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Circulation Arrhythmia and Electrophysiology 04/2013; 6(2):429-435. · 6.46 Impact Factor
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Ashish Shukla, Anne B Curtis,
Mandeep R Mehra,
Nancy M Albert,
Mihai Gheorghiade,
J Thomas Heywood,
Yang Liu,
Christopher M O'Connor,
Dwight Reynolds,
Mary Norine Walsh,
Clyde W Yancy,
Gregg C Fonarow
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ABSTRACT: BACKGROUND: There is a well-recognized gap between the number of patients in whom cardiac resynchronization therapy (CRT) is indicated based on current guidelines and its actual utilization. In the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) study, there was a significant increase in the use of CRT at 24 months in patients with heart failure (HF) in comparison to baseline. This study evaluated patient, physician, and practice factors associated with this increase in CRT utilization. METHODS: Patients with reduced left ventricular ejection fraction and chronic HF who met the eligibility criteria for CRT at baseline and 24 months were analyzed. Multivariate analyses using patient, physician, and practice characteristics were performed to evaluate factors associated with increased CRT utilization at 24 months. RESULTS: There were 440 patients eligible for CRT both at baseline and 24 months, with 217 (49.3%) treated at baseline and 374 (85%) treated at 24 months, leading to an absolute increase in use of CRT of 35.7%, P < 0.001. Although serum sodium and the absence of rales had modest associations, none of the patient, physician, or practice characteristics had any significant association with the extent of increase in CRT utilization. There was a significant reduction in the variation of CRT utilization across practice sites after the implementation of the performance improvement initiative. CONCLUSIONS: The performance improvement initiative in IMPROVE HF was the most important factor associated with an increase in guideline-recommended CRT utilization. This improvement in CRT utilization and reduced practice variability was found across a variety of cardiology and multispecialty practice sites.
Pacing and Clinical Electrophysiology 02/2013; · 1.35 Impact Factor
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European Heart Journal 01/2013; · 10.48 Impact Factor
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Andrew P Ambrosy,
Gregg C Fonarow,
Nancy M Albert, Anne B Curtis,
J Thomas Heywood,
Mandeep R Mehra,
Christopher M O'Connor,
Dwight Reynolds,
Mary N Walsh,
Clyde W Yancy,
Mihai Gheorghiade
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ABSTRACT: B-type natriuretic peptide (BNP) levels provide diagnostic and prognostic information in heart failure. This study determined the frequency of BNP assessment and analyzed demographic characteristics, clinical variables and the utilization of guideline-recommended heart failure therapies by BNP level in outpatients with reduced left ventricular ejection fraction (LVEF).
The IMPROVE HF registry (The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting) is a prospective cohort study of patients at least 18 years of age with a LVEF 35% or less and chronic heart failure or previous myocardial infarction (MI) presenting to cardiology and multispecialty practices. The medical records of 15,381 patients were reviewed. BNP was measured in 4213 (27.4%) patients and the median plasma BNP level was 384 pg/ml (interquartile range 158-877 pg/ml). Patients were stratified by plasma BNP measurements into the following tertiles: 219 pg/ml or less, more than 219 to 649 pg/ml, and more than 649 pg/ml. Jugular venous distension, pedal edema, rales and systolic murmur on physical examination and elevated renal function parameters were associated with higher BNP levels. BNP assessment and elevated BNP levels were not associated with greater use of any of the quality of care measures. However, patients with a BNP in the top tertile were less likely to be treated with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or aldosterone antagonists compared with patients with a BNP in the bottom tertile.
Among practices participating in IMPROVE HF, BNP was not measured in most outpatients with reduced LVEF and chronic heart failure or previous MI. BNP assessment or the BNP level in patients with recorded measurements, with few exceptions, did not impact the utilization of guideline-recommended therapies.
Journal of Cardiovascular Medicine 04/2012; 13(6):360-7. · 1.51 Impact Factor
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Mary Norine Walsh,
Nancy M Albert, Anne B Curtis,
Mihai Gheorghiade,
J Thomas Heywood,
Yang Liu,
Mandeep R Mehra,
Christopher M O'Connor,
Dwight Reynolds,
Clyde W Yancy,
Gregg C Fonarow
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ABSTRACT: Electronic health record systems (EHR) are expected to facilitate higher quality patient care; however, studies evaluating EHR effectiveness in improving care have yielded mixed results.
Implementation of a performance improvement system in outpatient practices with EHR may better demonstrate the value of EHR in improving quality.
The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) prospectively evaluated the effectiveness of a performance improvement initiative on use of evidence-based therapies for patients with heart failure (HF) or prior MI and LVSD. This study assessed improvement in the use of 7 quality measures from baseline to 24 months.
Complete data were available for 155 of 167 (92.8%) practices; 78 (50.3%) used EHR always, 15 (9.7%) switched to EHR, and 61 (39.4%) used paper always. EHR-always practices had significantly improved adherence to 5 measures at 24 months, and EHR-switched or paper-always practices had improved adherence to 6 measures. With a single exception, there were no significant differences in the magnitude of improvements in use of guideline-recommended care among the 3 practice types. Performance on individual quality measures was also similar at 24 months.
Implementation of the performance improvement intervention enhanced use of guideline-recommended HF therapies among outpatient cardiology practices. However, practices using or converting to EHR did not achieve greater improvements in quality of HF care than practices using paper systems. These findings raise doubts about whether implementation of EHR nationally will translate into better outpatient quality of care.
Clinical Cardiology 03/2012; 35(3):187-96. · 2.15 Impact Factor
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ABSTRACT: Several therapies are guideline-recommended to reduce mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction, but the incremental clinical effectiveness of these therapies has not been well studied. We aimed to evaluate the individual and incremental benefits of guideline-recommended HF therapies associated with 24-month survival.
We performed a nested case-control study of HF patients enrolled in IMPROVE HF. Cases were patients who died within 24 months and controls were patients who survived to 24 months, propensity-matched 1:2 for multiple prognostic variables. Logistic regression was performed, and the attributable mortality risk from incomplete application of each evidence-based therapy among eligible patients was calculated. A total of 1376 cases and 2752 matched controls were identified. β-Blocker and cardiac resynchronization therapy were associated with the greatest 24-month survival benefit (adjusted odds ratio for death 0.42, 95% confidence interval (CI), 0.34-0.52; and 0.44, 95% CI, 0.29-0.67, respectively). Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, implantable cardioverter-defibrillators, anticoagulation for atrial fibrillation, and HF education were also associated with benefit, whereas aldosterone antagonist use was not. Incremental benefits were observed with each successive therapy, plateauing once any 4 to 5 therapies were provided (adjusted odds ratio 0.31, 95% CI, 0.23-0.42 for 5 or more versus 0/1, P<0.0001).
Individual, with a single exception, and incremental use of guideline-recommended therapies was associated with survival benefit, with a potential plateau at 4 to 5 therapies. These data provide further rationale to implement guideline-recommended HF therapies in the absence of contraindications to patients with HF and reduced left ventricular ejection fraction. (J Am Heart Assoc. 2012;1:16-26.).
Journal of the American Heart Association. 02/2012; 1(1):16-26.
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Mihai Gheorghiade,
Nancy M Albert, Anne B Curtis,
J Thomas Heywood,
Mark L McBride,
Patches Johnson Inge,
Mandeep R Mehra,
Christopher M O'Connor,
Dwight Reynolds,
Mary Norine Walsh,
Clyde W Yancy,
Gregg C Fonarow
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ABSTRACT: Eligible outpatients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF) frequently do not receive target doses of HF medications. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) evaluated the effect of a practice-based performance improvement intervention on treatment of outpatients with LVEF ≤35%. Specific agent and dose were collected at baseline and 24 months for angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β-blockers, and aldosterone antagonists. Changes in dosing over time were analyzed for each medication class. Data were available for 7605 patients. At baseline, target dose treatment rates were 36.1%, 20.5%, and 74.4%, respectively. Absolute and relative improvements of 9.8% and 47.7% ( P<.001) were achieved for β-blocker dosing at 24 months. The IMPROVE HF intervention was associated with significantly increased treatment of eligible patients with target doses of β-blockers but not ACE inhibitors/ARBs or aldosterone antagonists. Additional research to determine barriers to use of target doses of HF medications may be necessary.
Congestive Heart Failure 01/2012; 18(1):9-17.
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Jane E Wilcox,
Gregg C Fonarow,
Clyde W Yancy,
Nancy M Albert, Anne B Curtis,
J Thomas Heywood,
Patches Johnson Inge,
Mark L McBride,
Mandeep R Mehra,
Christopher M O'Connor,
Dwight Reynolds,
Mary Norine Walsh,
Mihai Gheorghiade
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ABSTRACT: Available data suggest that improvement in left ventricular ejection fraction (LVEF) is a major predictor of improved survival in heart failure (HF). Although certain factors are associated with improvements in LVEF in select patients with HF enrolled in clinical trials, relatively little is known about such factors among patients in clinical practice. This study evaluated changes in LVEF and associated factors in outpatients with systolic HF or post-myocardial infarction with reduced LVEF during 24 months of follow-up.
IMPROVE HF is a prospective evaluation of a practice-based performance improvement intervention implemented at outpatient cardiology/multispecialty practices to increase use of guideline-recommended care for eligible patients. Data were analyzed by patient groups based on absolute improvement in LVEF (<0%, 0-≤10%, and >10%) from baseline to 24 months and by change in LVEF as a continuous variable.
A total of 3,994 patients from 155 of 167 practices were eligible for analysis. The overall mean LVEF increased from 25.8% at baseline to 32.3% (+6.4%) at 24 months (P < .001), and 28.6% of patients had a >10% improvement in ejection fraction (from 24.5% to 46.2%, 92% relative improvement). Age, race, and practice setting were similar between the 3 LVEF improvement groups. Multivariate analysis revealed female sex, no prior myocardial infarction, nonischemic HF etiology, and no digoxin use were associated with >10% improvement in LVEF.
Among patients with HF receiving care in cardiology/multispecialty practices participating in a performance measure intervention, surviving, and having repeat LVEF assessment, close to one third of patients had a >10% improvement in LVEF at 24 months. These findings indicate that HF is not always a progressive disease and that differentiation of the heterogeneous HF phenotypes may set the stage for future research and therapeutic targets.
American heart journal 01/2012; 163(1):49-56.e2. · 4.65 Impact Factor
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Mandeep R Mehra,
Nancy M Albert, Anne B Curtis,
Mihai Gheorghiade,
J Thomas Heywood,
Yang Liu,
Christopher M O'Connor,
Dwight Reynolds,
Mary Norine Walsh,
Clyde W Yancy,
Gregg C Fonarow
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ABSTRACT: IMPROVE HF, a 24-month performance improvement initiative for outpatient cardiology and multispecialty practices, demonstrated significant improvement in guideline-based use of implantable cardioverter-defibrillators (ICDs) for patients with heart failure (HF). We investigated patient, physician, and practice factors associated with improvements in ICD use.
Patients with HF or postmyocardial infarction (MI) left ventricular systolic dysfunction who met eligibility criteria for ICDs at baseline and 24 months were analyzed. Multivariate analyses were performed to identify patient, physician, and practice characteristics associated with greater improvement in ICD therapy rates from baseline to 24 months.
There were 4,058 patients eligible for ICD therapy at baseline and 24 months, with 2,600 (64.1%) treated at baseline and 3,361 (82.8%) treated at 24 months (+18.7%, P < 0.001). Practice heterogeneity in ICD use was significantly decreased after implementation of the performance improvement initiative. Characteristics independently associated with improvement in use of ICD therapy included race, history of MI, presence of edema, QRS duration, months since last measured left ventricular ejection fraction, and number of physicians in the practice. Improvement in ICD use was independent of other patient, physician, and practice characteristics, including age and sex.
The IMPROVE HF performance improvement initiative was associated with substantially improved adherence to guideline-recommended ICD therapy. Certain patient and practice characteristics, including race, history of MI, edema, QRS duration, and number of physicians in the practice, were independently associated with improvement in ICD use. These findings highlight the need for ongoing quality improvement monitoring and performance improvement activities.
Pacing and Clinical Electrophysiology 12/2011; 35(2):135-45. · 1.35 Impact Factor
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Zubin J Eapen,
Eric D Peterson,
Gregg C Fonarow,
Gillian D Sanders,
Clyde W Yancy,
Samuel F Sears,
Mark D Carlson, Anne B Curtis,
Laura Lee Hall,
David L Hayes,
Adrian F Hernandez,
Michael Mirro,
Eric Prystowsky,
Andrea M Russo,
Kevin L Thomas,
Sana M Al-Khatib
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ABSTRACT: Sudden cardiac arrest (SCA) is the most common cause of death in the United States. Despite national guidelines, patients at risk for SCA often fail to receive evidence-based therapies. Racial and ethnic minorities and women are at particularly high risk for undertreatment. To address the persistent challenges in improving the quality of care for SCA, the Duke Center for the Prevention of Sudden Cardiac Death at the Duke Clinical Research Institute (Durham, NC) reconvened the Sudden Cardiac Arrest Thought Leadership Alliance. Experts from clinical cardiology, cardiac electrophysiology, health policy and economics, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health Care Research and Quality, and device and pharmaceutical manufacturers discussed the development of SCA educational tools for patients and providers, mechanisms of implementing successful tools to help providers identify patients in their practice at risk for SCA, disparities in SCA prevention, and performance measures related to SCA care. This article summarizes the discussions held at this meeting.
American heart journal 08/2011; 162(2):222-31. · 4.65 Impact Factor
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Bruce D Lindsay,
Samuel J Asirvatham, Anne B Curtis,
Melanie T Gura,
David L Hayes,
Jose Jalife,
George J Klein,
Bradley P Knight,
Rachel Lampert,
Andrea Natale,
Douglas L Packer,
Richard L Page,
Melvin M Scheinman,
Amit J Shanker,
Paul J Wang,
Jonathan P Weiss,
Bruce L Wilkoff,
Chris D Busky
Heart rhythm: the official journal of the Heart Rhythm Society 07/2011; 8(7):e19-23. · 4.56 Impact Factor
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N A Mark Estes,
Ralph L Sacco,
Sana M Al-Khatib,
Patrick T Ellinor,
Judy Bezanson,
Alvaro Alonso,
Charles Antzelevitch,
Randall G Brockman,
Peng-Sheng Chen,
Sumeet S Chugh, [......],
Richard Lee,
Douglas L Packer,
Sunny S Po,
Eric N Prystowsky,
Susan Redline,
Yves Rosenberg,
David R Van Wagoner,
Kathryn A Wood,
Lixia Yue,
Emelia J Benjamin
Circulation 06/2011; 124(3):363-72. · 14.74 Impact Factor
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Gregg C Fonarow,
Nancy M Albert, Anne B Curtis,
Mihai Gheorghiade,
J Thomas Heywood,
Yang Liu,
Mandeep R Mehra,
Christopher M O'Connor,
Dwight Reynolds,
Mary Norine Walsh,
Clyde W Yancy
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ABSTRACT: Assessment of the quality of care for outpatients with heart failure (HF) has focused on the development and use of process-based performance measures, with the supposition that these care process measures are associated with clinical outcomes. However, this association has not been evaluated for current and emerging outpatient HF measures.
Performance on 7 HF process measures (4 current and 3 emerging) and 2 summary measures was assessed at baseline in patients from 167 US outpatient cardiology practices with patients prospectively followed up for 24 months. Participants included 15 177 patients with reduced left ventricular ejection fraction (≤35%) and chronic HF or post-myocardial infarction. Multivariable analyses were performed to assess the process-outcome relationship for each measure in eligible patients. Vital status was available for 11 621 patients. The mortality rate at 24 months was 22.1%. Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, β-blocker use, anticoagulant therapy for atrial fibrillation, cardiac resynchronization therapy, implantable cardioverter-defibrillators, and HF education for eligible patients were each independently associated with improved 24-month survival, whereas aldosterone antagonist use was not. The all-or-none and composite care summary measures were also independently associated with improved survival. Each 10% improvement in composite care was associated with a 13% lower odds of 24-month mortality (adjusted odds ratio, 0.87; 95% confidence interval, 0.84 to 0.90; P<0.0001).
Current and emerging outpatient HF process measures are positively associated with patient survival. These HF measures may be useful for assessing and improving HF care. CLINICAL TRIAL REGISTRATION- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00303979.
Circulation 04/2011; 123(15):1601-10. · 14.74 Impact Factor
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Valentin Fuster,
Lars E Rydén,
Davis S Cannom,
Harry J Crijns, Anne B Curtis,
Kenneth A Ellenbogen,
Jonathan L Halperin,
G Neal Kay,
Jean-Yves Le Huezey,
James E Lowe,
S Bertil Olsson,
Eric N Prystowsky,
Juan Luis Tamargo,
L Samuel Wann
Journal of the American College of Cardiology 03/2011; 57(11):e101-98. · 14.16 Impact Factor
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Valentin Fuster,
Lars E Rydén,
Davis S Cannom,
Harry J Crijns, Anne B Curtis,
Kenneth A Ellenbogen,
Jonathan L Halperin,
G Neal Kay,
Jean-Yves Le Huezey,
James E Lowe, [......],
Nancy Albert,
Christopher E Buller,
Mark A Creager,
Steven M Ettinger,
Robert A Guyton,
Judith S Hochman,
Frederick G Kushner,
Erik Magnus Ohman,
Lynn G Tarkington,
Clyde W Yancy
Circulation 03/2011; 123(10):e269-367. · 14.74 Impact Factor
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ABSTRACT: Obesity is associated with new-onset atrial fibrillation (AF). However, the effect of obesity on AF recurrence or burden has not been studied. The aim of this study was to investigate the relation between AF recurrence, AF burden, and body mass index (BMI). A limited-access data set from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial provided by the National Heart, Lung, and Blood Institute was used. Statistical analysis was done with a generalized linear mixed model. In 2,518 patients who had BMIs recorded, higher BMI was associated with a higher number of cardioversions (odds ratio [OR] 1.017, 95% confidence interval [CI] 1.005 to 1.029 for a BMI increase of 1 kg/m(2); OR 1.088, 95% CI 1.024 to 1.155 for a BMI increase of 5 kg/m(2); OR 1.183, 95% CI 1.049 to 1.334 for a BMI increase of 10 kg/m(2); p = 0.006 for each). Increased BMI was also associated with a higher likelihood of being in AF on follow-up (OR 1.020, 95% CI 1.002 to 1.038 per 1 kg/m(2) increased BMI, p = 0.0283; OR 1.104, 95% CI 1.011 to 1.205 per 5 kg/m(2) increased BMI, p = 0.0283; OR 1.218, 95% CI 1.021 to 1.452 per 10 kg/m(2) increased BMI, p = 0.0283). In a multivariate analysis, left atrial size but not BMI was an independent predictor of AF recurrence and AF burden. Because left atrial size was correlated with BMI, the effect of BMI on AF can be likely explained by greater left atrial size in subjects with higher BMIs. In conclusion, obesity is associated with a higher incidence of recurrence of AF and greater AF burden.
The American journal of cardiology 02/2011; 107(4):579-82. · 3.58 Impact Factor
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ABSTRACT: The need for consistent and current data describing the true incidence of sudden cardiac arrest (SCA) and/or sudden cardiac death (SCD) was highlighted during the most recent Sudden Cardiac Arrest Thought Leadership Alliance's (SCATLA) Think Tank meeting of national experts with broad representation of key stakeholders, including thought leaders and representatives from the American College of Cardiology, American Heart Association, and the Heart Rhythm Society. As such, to evaluate the true magnitude of this public health problem, we performed a systematic literature search in MEDLINE using the MeSH headings, "death, sudden" OR the terms "sudden cardiac death" OR "sudden cardiac arrest" OR "cardiac arrest" OR "cardiac death" OR "sudden death" OR "arrhythmic death." Study selection criteria included peer-reviewed publications of primary data used to estimate SCD incidence in the U.S. We used Web of Science's Cited Reference Search to evaluate the impact of each primary estimate on the medical literature by determining the number of times each "primary source" has been cited. The estimated U.S. annual incidence of SCD varied widely from 180,000 to >450,000 among 6 included studies. These different estimates were in part due to different data sources (with data age ranging from 1980 to 2007), definitions of SCD, case ascertainment criteria, methods of estimation/extrapolation, and sources of case ascertainment. The true incidence of SCA and/or SCD in the U.S. remains unclear, with a wide range in the available estimates that are badly dated. As reliable estimates of SCD incidence are important for improving risk stratification and prevention, future efforts are clearly needed to establish uniform definitions of SCA and SCD and then to prospectively and precisely capture cases of SCA and SCD in the overall U.S. population.
Journal of the American College of Cardiology 02/2011; 57(7):794-801. · 14.16 Impact Factor
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L Samuel Wann, Anne B Curtis,
Kenneth A Ellenbogen,
N A Mark Estes,
Michael D Ezekowitz,
Warren M Jackman,
Craig T January,
James E Lowe,
Richard L Page,
David J Slotwiner, [......],
Alice K Jacobs,
Jeffrey L Anderson,
Nancy Albert,
Mark A Creager,
Steven M Ettinger,
Robert A Guyton,
Judith S Hochman,
Frederick G Kushner,
Erik Magnus Ohman,
Clyde W Yancy
Circulation 02/2011; 123(10):1144-50. · 14.74 Impact Factor
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L Samuel Wann, Anne B Curtis,
Kenneth A Ellenbogen,
N A Mark Estes,
Michael D Ezekowitz,
Warren M Jackman,
Craig T January,
James E Lowe,
Richard L Page,
David J Slotwiner, [......],
Alice K Jacobs,
Jeffrey L Anderson,
Nancy Albert,
Mark A Creager,
Steven M Ettinger,
Robert A Guyton,
Judith S Hochman,
Frederick G Kushner,
Erik Magnus Ohman,
Clyde W Yancy
Heart rhythm: the official journal of the Heart Rhythm Society 02/2011; 8(3):e1-8. · 4.56 Impact Factor
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L Samuel Wann, Anne B Curtis,
Kenneth A Ellenbogen,
N A Mark Estes,
Michael D Ezekowitz,
Warren M Jackman,
Craig T January,
James E Lowe,
Richard L Page,
David J Slotwiner,
William G Stevenson,
Cynthia M Tracy
Journal of the American College of Cardiology 02/2011; 57(11):1330-7. · 14.16 Impact Factor