pandie, Shaiful Azmi Yahaya, Shamir Mehta, Shao-Ping Nie, Sharad Chandra, Sharder Islam, Sharon Tai, Sheetal Rupesh Karwa, Sheri Ussery, Sheromani Bajaj, Sherron C Crook, Shigeyuki Nishimura, Shintaro Nakano, Shirin Heydari, Shiv Kumar Choudhary, Shivali Patel, Shobana Ganesan, Shruti Pandey, Shuyang Zhang, Shweta Hande, Siddharth Gadage, Sik-Yin V Tan, Silvia Zottis Poletti, Silvia Riera, Silvia Valbuena, Simon Walsh, Simona Maspoli, Simone Savaris, Si-Ting Feng, So Yang Cho, Solomon Yakubov, Songlin Zhu, Songtao Wang, Sonia Guerrero, Sonika Gupta, Sonja Salinger Martinovic, Sonya Brons, Sorin Brener, Sothinathan Gurunathan, Souheil Saba, Soundarya Nayak, Sowjanya Reddy, Srinivasa Potluri, Sriram Sudarshan, Srun Kuanprasert, Stacie Van Oosterhout, Stamatios Lerakis, Stanley E Cobos, Stefan C Bertog, Stefan M Simović, Stefan Weikl, Stefano Di Marco, Stefano Provasoli, Stephanie A Tirado, Stephanie C Boer, Stephanie M Lane, Stephanie Ferket, Stephanie Kelly, Stephanie Wasmiller, Stephen H McKellar, Stephen P Hoole, Stephen Fremes, Stephen Preston, Steve Leung, Steven A Fein, Steven J Lindsay, Steven P Sedlis, Steven Giovannone, Steven Michael, Steven Weitz, Stijn van Vugt, Subhash Banerjee, Sudhir Naik, Suellen Hosino, Sukie Desire, Sukit Yamwong, Suku T Thambar, Sulagna Mookherjee, Suman Singh, Sundeep Mishra, Sunil Kumar Verma, Supap Kulthawong, Supatchara Khwakhong, Surendra Naik, Suresh Babu, Surin Woragidpoonpol, Suryaprakash Narayanappa, Susan Derbyshire, Susan Gent, Susan Mathus, Susan Milbrandt, Susan Moore, Susan Regan, Susan Stinson, Susan Webber, Susana Silva, Susanna Stevens, Susanne Gruensfelder, Suthara Aramcharoen, Suvarna Kolhe, Suzana Tavares, Suzanne Arnold, Suzanne Welsh, Svetlana Apostolovic, Swapna Kunhunny, Ta-Chuan Hung, Taissa Zappernick, Tali Sharir, Talita Silva, Tamara Colaiácovo Soares, Tapan Umesh Pillay, Tarun K Mittal, Tatiana Trifonova, Tauane Bello Duarte, Tauqir Huk, Téodora Dutoiu, Terrance Chua, Terry Weyand, Thabitha Charles, Theodoros Kofidis, Theresa McCreary, Thierry Lefevre, Thippeekaa Arumairajah, Thitipong Tepsuwan, Thomas J Mulhearn, Thomas M Meyer, Thomas P Rocco, Thomas R Downes, Thomas Crain, Thomas Haldis, Thomas Mathew, Thomas Redick, Thounaojam Indira Devi, Thuraia Nageh, Tia Cauthren, Tiago Silva, Tiffany Little, Tijana Andric, Tina Harding, Titus Lau, Tiziana Formisano, Tiziano Moccetti, Tomasz Ciurus, Tomasz Mazurek, Tomasz Tarchalski, Toshiyuki Nagai, Tri Tran, Tricia Youn, Trish Tucker, Trudie Milner, Tuhina Bose, Tushar Kotecha, Udo Sechtem, Uma S Valeti, Umberto Cucchini, Umesh Badami, Upendra Kaul, V K Bahl, V S Narain, Valentina Casali, Valeria Godoy, Valerie Robesyn, Vamshi P Priya, Vandana Yadav, Vera McKinney, Veronica De Lenges, Veronica Tinnirello, Vicente Miro, Victor Navarro, Victoria Gumerova, Victoria Hernandez, Vidya Seeratan, Vijay Kumar, Vikentiy Y Kozulin, Viktoria Bulkley, Vilmar Veiga Jr, Vincent Setang, C P Vineeth, Virginai Pubull Nuñez, Virginia Fernández-Figares, Vitor Gomes, Viviana Gabriel, Viviane Dos Santos, Viviane Almeida, Vlad A Iliescu, Vladan Mudrenovic, Vladimir Dzavik, Vojislav L Giga, Walter Enrique Mogrovejo, Wan Xian Chan, Wanda C Marfori, Wanda Parker, Warangkana Mekara, Wassim Nona, Wayne Old, Wayne Pennachi, Weerachai Nawarawong, Wei Chen, Wei Su, Weibing Xing, Wei-Ren Lan, Wenda Crawford, Wendy L Stewart, Wendy Drewes, Wenhua Lin, William B Abernethy, William D Salerno, William F Fearon, William Vergoni, William Weintraub, Winnie C Sia, Wlodzimierz J Musial, Xacobe Flores-Ríos, Xavier Garcia-Moll Marimon, Xi Su, Xiang Ma, Xiangqiong Gu, Xiao Wang, Xiaomei Li, Xiaowei Yao, Xin Fu, Xin Su, Xin Zeng, Xinchun Yang, Xiuhong Li, Xuehua Fang, Xutong Wang, Yaming Geng, Yan Yan, Yanek Pépin-Dubois, Yanfu Wang, Yang Wang, Yanmeng Tian, Yaping Huang, Yechen Han, Yesenia Zambrano, Yi-Hsuan Yang, Ying Tung Sia, Yining Yang, Yitong Ma, Yolayfi Peralta, Yongjian Wu, Yu Kunwu, Yu Zhao, Yudong Peng, Yueh-Hung Lin, Yulan Zhao, Yumei Dong, Yunhai Zhao, Yutthaphan Wannasopha, Yvonne Taul, Zakir Sahul, Zalina Kudzoeva, Zbigniew Kalarus, Zeljko Z Markovic, Zhen Huang, Zheng Ji, Zhenyu Liu, Zhou Yue, Zhulin Zhang, Zhuxi Li, Zile Singh Meharwal, Ziliang Bai, Zixiang Yu, Zohra Huda, Zoltan Davidovits
Subjects: Male, Cardiac Catheterization, Computed Tomography Angiography, medicine.medical_treatment, Myocardial Ischemia, Coronary Disease, Coronary Artery Disease, Kaplan-Meier Estimate, 030204 cardiovascular system & hematology, Coronary Angiography, ISCHEMIA Research Group, law.invention, Angina, Coronary artery disease, 0302 clinical medicine, Randomized controlled trial, law, Cardiovascular Disease, Myocardial Revascularization, 030212 general & internal medicine, Coronary Artery Bypass, 11 Medical and Health Sciences, Cardiac catheterization, General Medicine, Middle Aged, humanities, Cardiovascular Diseases, Cardiology, Female, Human, medicine.medical_specialty, Ischemia, Article, 03 medical and health sciences, Geriatric cardiology, Percutaneous Coronary Intervention, General & Internal Medicine, Internal medicine, medicine, Humans, Angina, Unstable, Aged, business.industry, Coronary Artery Bypa, Percutaneous coronary intervention, Bayes Theorem, medicine.disease, Heart failure, Quality of Life, business
Abstract: BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).
Published: 2020
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47. Assessing Microvascular Dysfunction in Angina With Unobstructed Coronary Arteries

Author: Tim P. van de Hoef, Valeria Paradies, Tijn P.J. Jansen, Peter Ong, Annemiek M.J. de Vos, Stijn C. van den Oord, Peter Damman, Niels van Royen, Suzette E. Elias-Smale, Pieter C. Smits, and Regina E. Konst
Subjects: medicine.medical_specialty, Modalities, business.industry, Blood flow, medicine.disease, Diagnostic modalities, Coronary arteries, Angina, Coronary artery disease, Microvascular resistance, medicine.anatomical_structure, Internal medicine, medicine, Cardiology, In patient, Cardiology and Cardiovascular Medicine, business
Abstract: Coronary microvascular dysfunction is a highly prevalent condition of both structural and functional coronary disorders in patients with angina and nonobstructive coronary artery disease (ANOCA). Current diagnostic modalities to assess microvascular function are related to prognosis, but these modalities have several technical shortcomings and lack the opportunity to determine true coronary blood flow and microvascular resistance. Intracoronary continuous thermodilution assessment of absolute coronary flow (Q) and microvascular resistance (R) was recently shown to be safe and feasible in ANOCA. Further exploration and implementation could lead to a better understanding and treatment of patients with ANOCA. This review discuss the coronary pathophysiology of microvascular dysfunction, provides an overview of noninvasive and invasive diagnostics, and focuses on the novel continuous thermodilution method. Finally, how these measurements of absolute Q and R could be integrated and how this would affect future clinical care are discussed.
Published: 2021
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48. [Management of chronic coronary syndrome]

Author: Udo, Sechtem, Andreas, Seitz, Peter, Ong, and Raffi, Bekeredjian
Subjects: Cardiology, Humans, American Heart Association, Coronary Artery Disease, United States
Abstract: Coronary artery disease remains the leading cause of death in developed countries. This CME article addresses and comments on important aspects from the current guidelines for the diagnosis and management of chronic coronary syndrome of the European Society of Cardiology (ESC) and the current guidelines for the evaluation and diagnosis of chest pain of the American Heart Association (AHA)/the American College of Cardiology (ACC).Die koronare Herzkrankheit ist immer noch die häufigste Todesursache in den Industrieländern. Dieser CME-Artikel greift wichtige Punkte aus den aktuellen Leitlinien zum chronischen Koronarsyndrom der European Society of Cardiology (ESC) bzw. zum Brustschmerz der American Heart Association (AHA)/des American College of Cardiology (ACC) auf und kommentiert sie.
Published: 2022

49. A COMPARISON OF FORM 2 ENGLISH CURRICULUM CHANGE IN MALAYSIAN SECONDARY SCHOOLS

Author: PETER ONG, MD JAIS ISMAIL, AZU FARHANA ANUAR, FAUZILA ABDUL LATIF, and SIM PEI PEI CHRISTINA
Subjects: ComputingMilieux_COMPUTERSANDEDUCATION
Abstract: This study investigates the curriculum change of Form 2 English syllabus and compares the mentioned curriculum between two Malaysian public secondary schools. Study on the curriculum change in teaching, learning and assessment of Form 2 KSSM English Language curriculum in the two public secondary schools is discussed. A curriculum change is being implemented because the current curriculum is needed to be revised. The schools have been using the current curriculum for many years. However, recent research has shown that better, more innovative methods help students succeed in the curriculum. A team looked at new learning priorities earlier in the year, and another looked at classroom tools and materials. It is time to develop and revise aspects of the curriculum in Form 2 English. In-depth interview was carried out to obtain the findings. An English teacher from an urban secondary school and another English teacher from a rural secondary school were selected as the participants. Three interview sessions were conducted with each respondent over a period of one month. Interview sessions via Whatsapp were conducted on one-to-one basis between the researcher and the participants. After the interview, follow-up information correspondence via email was accomplished. Items in the interview were developed by the researchers. Three experts in related field were involved in validating the interview protocol and appropriacy of the language employed for this study. Findings on comparison between the curriculum change in urban secondary school and rural secondary school are discussed. This study provides the overview of Form 2 English Language curriculum of the 21st century educational setting, especially for other researchers and practitioners.
Published: 2021
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50. Expansion of CD4+CD28NULL T lymphocytes in patients with focal epicardial spasm. A potential novel pathogenetic role

Author: Astrid Hubert, Peter Ong, Sebastian Kubik, Sibylle Thude, Udo Sechtem, and Kirstin Linke
Subjects: Pathology, medicine.medical_specialty, business.industry, Medicine, In patient, Cardiology and Cardiovascular Medicine, business
Published: 2021
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