Publications
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Davis EF, Crousillat DR, Peteiro J, et al., 2023, Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA study., J Am Soc Echocardiogr
BACKGROUND: Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA). OBJECTIVES: To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA. METHODS: Left ventricular GLS was calculated offline on resting SE images at enrollment (n=144) and 1-year follow-up (n=120) in the CIAO-ISCHEMIA study, which enrolled participants with moderate or severe ischemia by local SE interpretation (>3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) CAD on coronary CT angiography. RESULTS: GLS values were normal in 83.3% at enrollment and 94.2% at follow-up. GLS values were not associated with a positive SE at enrollment (GLS -21.5% positive SE vs. GLS -19.9% negative SE, p=0.443), or follow-up (GLS -23.2% positive SE vs. GLS -23.1% negative SE, p=0.859). Significant change in GLS was not associated with positive SE in follow-up (p=0.401). Regional strain was not associated with co-localizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β=0.41, 95% CI 0.16, 0.67, p=0.002). CONCLUSIONS: In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.
Hewitson LJ, Cadiz S, Al-Sayed S, et al., 2023, Time to TAVI: streamlining the pathway to treatment., Open Heart, Vol: 10, ISSN: 2053-3624
INTRODUCTION: Severe aortic stenosis is a major cause of morbidity and mortality. The existing treatment pathway for transcatheter aortic valve implantation (TAVI) traditionally relies on tertiary Heart Valve Centre workup. However, this has been associated with delays to treatment, in breach of British Cardiovascular Intervention Society targets. A novel pathway with emphasis on comprehensive patient workup at a local centre, alongside close collaboration with a Heart Valve Centre, may help reduce the time to TAVI. METHODS: The centre performing local workup implemented a novel TAVI referral pathway. Data were collected retrospectively for all outpatients referred for consideration of TAVI to a Heart Valve Centre from November 2020 to November 2021. The main outcome of time to TAVI was calculated as the time from Heart Valve Centre referral to TAVI, or alternative intervention, expressed in days. For the centre performing local workup, referral was defined as the date of multidisciplinary team discussion. For this centre, a total pathway time from echocardiographic diagnosis to TAVI was also evaluated. A secondary outcome of the proportion of referrals proceeding to TAVI at the Heart Valve Centre was analysed. RESULTS: Mean±SD time from referral to TAVI was significantly lower at the centre performing local workup, when compared with centres with traditional referral pathways (32.4±64 to 126±257 days, p<0.00001). The total pathway time from echocardiographic diagnosis to TAVI for the centre performing local workup was 89.9±67.6 days, which was also significantly shorter than referral to TAVI time from all other centres (p<0.003). Centres without local workup had a significantly lower percentage of patients accepted for TAVI (49.5% vs 97.8%, p<0.00001). DISCUSSION: A novel TAVI pathway with emphasis on local workup within a non-surgical centre significantly reduced both the time to TAVI and rejection rates from a He
Shah BN, Senior R, 2023, Sensitivity and specificity of non-invasive stress imaging techniques-an outdated paradigm in contemporary clinical cardiology?, Eur Heart J Cardiovasc Imaging, Vol: 24, Pages: e276-e277
Surkova E, Constantine A, Xu Z, et al., 2023, Prognostic significance of subpulmonary left ventricular size and function in patients with a systemic right ventricle, European Heart Journal - Cardiovascular Imaging, ISSN: 2047-2404
AimTo assess the additional prognostic significance of echocardiographic parameters of subpulmonary left ventricular (LV) size and function in patients with a systemic right ventricle (SRV).Methods and ResultsAll adults with a SRV who underwent transthoracic echocardiography in 2010-2018 at a large tertiary center were identified. Biventricular size and function were assessed at the most recent exam. The study endpoint was all-cause mortality or heart/heart-lung transplantation.We included 180 patients, 100(55.6%) male, mean age 42.4±12.3 years, of whom 103(57.2%) had undergone Mustard/Senning operations and 77(42.8%) had congenitally corrected transposition of great arteries.Over 4.9[3.8-5.7] years, 28(15.6%) patients died and 4(2.2%) underwent heart or heart-lung transplantation. Univariable predictors of the study endpoint included age, NYHA functional class III or IV, history of atrial arrhythmias, presence of pacemaker or cardioverter-defibrillator, high BNP, and echocardiographic markers of SRV and subpulmonary LV size and function. On multivariable Cox analysis of echocardiographic variables, indexed LV end-systolic diameter (ESDi; HR 2.77 [95%CI 1.35-5.68], p=0.01), LV fractional area change (FAC; HR 0.7 [95%CI 0.57-0.85], p=0.002), SRV basal diameter (HR 1.66 [95%CI 1.21-2.29], p=0.005), and SRV FAC (HR 0.65 [95%CI 0.49-0.87], p=0.008) remained predictive of mortality or transplantation. On ROC analysis, subpulmonary LV parameters performed better than SRV markers in predicting adverse events.ConclusionsSRV basal diameter, SRV FAC, LV ESDi, and LV FAC are significantly and independently associated with mortality and transplantation in adults with a SRV. Accurate echocardiographic assessment of both SRV and subpulmonary LV is therefore essential to inform risk stratification and management.
Kwan CT, Ching OHS, Yap PM, et al., 2023, Intraventricular 4D flow cardiovascular magnetic resonance for assessing patients with heart failure with preserved ejection fraction: a pilot study., Int J Cardiovasc Imaging
Diagnosing heart failure with preserved ejection fraction (HFpEF) remains challenging. Intraventricular four-dimensional flow (4D flow) phase-contrast cardiovascular magnetic resonance (CMR) can assess different components of left ventricular (LV) flow including direct flow, delayed ejection, retained inflow and residual volume. This could be utilised to identify HFpEF. This study investigated if intraventricular 4D flow CMR could differentiate HFpEF patients from non-HFpEF and asymptomatic controls. Suspected HFpEF patients and asymptomatic controls were recruited prospectively. HFpEF patients were confirmed using European Society of Cardiology (ESC) 2021 expert recommendations. Non-HFpEF patients were diagnosed if suspected HFpEF patients did not fulfil ESC 2021 criteria. LV direct flow, delayed ejection, retained inflow and residual volume were obtained from 4D flow CMR images. Receiver operating characteristic (ROC) curves were plotted. 63 subjects (25 HFpEF patients, 22 non-HFpEF patients and 16 asymptomatic controls) were included in this study. 46% were male, mean age 69.8 ± 9.1 years. CMR 4D flow derived LV direct flow and residual volume could differentiate HFpEF vs combined group of non-HFpEF and asymptomatic controls (p < 0.001 for both) as well as HFpEF vs non-HFpEF patients (p = 0.021 and p = 0.005, respectively). Among the 4 parameters, direct flow had the largest area under curve (AUC) of 0.781 when comparing HFpEF vs combined group of non-HFpEF and asymptomatic controls, while residual volume had the largest AUC of 0.740 when comparing HFpEF and non-HFpEF patients. CMR 4D flow derived LV direct flow and residual volume show promise in differentiating HFpEF patients from non-HFpEF patients.
Johnson CL, Woodward W, McCourt A, et al., 2023, Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study., Echo Res Pract, Vol: 10, ISSN: 2055-0464
BACKGROUND: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. METHODS: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. RESULTS: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated w
Nguyen DD, Spertus JA, Alexander KP, et al., 2023, Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial., J Am Coll Cardiol, Vol: 81, Pages: 1697-1709
BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in old
Gurunathan S, Shanmuganathan M, Chopra A, et al., 2023, Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with suspected coronary artery disease: a randomized study., Eur Heart J Open, Vol: 3
AIMS: There is a paucity of randomized diagnostic studies in women with suspected coronary artery disease (CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise electrocardiography (Ex-ECG) in women with CAD. METHODS AND RESULTS: Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilization. The PPV of ESE and Ex-ECG were 33% and 30% (P = 0.87), respectively for the detection of CAD. There were similar clinic visits (36 vs. 29, P = 0.44) and emergency visits with chest pain (28 vs. 25, P = 0.55) in the Ex-ECG and ESE arms, respectively. At 2.9 years, cardiac events were 6 Ex-ECG vs. 3 ESE, P = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs. 17, P = 0.003). Overall, there was higher downstream resource utilization (hospital attendances and investigations) in the Ex-ECG arm (P = 0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG. CONCLUSION: In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilization whilst providing cost savings.
Tang HS, Kwan CT, He J, et al., 2023, Prognostic Utility of Cardiac MRI Myocardial Strain Parameters in Patients With Ischemic and Nonischemic Dilated Cardiomyopathy: A Multicenter Study., AJR Am J Roentgenol, Vol: 220, Pages: 524-538
BACKGROUND. Prior small single-center studies have yielded conflicting results regarding the prognostic significance of myocardial strain parameters derived from feature tracking (FT) on cardiac MRI in patients with dilated cardiomyopathy (DCM). OBJECTIVE. The purpose of this study was to evaluate the prognostic utility of FT parameters on cardiac MRI in patients with ischemic and nonischemic DCM and to determine the optimal strain parameter for outcome prediction. METHODS. This retrospective study included 471 patients (median age, 61 years; 365 men, 106 women) with ischemic (n = 233) or nonischemic (n = 238) DCM and left ventricular (LV) ejection fraction (EF) less than 50% who underwent cardiac MRI at any of four centers from January 2011 to December 2019. Cardiac MRI parameters were determined by manual contouring. In addition, software-based FT was used to calculate six myocardial strain parameters (LV and right ventricular [RV] global radial strain, global circumferential strain, and global longitudinal strain [GLS]). Late gadolinium enhancement (LGE) was also evaluated. Patients were assessed for a composite outcome of all-cause mortality and/or heart-failure hospitalization. Cox regression models were used to determine associations between strain parameters and the composite outcome. RESULTS. Mean LV EF was 27.5% and mean LV GLS was -6.9%. The median follow-up period was 1328 days. The composite outcome occurred in 220 patients (125 deaths, 95 heart-failure hospitalizations). All six myocardial strain parameters were significant independent predictors of the composite outcome (hazard ratio [HR] = 0.92-1.16; all p < .05). In multivariable models that included age, corrected LV and RV end-diastolic volume, LV and RV EF, and presence of LGE, the only strain parameter that was a significant independent predictor of the composite outcome was LV GLS (HR = 1.13, p = .006); LV EF and presence of LGE were not independent predictors of the composite outcome in the
Ng M-Y, Kwan CT, Yap PM, et al., 2023, Diagnostic accuracy of cardiovascular magnetic resonance strain analysis and atrial size to identify heart failure with preserved ejection fraction., Eur Heart J Open, Vol: 3
AIMS: Heart failure with preserved ejection fraction (HFpEF) continues to be a diagnostic challenge. Cardiac magnetic resonance atrial measurement, feature tracking (CMR-FT), tagging has long been suggested to diagnose HFpEF and potentially complement echocardiography especially when echocardiography is indeterminate. Data supporting the use of CMR atrial measurements, CMR-FT or tagging, are absent. Our aim is to conduct a prospective case-control study assessing the diagnostic accuracy of CMR atrial volume/area, CMR-FT, and tagging to diagnose HFpEF amongst patients suspected of having HFpEF. METHODS AND RESULTS: One hundred and twenty-one suspected HFpEF patients were prospectively recruited from four centres. Patients underwent echocardiography, CMR, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements within 24 h to diagnose HFpEF. Patients without HFpEF diagnosis underwent catheter pressure measurements or stress echocardiography to confirm HFpEF or non-HFpEF. Area under the curve (AUC) was determined by comparing HFpEF with non-HFpEF patients. Fifty-three HFpEF (median age 78 years, interquartile range 74-82 years) and thirty-eight non-HFpEF (median age 70 years, interquartile range 64-76 years) were recruited. Cardiac magnetic resonance left atrial (LA) reservoir strain (ResS), LA area index (LAAi), and LA volume index (LAVi) had the highest diagnostic accuracy (AUCs 0.803, 0.815, and 0.776, respectively). Left atrial ResS, LAAi, and LAVi had significantly better diagnostic accuracy than CMR-FT left ventricle (LV)/right ventricle (RV) parameters and tagging (P < 0.01). Tagging circumferential and radial strain had poor diagnostic accuracy (AUC 0.644 and 0.541, respectively). CONCLUSION: Cardiac magnetic resonance LA ResS, LAAi, and LAVi have the highest diagnostic accuracy to identify HFpEF patients from non-HFpEF patients amongst clinically suspected HFpEF patients. Cardiac magnetic resonance feature tracking LV/RV parameters and tagging
Hochman JS, Anthopolos R, Reynolds HR, et al., 2023, Survival After Invasive or Conservative Management of Stable Coronary Disease, CIRCULATION, Vol: 147, Pages: 8-19, ISSN: 0009-7322
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- Citations: 2
Reynolds HR, Diaz A, Cyr DD, et al., 2023, Ischemia With Nonobstructive Coronary Arteries: Insights From the ISCHEMIA Trial., JACC Cardiovasc Imaging, Vol: 16, Pages: 63-74
BACKGROUND: Ischemia with nonobstructive coronary arteries (INOCA) is common clinically, particularly among women, but its prevalence among patients with at least moderate ischemia and the relationship between ischemia severity and non-obstructive atherosclerosis severity are unknown. OBJECTIVES: The authors investigated predictors of INOCA in enrolled, nonrandomized participants in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), sex differences, and the relationship between ischemia and atherosclerosis in patients with INOCA. METHODS: Core laboratories independently reviewed screening noninvasive stress test results (nuclear imaging, echocardiography, magnetic resonance imaging or nonimaging exercise tolerance testing), and coronary computed tomography angiography (CCTA), blinded to results of the screening test. INOCA was defined as all stenoses <50% on CCTA in a patient with moderate or severe ischemia on stress testing. INOCA patients, who were excluded from randomization, were compared with randomized participants with ≥50% stenosis in ≥1 vessel and moderate or severe ischemia. RESULTS: Among 3,612 participants with core laboratory-confirmed moderate or severe ischemia and interpretable CCTA, 476 (13%) had INOCA. Patients with INOCA were younger, were predominantly female, and had fewer atherosclerosis risk factors. For each stress testing modality, the extent of ischemia tended to be less among patients with INOCA, particularly with nuclear imaging. There was no significant relationship between severity of ischemia and extent or severity of nonobstructive atherosclerosis on CCTA. On multivariable analysis, female sex was independently associated with INOCA (odds ratio: 4.2 [95% CI: 3.4-5.2]). CONCLUSIONS: Among participants enrolled in ISCHEMIA with core laboratory-confirmed moderate or severe ischemia, the prevalence of INOCA was 13%. Severity of ischemia was not associated
Hochman JS, Maron DJ, Anthopolos R, et al., 2022, ISCHEMIA-EXTENDed Follow-Up Interim Report, Publisher: LIPPINCOTT WILLIAMS & WILKINS, Pages: E579-E579, ISSN: 0009-7322
Porter TR, Feinstein SB, Senior R, et al., 2022, CEUS cardiac exam protocols International Contrast Ultrasound Society (ICUS) recommendations, ECHO RESEARCH AND PRACTICE, Vol: 9, ISSN: 2055-0464
Bangalore S, Spertus JA, Stevens SR, et al., 2022, Outcomes With Intermediate Left Main Disease: Analysis From the ISCHEMIA Trial, CIRCULATION-CARDIOVASCULAR INTERVENTIONS, Vol: 15, ISSN: 1941-7640
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Hampson R, Botrous C, Chahal N, et al., 2022, Feasibility, efficacy and safety of exercise stress echocardiography during the COVID-19 pandemic, OPEN HEART, Vol: 9, ISSN: 2053-3624
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Cosyns B, Helfen A, Leong-Poi H, et al., 2022, How to perform an ultrasound contrast myocardial perfusion examination?, EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING, Vol: 23, Pages: 727-729, ISSN: 2047-2404
Senior R, Reynolds HR, Min JK, et al., 2022, Predictors of Left Main Coronary Artery Disease in the ISCHEMIA Trial, JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, Vol: 79, Pages: 651-661, ISSN: 0735-1097
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- Citations: 5
Sze S, Bates O, Toulemonde M, et al., 2022, Semi-automatic Segmentation of the Myocardium in High-Frame Rate and Clinical Contrast Echocardiography Images, IEEE International Ultrasonics Symposium (IUS), Publisher: IEEE, ISSN: 1948-5719
Surkova E, Kovacs A, Lakatos BK, et al., 2021, Contraction patterns of the systemic right ventricle: a three-dimensional echocardiography study, EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING, Vol: 23, Pages: 1654-1662, ISSN: 2047-2404
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- Citations: 2
Yakupoglu HY, Saeed S, Senior R, et al., 2021, Reversible exercise-induced left ventricular dysfunction in symptomatic patients with previous Takotsubo syndrome: insights from stress echocardiography, Congress of the European-Society-of-Cardiology (ESC) / World Congress of Cardiology, Publisher: OXFORD UNIV PRESS, Pages: 1405-1412, ISSN: 2047-2404
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Vamvakidou A, Danylenko O, Pradhan J, et al., 2021, Relative clinical value of coronary computed tomography and stress echocardiography-guided management of stable chest pain patients: a propensity-matched analysis, EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING, Vol: 22, Pages: 1473-1481, ISSN: 2047-2404
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Zhou X, Toulemonde M, Zhou X, et al., 2021, Volumetric Flow Estimation in a Coronary Artery Phantom Using High-Frame-Rate Contrast-Enhanced Ultrasound, Speckle Decorrelation, and Doppler Flow Direction Detection, IEEE TRANSACTIONS ON ULTRASONICS FERROELECTRICS AND FREQUENCY CONTROL, Vol: 68, Pages: 3299-3308, ISSN: 0885-3010
Vamvakidou A, Annabi M-S, Pibarot P, et al., 2021, Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study, CIRCULATION-CARDIOVASCULAR IMAGING, Vol: 14, ISSN: 1941-9651
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Jenkins S, Alabed S, Swift A, et al., 2021, Diagnostic accuracy of handheld cardiac ultrasound device for assessment of left ventricular structure and function: systematic review and meta-analysis, HEART, Vol: 107, Pages: 1826-1834, ISSN: 1355-6037
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Bioh G, Botrous C, Howard E, et al., 2021, Prevalence of cardiac pathology and relation to mortality in a multiethnic population hospitalised with COVID-19, OPEN HEART, Vol: 8, ISSN: 2053-3624
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Newman JD, Anthopolos R, Mancini GBJ, et al., 2021, Outcomes of Participants With Diabetes in the ISCHEMIA Trials, CIRCULATION, Vol: 144, Pages: 1380-1395, ISSN: 0009-7322
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Senior R, Khattar R, 2021, Stress echocardiography: the quest for risk stratification beyond myocardial ischaemia, EUROPEAN HEART JOURNAL, Vol: 42, Pages: 3879-3881, ISSN: 0195-668X
Seitler S, Al-Sakini N, Lacerna A, et al., 2021, Long term outcomes for adults with complete atrioventricular septal defects, Publisher: OXFORD UNIV PRESS, Pages: 1874-1874, ISSN: 0195-668X
Shah BN, Senior R, 2021, Discordant moderate aortic stenosis: is it clinically important?, OPEN HEART, Vol: 8, ISSN: 2053-3624
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