Is there an exercise duration threshold for exercise-induced troponin elevation in healthy recreational athletes? The NEEDED 2014 advanced heart rate monitor substudy

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Bjorkavoll-Bergseth ◽  
B Auestad ◽  
O Kleiven ◽  
O Skadberg ◽  
T Eftestol ◽  
...  
Keyword(s):  
Heart Rate ◽  
Clinical Status ◽  
Exercise Duration ◽  
Strenuous Exercise ◽  
Clinical Consequence ◽  
Funding Source ◽  
Recreational Athletes ◽  
National Budget ◽  
Exercise Induced ◽  
Public Grant

Abstract Background/Introduction Following prolonged strenuous exercise there is an exercise-induced troponin (cTn) elevation in healthy individuals. The precise mechanisms and clinical consequence of this cTn elevation remain to be determined. It has recently been demonstrated that exercise intensity, exceeding a heart rate (HR) of 150 bpm, is correlated with exercise-induced cTn elevation. Purpose The present work aims to determine if there is a threshold for exercise duration with a HR exceeding 150 bpm associated with an excessive exercise-induced cTn elevation. Methods A total of 177 healthy subjects were included in the present analysis of HR data obtained from sport watches used during a 91-km recreational mountain bike cycle race. Clinical status, cTnI, ECGs, blood pressure and demographics were obtained 24 h prior to- and at 3 h and 24 h after the race. Results are reported as median and 25th and 75th percentile. We used Tree regression to determine the association between elevated cTnI and exercise duration exceeding a HR of 150 bpm. Results Subjects were 82% (n=146) males, 44 (39–51) years, with a race time of 3.5 (3.1–3.9) h. Baseline cTnI was 1.9 (1.6–3.3) ng/L. There was a cTnI elevation in all study participants at 3 h, cTnI: 60.0 (36.0–99.3) ng/L, with a significant (p<0.001) reduction at 24 hours following exercise, cTnI: 10.9 (6.1–22.4) ng/L. Tree regression identified 168 min of exercise, with a HR exceeding 150 bpm, to be associated with an excessive increase in cTnI both at 3 h, and at 24 h following the race (figure). The median cTn values above and below the threshold are presented in the Table. Conclusion The present analysis suggests that exceeding a specific duration of high intensity exercise may be associated with excessive cTn elevation in susceptible individuals. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Western Norway Health authoritites.

Ventricular premature contractions coupling interval behavior and efficacy of anti-arrhythmic drugs

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Abdel-Wahed ◽  
A Abdel-Wahed ◽  
H Maekynen ◽  
P Raatikainen
Keyword(s):  
Heart Rate ◽  
Ventricular Arrhythmia ◽  
Ventricular Arrhythmias ◽  
Funding Source ◽  
National Budget ◽  
Rr Interval ◽  
Therapy Efficacy ◽  
Coupling Interval ◽  
Public Grant ◽  
Ministry Of Higher Education

Abstract Introduction The Idiopathic ventricular arrhythmias are special type of arrhythmia that occurs in the absence of clinically apparent structural heart. They have different pattern of recurrence sporadic, bigeminy, trigeminy, couplets and Ventricular tachycardia runs. They have special behavior of relatively constant coupling interval and recurrence depending on heart rate variability and autonomic nervous system dominance.Objectives: To assess the effect of Coupling interval on the efficacy of different anti-arrhythmic drug. Methods Each subject among 125 consecutive patients with high ventricular premature contractions burden, 24 h ambulatory electrocardiograms were recorded in the absence of anti-arrhythmic drug (control), and during treatment with various anti-arrhythmic drugs. The ratio of the coupling interval (CI) to the preceding R-R intervals was calculated.Patients were treated by different anti-arrhythmic therapy. Efficacy of anti-arrhythmic therapy was documented by ambulatory electrocardiogram for 24 hour by estimating the reduction of Ventricular arrhythmia burden. Results The burden of ventricular premature contractions was reduced effectively (>70% reduction of PVCs burden) in patients receiving BB with RR interval <680 ms, CI/RR <0.4, (P=0.002) (relative tachycardia), while in patients receiving CCB it was effective with RR 650- 830 ms, CI/RR 0.4–0.7, (P=0.04) (average heart rate). While in patients receiving Flecanide were found to have effective therapy with RR >900 ms, CI/RR>0.7, (relative bradycardia) (P=0.005). Conclusion The coupling interval of ventricular premature contractions can predict the efficacy of anti-arrhythmic drugs. The efficacy of anti-arrhythmic therapy may be dependent on the ventricular arrhythmia behavior of the coupling interval and RR interval of the preceding sinus rhythm. Efficacy of different anti-arrhythmic Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Egyptian Ministry of Higher Education

scholarly journals Quantitative 4D Flow CMR analysis of intracardiac blood flow energetics in ischemic cardiomyopathy patients

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Riva ◽  
A Camporeale ◽  
F Sturla ◽  
S Pica ◽  
L Tondi ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Cardiomyopathy ◽  
Inverse Correlation ◽  
Lv Function ◽  
Funding Source ◽  
4D Flow ◽  
Anterior Myocardial Infarction ◽  
National Budget ◽  
4D Flow Cmr ◽  
Public Grant

Abstract Background Ischemic cardiomyopathy (ICM) is often associated with negative LV remodelling after myocardial infarction, sometimes resulting in impaired LV function and dilation (iDCM). 4D Flow CMR has been recently exploited to assess intracardiac hemodynamic changes in presence of LV remodelling. Purpose To quantify 4D Flow intracardiac kinetic energy (KE) and viscous energy loss (EL) and investigate their relation with LV dysfunction and remodelling. Methods Patients with prior anterior myocardial infarction underwent a CMR study with 4D Flow sequences acquisition; they were divided into ICM (n=10) and iDCM (n=10, EDV>208 ml and EF<40%). 10 controls were used for comparison. LV was semi-automatically segmented using short axis CMR stacks and co-registered with 4D Flow. Global KE and EL were computed over the cardiac cycle. NT-proBNP measurements were correlated with average and peak values, during systole and diastole. Results Both LV volume and EF significantly differ (P<0.0001) between iDCM (EDV=294±56 ml, EF=24±8%), ICM (EDV=181±32 ml, EF=34±6%) and controls (EDV=124±29 ml, EF=72±5%). If compared to controls, both ICM and iDCM showed significantly lower KE (P≤0.0008); though lower than controls, EL was higher in iDCM than ICM. Within the iDCM subgroup, diastolic mean KE and peak EL reported good inverse correlation with NT-proBNP (r=−0.75 and r=−0.69, respectively). EL indexed (ELI) to average KE during systole was higher in the entire ischemic group as compared to controls (ELI(ischemic) = 0.17 vs. ELI(controls) = 0.10, P=0.0054). Conclusions 4D Flow analyses effectively mapped post-ischemic LV energetic changes, highlighting the disproportionate intraventricular EL relative to produced KE; preliminary good correlation between LV energetic changes and NT-proBNP will deserve further investigation in order to contribute to early detection of heart failure. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health

scholarly journals Regular consumption of cod liver oil is associated with reduced basal and exercise-induced C-reactive protein levels; a prospective observational trial

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Mette Wærstad Hansen ◽  
Stein Ørn ◽  
Christine B. Erevik ◽  
Magnus Friestad Bjørkavoll-Bergseth ◽  
Øyvind Skadberg ◽  
...  
Keyword(s):  
Fatty Acid ◽  
Strenuous Exercise ◽  
Cod Liver Oil ◽  
Omega 3 ◽  
C Reactive Protein ◽  
Omega 3 Fatty Acid ◽  
Recreational Athletes ◽  
Reactive Protein ◽  
Supplement Use ◽  
Exercise Induced

Abstract Background Dietary supplement use among recreational athletes is common, with the intention of reducing inflammation and improving recovery. We aimed to describe the relationship between omega-3 fatty acid supplement use and inflammation induced by strenuous exercise. Methods C-reactive protein (CRP) concentrations were measured in 1002 healthy recreational athletes before and 24 h after a 91-km bicycle race. The use of omega-3 fatty acid supplements was reported in 856 out of 1002 recreational athletes, and the association between supplement use and the exercise-induced CRP response was assessed. Results Two hundred seventy-four subjects reported regular use of omega-3 fatty acid supplements. One hundred seventy-three of these used cod liver oil (CLO). Regular users of omega-3 fatty acid supplements had significantly lower basal and exercise-induced CRP levels as compared to non-users (n = 348, p < 0.001). Compared to non-users, regular users had a 27% (95% confidence interval (CI): 14–40) reduction in Ln CRP response (unadjusted model, p < 0.001) and 16% (95% CI: 5–28, p = 0.006) reduction after adjusting for age, sex, race duration, body mass index, delta creatine kinase, MET hours per week, resting heart rate and higher education. CLO was the primary driver of this response with a 34% (95% CI: 19–49) reduction (unadjusted model, p < 0.001) compared to non-users. Corresponding numbers in the adjusted model were 24% (95% CI: 11–38, p < 0.001). Conclusion Basal CRP levels were reduced, and the exercise-induced CRP response was attenuated in healthy recreational cyclists who used omega-3 fatty acid supplements regularly. This effect was only present in regular users of CLO. Trial registration NCT02166216, registered June 18, 2014 – Retrospectively registered.

scholarly journals Assessment of myocardial deformation with CMR: a comparison with ultrasound speckle tracking in a cohort of highly trained endurance athletes

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
B Domenech-Ximenos ◽  
M Sanz-De La Garza ◽  
A Sepulveda-Martinez ◽  
D Lorenzatti ◽  
F Simard ◽  
...  
Keyword(s):  
Speckle Tracking ◽  
Longitudinal Strain ◽  
Systolic Function ◽  
Global Longitudinal Strain ◽  
Myocardial Deformation ◽  
Endurance Athletes ◽  
National Budget ◽  
Complex Anatomy ◽  
Exercise Induced ◽  
Public Grant

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Plan Nacional I.D., Del Programa Estatal de Fomento De La Investigación Científica y Técnica de Excelencia, Subprograma De Generación Del Conocimiento, Ministerio de Economía y Competitividad 2013. Background  Myocardial deformation integrated with cardiac dimensions provides a comprehensive assessment of the ventricular remodelling patterns induced by cumulative effects of intensive exercise. Feature tracking(FT) can measure myocardial deformation from cardiac magnetic resonance(CMR) cine sequences; however, its accuracy is still scarcely validated. Purpose  Our aim was to compare FT’s accuracy and reproducibility to speckle tracking echocardiography (STE) in highly trained endurance athletes (EAs). Methods  93 EAs (&gt;12 hours training/week during the last 5 years, 52% male, 35 ± 5.1 years) and 72 age-matched controls underwent a resting CMR and a transthoracic echocardiography to assess biventricular exercise-induced remodelling and biventricular global longitudinal strain (GLS) by CMR-FT and STE. Results   High endurance training load was associated with larger bi-ventricular and bi-atrial sizes and mildly reduced systolic function of both ventricles (p &lt; 0,05). Strain values (both by CMR-FT and STE) proportionally decreased with increasing ventricular volumes potentially depicting the increased volume and functional biventricular reserve that characterize EAs heart. Strain values were lower when assessed by CMR-FT as compared to STE (p &lt; 0.001), with good reproducibility for the LV (bias = 3.94%, LOA= ± 4.27%) but wider variability for RV strains (Figure 2). Conclusions   Biventricular longitudinal strain values were lower when assessed by FT compared to STE. Both methods were comparable when measuring LV strain but not RV strain. These differences might be justified by FT’s lower in-plane spatial and temporal resolution, which is particularly relevant for the complex anatomy of the RV. Abstract Figure. Fig 1. Bland-Altman plots; FT vs STE.

Effect of infarct stiffness on non-infarcted left and right ventricular tissue remodeling: a computational study based on myocardial mechano-transduction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Koopsen ◽  
N Van Osta ◽  
E Willemen ◽  
F.A Van Nieuwenhoven ◽  
J Gorcsan ◽  
...  
Keyword(s):  
Computational Model ◽  
Computational Study ◽  
Compensatory Hypertrophy ◽  
Funding Source ◽  
Tissue Mass ◽  
Model Simulations ◽  
National Budget ◽  
End Diastolic Volume ◽  
Public Grant ◽  
Infarcted Tissue

Abstract Background/Introduction The mechanical properties of infarcted myocardium are important determinants of cardiac pump function and risk of developing heart failure following myocardial infarction (MI). Purpose To better understand the effects of infarct stiffness on compensatory hypertrophy and dilation of non-infarcted tissue in the left (LV) and right ventricle (RV), by using a computational model. Methods The CircAdapt computational model of the human heart and circulation was applied to simulate an acute MI involving 20% of LV wall mass. The simulation was validated using previously published experimental data. Subsequently, two degrees of increased infarct stiffness were simulated. In all three simulations, a model of structural myocardial adaptation of the non-infarcted tissue was applied, based on sensing of mechanical loading of myocytes and extracellular matrix (ECM). Results Mild and severe stiffening of the infarct reduced the increase of LV end-diastolic volume (EDV) from +23 mL to +17 mL and +16 mL, respectively, and the increase of LV non-infarcted tissue mass from +31% to +21% and +18%. RV EDV decreased after adaptation, and mild and severe infarct stiffening reduced the decrease of RV EDV from −21 mL to −12 mL and −10 mL, respectively. Increase of RV tissue mass was reduced from +13% to +8% and +7% with mild and severe infarct stiffening. In the LV, reduced dilation and hypertrophy were driven mainly by a reduction of maximum stress in the ECM and a higher stress between the myocytes and ECM following infarct stiffening. The decreased RV hypertrophy, but not EDV reduction, was caused by a reduction of maximum RV ECM stress and maximum RV active myofiber stress. Conclusions Model simulations predicted that a stiffened LV infarct reduces both LV and RV non-infarcted tissue hypertrophy as well as LV dilation. In LV remodeling, maximum ECM stress and stress between myocyte and ECM played a more prominent role than in RV remodeling, while maximum active stress was more important in the RV. Overview of all model simulations Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was funded by the Netherlands Organisation for Scientific Research and the Dutch Heart Foundation.

Grading, Time Course, and Incidence of Exercise-Induced nduced Airway Obstruction and Hyperinflation in Asthmatic Children

PEDIATRICS ◽  
1975 ◽  
Vol 56 (5s) ◽  
pp. 868-879
Author(s):  
Gerd J. A. Cropp ◽  
I. J. Schmultzler
Keyword(s):  
Pulmonary Function ◽  
Airway Obstruction ◽  
Clinical Status ◽  
Small Airway ◽  
Strenuous Exercise ◽  
Normal Children ◽  
Asthmatic Children ◽  
Ergometer Exercise ◽  
Exercise Induced ◽  
Small Airway Obstruction

We evaluated clinical status and pulmonary function in 60 perennially asthmatic and 11 normal children before and repeatedly after incrementally increasing bicycle ergometer exercise. The changes in clinical status and pulmonary function which were elicited by strenuous exercise were graded by an air exchange and a physiological grading system respectively. Normal children showed no significant clinical or physiological changes after exercise. Strenuous exercise elicited significant deteriorations in clinical and physiological measurements in 36% to 77% of asthmatic girls and 46% to 90% of asthmatic boys, the frequency depending on the test used to determine exercise-induced abnormalities. The incidence of exercise-induced asthma (EIA) was statistically significantly higher in asthmatic boys than girls. The higher incidence of EIA in boys was primarily due to a larger number of very severe attacks in boys than girls; mild and moderate EIA was about equally common in the two sexes. Most patients with EIA developed large and small airway obstruction, although large airway obstruction tended to be the predominant and the more severe abnormality. Clinical and physiological abnormalities, regardless of severity, were usually most marked during the first ten minutes after exercise and lessened thereafter. Mild EIA usually lasted for only 15 minutes or less; severe EIA improved, but usually did not resolve within 35 minutes of exercise. There were three patients in whom the severity of EIA got worse after exercise and an additional seven in whom the improvement was minimal. In these ten patients isoproterenol aerosol terminated EIA, indicating that exercise-induced large and small airway obstruction in asthmatic children is primarily. if not solely. due to bronchospasm.

Parameters to Be Measured during Exercise

2018 ◽  
pp. 82-105
Author(s):  
Gregory S. Thomas ◽  
Myrvin H. Ellestad
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Myocardial Ischemia ◽  
Oxygen Uptake ◽  
Exercise Duration ◽  
Metabolic Equivalents ◽  
Include Blood Pressure ◽  
Electrocardiographic Changes ◽  
Health And Disease ◽  
Exercise Induced

The chapter Parameters to be Measured During Exercise reviews the physiologic changes with exercise which indicate health and disease. Key parameters include blood pressure, heart rate, electrocardiographic changes, exercise duration, maximum oxygen uptake (VO2max), and anaerobic threshold. An in-depth review and consensus estimate is provided to estimate metabolic equivalents (METs) achieved based on exercise duration on the Bruce and Ellestad protocols. Use of bipolar leads for detection of exercise induced myocardial ischemia is discussed, typified by CM5 which captures up to 90% of patients with an electrocardiographic manifestation of ischemia. Changes in murmurs that occur with exercise are reviewed; walk-through angina and chronotropic incompetence.

scholarly journals Distinguishing sinus rhythm from atrial fibrillation on single-lead ECGs using a deep neural network

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Oudkerk Pool ◽  
B.D De Vos ◽  
J.M Wolterink ◽  
S Blok ◽  
M.J Schuuring ◽  
...  
Keyword(s):  
Neural Network ◽  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Roc Curve ◽  
Model Development ◽  
Independent Set ◽  
Funding Source ◽  
National Budget ◽  
Validation Set ◽  
Public Grant

Abstract Background The growing availability of mobile phones increases the popularity of portable telemonitoring devices. An atrial fibrillation diagnosis can be reached with a recording of 30s on such telemonitoring devices. However, current commercially available automatic algorithms still require approval by experts. Purpose In this research we aimed to build an artificial intelligence (AI) algorithm to improve automatic distinction of atrial fibrillation (AF) from sinus rhythm (SR), to ultimately save time, costs, and to facilitate telemonitoring programs. Methods We developed a deep convolutional neural network (CNN), based on a residual neural network (ResNet), tailored to single-lead ECG analysis. The CNN was trained using publicly available single-lead ECGs from the 2017 PhysioNet/ Computing in Cardiology Challenge. This dataset consists of 60% SR, 9% AF, 30% alternative rhythm, and 1% noise ECGs. The 8528 available ECGs were divided into a training (90%) and validation set (10%) for model development and hyperparameter optimization. Results The trained CNN was applied to an independent set containing single-lead ECGs of 600 patients equally divided into two groups: SR and AF. Both groups comprised of 300 unique ECGs (SR; 60% male, 63±11 years, AF; 38% male, 56±14 years). In distinguishing between AF and SR, the method achieved an accuracy of 0.92, an F1-score of 0.91, and area under the ROC-curve of 0.98. Conclusion The results demonstrate that distinguishing SR and AF by a fully automatic AI algorithm is feasible. This approach has the potential to reduce cost by minimizing expert supervision, especially when extending the algorithm to other heart rhythms, like premature atrial/ventricular contractions and atrial flutter. Figure 1. ROC curve Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Dekkerbeurs - Hartstichting

Exercise-induced functional desensitization of canine cardiac beta-adrenergic receptors

1987 ◽  
Vol 62 (4) ◽  
pp. 1721-1723 ◽  
Author(s):  
D. B. Friedman ◽  
G. A. Ordway ◽  
R. S. Williams
Keyword(s):  
Heart Rate ◽  
Adrenergic Receptors ◽  
Treadmill Running ◽  
Strenuous Exercise ◽  
Beta Adrenergic Receptors ◽  
Similar Reduction ◽  
Beta Adrenergic ◽  
Single Bout ◽  
Chronotropic Effects ◽  
Exercise Induced

To test the hypothesis that the high levels of endogenous catecholamines associated with strenuous exercise produce functional desensitization of cardiac beta-adrenergic receptors, we measured the bolus chronotropic dose of isoproterenol necessary to produce a 25-beats/min increase in heart rate (CD25) in the resting state and after the return of heart rate to resting levels after 60 min of treadmill running in 13 normal dogs. Immediately after exercise, 12 of 13 dogs were less sensitive to the chronotropic effects of beta-adrenergic receptor stimulation: mean CD25 increased from 1.16 +/- 0.17 to 3.50 +/- 0.98 micrograms (P less than 0.02). A similar reduction in isoproterenol sensitivity was evident regardless of whether testing was performed in the presence or absence of vagal blockade with atropine. By 3 h after exercise, CD25 had returned to the preexercise level, with no further change noted 24 h after exercise. There was no change in the CD25 when measured serially in three unexercised dogs. We conclude that a single bout of dynamic exercise is sufficient to produce a significantly decreased chronotropic responsiveness to isoproterenol. This phenomenon may represent an acute but transient desensitization of cardiac beta-adrenergic receptors.

scholarly journals The clinical atlas of cardiomyopathies: data from the prospective DZHK TORCH study

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
F Sedaghat-Hamedani ◽  
J Trebing ◽  
A Kindermann ◽  
E Kayvanpour ◽  
K Tan ◽  
...  
Keyword(s):  
Arrhythmogenic Right Ventricular Cardiomyopathy ◽  
Left Ventricular ◽  
Favourable Outcome ◽  
Funding Source ◽  
Icd Implantation ◽  
Cardiovascular Research ◽  
National Budget ◽  
Public Grant ◽  
High Level

Abstract Introduction Cardiomyopathies (CMPs) are leading causes of heart failure (HF) and sudden cardiac death (SCD). Comparative data of the multiple cardiomyopathy forms are largely missing. The TranslatiOnal Registry for CardiomyopatHies (TORCH) is the largest prospective multicentre CMP registry world-wide. Enrolled patients are comprehensively phenotyped by clinical examinations, state-of-the-art imaging, and molecular investigations. In this study, we present the baseline and 1-year follow-up data. Methods TORCH is a national, prospective, multicentre registry within the German Centre for Cardiovascular Research (DZHK) and includes 2300 patients with non-ischemic (primary and secondary) CMP from 20 centres. The minimum follow up was one year. The DZHK-wide harmonization of datasets and SOPs ensure a high level of data quality and comparability across different CMP forms. Results Dilated cardiomyopathy (DCM) has the highest prevalence with 64% of all enrolled patients, followed by hypertrophic cardiomyopathy (HCM) with 16%. At baseline, patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) were treated more often with ICD implantation and showed high rates of adequate ICD therapies (65.8%, p&lt;0.05 and 47.8%, p&lt;0.05, respectively). The prevalence of stroke or transient ischemic attack (TIA) was in multivariate analysis significantly higher (p&lt;0.05) in left ventricular non-compaction cardiomyopathy (LVNC, 14.9%), while atrial fibrillation was lower than in other cardiomyopathy forms. Patients with amyloidosis had the worst outcome (HR: 6; 95% CI: 2.5–14.5, P&lt;0.05) with annual mortality of &gt;15% and 12% receiving heart transplantation. In DCM, reverse remodelling with improvement of functional parameters and biomarkers was more often observed in idiopathic and inflammatory cases compared to familial ones. HCM patients had the most favourable outcome. Conclusion and outlook TORCH is the largest prospective study focusing on CMPs. We provided for the first time prospectively the clinical data of patients with diverse cardiomyopathies with outcome. Furthermore, comparing the different CMP forms on the clinical and molecular level will be an important step to enable translational research projects. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Centre for Cardiovascular Research (DZHK)

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