Gregory Y H Lip

Aalborg University, Ålborg, North Denmark, Denmark

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Publications (850)5026.99 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Females with atrial fibrillation (AF) are at increased risk for ischemic stroke but have been under-represented in AF ablation cohorts. Whether the incidence of TE in women after catheter ablation is higher is unknown. We aimed to analyze the predictive value of thromboembolic scores and other clinical variants for thromboembolism (TE) after AF catheter ablation, separately in women and men. TE was combined endpoint of early (within first month) and late (during long-term follow-up) stroke, transient ischemic attack, or systemic embolism. Oral anticoagulation was prescribed for 6 months after catheter ablation and discontinued if CHADS2 was <2 and no AF recurrences were documented. The study population (n = 2,069, 66 % male, 60 ± 10 years; 62 % paroxysmal AF) was followed for a median of 18 months (IQR 12-29). Overall 31 TE (1.5 %) occurred with 16 events within 30 days of ablation and 15 TE during the follow-up. Fourteen females (2.0 %) and 17 males (1.2 %) suffered TE (p = 0.128). On multivariate analysis, higher CHADS2 (HR 1.65, 95 % CI 1.10-2.47, p = 0.015), CHA2DS2-VASc (HR 1.42, 95 % CI 1.03-1.96, p = 0.034), R2CHADS2 (HR 1.76, 95 % CI 1.32-2.35, p < 0.001) scores, and eGFR <60 ml/min/1.73 m(2) (HR 3.95, 95 % CI 1.23-12.7, p = 0.021) were significantly associated with TE in men. In females, LV-EF (HR 0.95, 95 % CI 0.91-0.99, p = 0.021) and CHA2DS2-VASc score (HR 1.52, 95 % CI 1.01-2.28, p = 0.044) remained significant predictors for TE. TE rates after AF catheter ablation are low in both genders. In females, LV-EF and CHA2DS2-VASc score and in males all three scores and renal dysfunction were associated with TE.
    Clinical Research in Cardiology 02/2015; · 4.17 Impact Factor
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    ABSTRACT: Oral anticoagulation (OAC) is highly effective for stroke prevention in nonvalvular atrial fibrillation. We explored rates of stroke/thromboembolism/transient ischemic attack among the "OAC not recommended" patient group defined according to the 2014 Canadian Cardiovascular Society (CCS) algorithm (based on the Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack [CHADS2] score) who would have been offered OAC using the European Society of Cardiology (ESC) guidelines approach (based on the Congestive Heart Failure, Hypertension, Age [≥75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female]; CHA2DS2-VASc score). We identified 22,582 nonanticoagulated patients age < 65 years with a CHADS2 score of 0 who were stratified according to the CHA2DS2-VASc score, except female sex, which would be an indication for OAC according to the ESC guidelines. Event rates for each risk strata were compared using Cox proportional hazard ratios. The overall rate of the combined end point of ischemic stroke/systemic embolism/transient ischemic attack was 4.32 per 100 person-years (95% confidence interval [CI], 3.26-5.74) at 1 year, among the patients who would have had an indication for OAC therapy according to ESC guidelines and "OAC not recommended" according to CCS algorithm. This corresponded to an adjusted hazard ratio of 3.08 (95% CI, 2.21-4.29) relative to the subgroup with no indication for OAC according to the ESC guidelines. A subgroup of patients with previous vascular disease and CHADS2 score of 0 (ie, recommended only aspirin treatment according to the CCS algorithm) had an event rate of 4.84 (95% CI, 3.53-6.62) per 100 person-years at 1-year follow-up. Based on the 2014 CCS algorithm, the "OAC not recommended" subgroup can have a high 1-year stroke rate overall, showing that such patients are not "low risk." Use of the ESC guideline approach (based on the CHA2DS2-VASc) offers refinement of stroke risk stratification in such patients. Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
    The Canadian journal of cardiology 01/2015; 31(1):24-8. · 3.12 Impact Factor
  • Dipak Kotecha, Amitava Banerjee, Gregory Y H Lip
    01/2015;
  • 01/2015; 10(9):1015-21.
  • Yee C. Lau, Richard A. Brown, Gregory Y.H. Lip
    Archives of Cardiovascular Diseases. 01/2015;
  • Circulation Journal 01/2015; 79. · 3.69 Impact Factor
  • British Journal of General Practice 01/2015; 65(630):4-5. · 2.36 Impact Factor
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    ABSTRACT: Oral anticoagulation (OAC) is recommended for effective stroke prevention in the majority of atrial fibrillation patients but is often under-utilised. To use the Guidance on Risk Assessment and Stroke Prevention in the Atrial Fibrillation (GRASP-AF) tool to risk stratify patients, identify antithrombotic therapy received, and determine predictors of stroke and death in a UK general practice cohort. Retrospective-observational cohort study in 11 general practices in Darlington, England, with 105 000 patients. The study included patients with atrial fibrillation (AF) identified from GP databases using the GRASP-AF tool. Stroke risk was determined by CHADS2 and CHA2DS2-VASc scores. A total of 2259 (2.15%) patients with AF (mean age 76 years [SD 12]; 46% female) were identified. Use of CHA2DS2-VASc rather than CHADS2 increased the proportion eligible for OAC from 86.0% to 92.5%. Of those with CHA2DS2-VASc score of ≥2, 39.7% were not receiving appropriate OAC, and of those with CHADS2 score of ≥1, 39.5% were not receiving appropriate OAC. Antiplatelet monotherapy was utilised in 33-40% of patients at high risk of stroke. During 12-month follow-up, 67 (3.0%) patients experienced a stroke and 214 (9.5%) died. Use of OAC significantly reduced stroke risk (odds ratio [OR] 0.60, 95% confidence intervals [CI] = 0.45 to 0.81) and death (OR = 0.54, 95% CI = 0.38 to 0.75, P<0.001) among patients at moderate-high risk of stroke. Use of antiplatelet agents also independently predicted death (OR = 0.69, 95% CI = 0.50 to 0.94; P = 0.020). Most patients with AF in general practice are at high risk of stroke, but OAC is under-utilised in about 40%. Risk of stroke and death was significantly reduced by OAC, yet antiplatelet monotherapy was inappropriately used in approximately 25% of patients at risk of stroke. Optimal implementation of the CHA2DS2-VASc score in the GRASP-AF tool could help prevent more strokes annually. © British Journal of General Practice 2015.
    British Journal of General Practice 01/2015; 65(630):e16-23. · 2.36 Impact Factor
  • S Ben Freedman, Bernard J Gersh, Gregory Y H Lip
    European heart journal. 12/2014;
  • Polskie Archiwum Medycyny Wewnetrznej. 12/2014;
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    ABSTRACT: Atrial fibrillation (AF) and coronary artery disease (CAD) often present concomitantly. Given the increased risk of thrombotic complications with either of them but different pathogenesis of clot formation combined antithrombotic therapy is necessary in patients developing acute coronary syndrome (ACS) and/or undergoing percutaneous coronary intervention (PCI). Different antithrombotic regimens in this group of patients have been summarised and discussed earlier. Triple therapy, remains the treatment of choice in this group of patients despite the increased risk of haemorrhagic complications. Given the absence of evidence from randomised controlled trials, balancing the risk of stroke and stent thrombosis against the risk of major bleeding is a challenge. Precise stroke and bleeding risk assessment is an essential part of the decision making process regarding antithrombotic management. Continuing the discussion of current concepts and concerns of antithrombotic management in AF patients undergoing PCI we emphasise the importance of various strategies to reduce bleeding in the modern era, namely radial access combined with careful selection of a P2Y12 receptor inhibitor, use of newer drug eluting stents and uninterrupted anticoagulation for patients undergoing procedures. We also focus on the role of the non-vitamin K oral anticoagulants (NOACs, e.g., dabigatran, rivaroxaban, apixaban, and edoxaban [awaiting approval]) which are increasingly used for stroke prevention in AF. Finally, recent recommendations on the management of antithrombotic therapy in AF patients presenting with acute coronary syndrome and/or undergoing PCI, as well as ongoing clinical trials and future directions are highlighted.
    Polskie Archiwum Medycyny Wewnetrznej. 12/2014;
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    ABSTRACT: Atrial fibrillation is often asymptomatic but outcomes need further characterization. To investigate clinical presentation, management and outcomes in asymptomatic and symptomatic atrial fibrillation patients prospectively enrolled in the EurObservational Research Programme - Atrial Fibrillation (EORP-AF) Pilot General Registry. A total of 3119 patients were enrolled, and 1237 (39.7%) were asymptomatic (EHRA score I). Among symptomatic patients, 963 (51.2%) had mild symptoms (EHRA score II) while 919 (48.8%) had severe or disabling symptoms (EHRA III-IV). Permanent atrial fibrillation was threefold more common in asymptomatic than in symptomatic patients. On multivariate analysis, male gender (OR 1.630, 95% CI 1.384-1.921), older age (OR 1.019, 95% CI 1.012-1.026), previous myocardial infarction (OR 1.681, 95% CI 1.350-2.093), and limited physical activity (OR 1.757, 95% CI 1.495-2.064) were significantly associated with asymptomatic (EHRA I) atrial fibrillation. Fully asymptomatic atrial fibrillation (absence of current and previous symptoms) was present in 520 patients (16.7%), and was independently associated with male gender, age and previous myocardial infarction. Appropriate guideline-based prescription of oral anticoagulants was lower in these patients, while aspirin was more frequently prescribed. In asymptomatic patients, mortality at 1 year was more than two-fold higher compared to symptomatic patients (9.4 vs. 4.2%, p<0.0001), and was independently associated with older age and comorbidities, including chronic kidney disease and chronic heart failure. Asymptomatic atrial fibrillation is common in daily cardiology practice, being associated with elderly age and more co-morbidities, as well as high thromboembolic risks. A higher 1-year mortality was found in asymptomatic compared to symptomatic patients. Copyright © 2014 Elsevier Inc. All rights reserved.
    The American Journal of Medicine 12/2014; · 5.30 Impact Factor
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    ABSTRACT: The balance between stroke reduction and increased bleeding associated with antithrombotic therapy among patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is controversial. This study assessed the risk associated with CKD in individual CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes mellitus; previous Stroke, transient ischemic attack, or thromboembolism; Vascular disease; Age 65 to 74 years; Sex category) strata and the net clinical benefit of warfarin in patients with AF and CKD in a nationwide cohort. By individual-level linkage of nationwide Danish registries, we identified all patients discharged with nonvalvular AF from 1997 to 2011. The stroke risk associated with non-end-stage CKD and end-stage CKD (e.g., patients on renal replacement therapy [RRT]) was estimated using Cox regression analyses. The net clinical benefit of warfarin was assessed using 4 endpoints: a composite endpoint of death/hospitalization from stroke/bleeding; a composite endpoint of fatal stroke/fatal bleeding; cardiovascular death; and all-cause death. From nonvalvular AF patients (n = 154,259), we identified 11,128 patients (7.2%) with non-end-stage CKD and 1,728 (1.1%) receiving RRT. In all CHA2DS2-VASc risk groups, RRT was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with CHA2DS2-VASc score = 0 to a 1.6-fold higher risk in patients with CHA2DS2-VASc score ≥2. In patients receiving RRT with CHA2DS2-VASc score ≥2, warfarin was associated with lower risk of all-cause death (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.72 to 0.99). In non-end-stage CKD patients with CHA2DS2-VASc score ≥2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR: 0.71, 95% CI: 0.57 to 0.88), a lower risk of cardiovascular death (HR: 0.80, 95% CI: 0.74 to 0.88), and a lower risk of all-cause death (HR: 0.64, 95% CI: 0.60 to 0.69). CKD is associated with a higher risk of stroke/thromboembolism across stroke risk strata in AF patients. High-risk CKD patients (CHA2DS2-VASc ≥2) with AF benefit from warfarin treatment for stroke prevention. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Cardiology 12/2014; 64(23):2471-82. · 15.34 Impact Factor
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    ABSTRACT: Introduction: Peroxiredoxin (PRDX) and Thioredoxin (TRX) are antioxidant proteins that control cellular signalling and redox balance, although their response to exercise is unknown. This study aimed to assess key aspects of the PRDX-TRX redox cycle in response to three different modes of exercise. Methods: Healthy males (n=10, mean ± SD: age 22 ± 3 yrs) undertook three exercise trials on separate days: two steady-state cycling trials at a moderate (60% MAX; 27 min, MOD) and high (80% MAX; 20 min, HIGH) intensity, and a low volume high intensity interval training trial (10×1 min 90% MAX, LV-HIIT). Peripheral blood mononuclear cells (PBMCs) were assessed for TRX-1 and over-oxidised PRDX (isoforms I-IV) protein expression before, during and 30 minutes following exercise (post+30). The activities of TRX reductase (TRX-R) and the NF-κB p65 subunit were also assessed. Results: TRX-1 increased during exercise in all trials (MOD +84.5%; HIGH +64.1%; LV-HIIT +205.7%; p<.05), whereas over-oxidised PRDX increased during HIGH only (MOD -28.7%; HIGH +202.9%; LV-HIIT -22.7%; p<.05). TRX-R and NF-κB p65 activity increased during exercise in all trials, with the greatest response in TRX-R activity seen in HIGH (p<.05). Discussion: All trials stimulated a transient increase in TRX-1 protein expression during exercise. Only HIGH induced a transient over-oxidation of PRDX, alongside the greatest change in TRX-R activity. Future studies are needed to clarify the significance of heightened peroxide exposure during continuous high intensity exercise and the mechanisms of PRDX-regulatory control.
    Free Radical Research 12/2014; · 3.28 Impact Factor
  • International Journal of Cardiology 12/2014; 177(2):666-8. · 6.18 Impact Factor
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    ABSTRACT: Background:Non-vitamin K antagonist oral anticoagulants (NOAC) have been developed as alternatives to warfarin. Until recently, the latter was the standard oral anticoagulant for patients with non-valvular atrial fibrillation (NVAF). The efficacy and safety of NOAC in Japanese patients with NVAF has been investigated in small trials or subgroups from global randomized control trials (RCT).Methods and Results:We conducted a systematic review and meta-analysis of RCT, to compare the efficacy and safety of NOAC to those of warfarin in Japanese patients with NVAF. Published research was systematically searched for RCT that compared NOAC to warfarin in Japanese patients with NVAF. Random-effects models were used to pool efficacy and safety data across RCT. Three studies, involving 1,940 patients, were identified. Patients randomized to NOAC had a decreased risk for stroke and systemic thromboembolism (relative risk [RR], 0.45; 95% CI: 0.24-0.85), with a non-significant trend for lower major bleeding (RR, 0.66; 95% CI: 0.29-1.47), intracranial bleeding (RR, 0.46; 95% CI: 0.18-1.16) and gastrointestinal bleeding (RR, 0.52; 95% CI: 0.25-1.08).Conclusions:NOAC are more efficacious than warfarin for the prevention of stroke and systemic embolism in Japanese patients with NVAF. The present findings offer clinicians a more comprehensive picture of NOAC as a therapeutic option to reduce the risk of stroke in Japanese NVAF patients.
    Circulation Journal 12/2014; · 3.69 Impact Factor
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    ABSTRACT: Much of the clinical epidemiology and treatment patterns for patients with atrial fibrillation (AF) are derived from Western populations. Limited data are available on antithrombotic therapy use over time and its impact on the stroke or bleeding events in newly diagnosed Chinese patients with AF. The present study investigates time-trends in warfarin and aspirin use in China), in relation to stroke and bleeding events in a Chinese population. We used a medical insurance database involving more than 10 million individuals for the years 2001 to 2012 in Yunnan, a southwestern province of China, and performed time-trend analysis on those with newly diagnosed AF. Cox proportional hazards time-varying exposures were used to determine the risk of stroke or bleeding events associated with antithrombotic therapy among AF patients. Among the randomly sampled 471,446 participants, there were 1,237 patients with AF, including 921 newly diagnosed AF, thus providing 4,859 person-years experience (62% males, mean attained age 70 years). The overall rate of antithrombotic therapy was 37.7% (347/921), with 4.1% (38/921) on warfarin and 32.3% (298/921) on aspirin. Antithrombotic therapy was not related to stroke/bleeding risk scores (CHADS2 score: P=0.522; CHA2 DS2 -VASc score: P=0.957; HAS-BLED: P=0.095). The use of antithrombotic drugs (mainly, aspirin) increased in both females and males over time, with the rate of aspirin from 4.0% in 2007 to 46.1% in 2012 in females, and from 7.7% in 2007 to 61.9% in 2012 in males (p value for trend, both < 0.005). In the overall cohort, the annual stroke rate approximated 6% and annual major bleeding rate was about 1%. Compared to non-antithrombotic therapy, the risk for ischaemic stroke (Hazard ratio, HR, [95% Confidence interval, CI]) was 0.68 (0.39-1.18) on aspirin, and 1.39 (0.54-3.59) on warfarin. Aspirin use increased amongst newly diagnosed Chinese AF patients with no relationship to the patient's stroke or bleeding risk. Warfarin use was very low. Given the healthcare burden of AF and its complications, our study has major implications for healthcare systems in non-Western countries, given the global burden of this common arrhythmia.
    Chest 12/2014; · 7.13 Impact Factor
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    ABSTRACT: Objectives Rheumatoid arthritis (RA) is a chronic inflammatory condition with increased all-cause and cardiovascular mortality. Accumulating evidence indicates that the immune and autonomic nervous systems (ANS) are major contributors to the pathogenesis of cardiovascular disease. We performed the first systematic literature review to determine the prevalence and nature of ANS dysfunction in RA and whether there is a causal relationship between inflammation and ANS function. Methods Electronic databases (Medline, Central and Cochrane Library) were searched for studies of RA patients where autonomic function was assessed. Results Forty studies in total were included. ANS function was assessed by clinical cardiovascular reflex tests (CCTs)(n=18), heart rate variability (HRV)(n=15), catecholamines (n=5), biomarkers of sympathetic activity (n=5), sympathetic skin responses (n=5), cardiac baroreflex sensitivity (cBRS) (n=2) and pupillary light reflexes (n=2). 9 small studies reported a ~60% (median, range 20-86%) prevalence of ANS dysfunction (defined by abnormal CCTs) in RA. 73% of studies (n=27/37) reported at least one abnormality in ANS function: parasympathetic dysfunction (n=20/26, 77%), sympathetic dysfunction (n=16/30, 53%) or reduced cBRS (n=1/2, 50%). An association between increased inflammation and ANS dysfunction was found (n=7/19, 37%) although causal relationships could not be elucidated from the studies available to date. Conclusions ANS dysfunction is prevalent in ~60% of RA patients. The main pattern of dysfunction is impairment of cardiovascular reflexes and altered HRV indicative of reduced cardiac parasympathetic (strong evidence) and elevated cardiac sympathetic activity (limited evidence). The literature to date is underpowered to determine causal relationships between inflammation and ANS dysfunction in RA.
    Seminars in Arthritis and Rheumatism 12/2014; · 3.63 Impact Factor
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    ABSTRACT: Recent findings suggest that patients with atrial fibrillation (AF), in addition to thromboembolic risk, are also at risk for myocardial infarction (MI). Our aim was to investigate predictors of MI and cardiovascular death in a cohort of anticoagulated AF patients. We prospectively followed-up 1019 AF patients for a median of 33.7 months (3223 person/years). All patients were treated with oral vitamin K antagonists. Primary outcome was a composite endpoint of cardiovascular events (CVEs) including fatal/non-fatal MI, cardiac revascularization and cardiovascular death. Mean age was 73.2 years, 43.8% were female. At follow-up, 111 CVEs (3,43%/year) occurred: 47 fatal-nonfatal MI/revascularization and 64 cardiovascular deaths. In addition, 31 stroke/TIA (0.96%/year) were recorded. Patients experiencing CVEs were older (p<0.001), with a higher prevalence of metabolic syndrome (MetS, p=0.005), heart failure (HF, p=0.001), prior cardiac (p<0.001) and cerebrovascular events (p<0.001). On a Cox proportional hazard analysis, age (hazard ratio [HR] 1.083, 95% confidence interval [CI], 1.053-1.113, p<0.001), smoking (HR 2.158, 95% CI, 1.193-3.901, p=0.011), history of cerebrovascular (HR 1.704, 95% CI, 1.119-2.597, p=0.013), and cardiac events (HR 1.658, 95% CI, 1.105-2.489, p=0.015), MetS (HR 1.663, 95% CI, 1.107-2.499, p=0.014), HF (HR 1.584, 95% CI, 1.021-2.456, p=0.040), male sex (HR 1.499, 95% CI, 1.010-2.223, p=0.044) predicted CVEs. AF patients still experience a high rate of CVEs despite being on anticoagulant treatment. MetS is a common clinical feature in AF patients, which increases the risk of CVEs. A holistic approach is needed to reduce the risk of cardiovascular risk in patients with AF. ClinicalTrials.gov NCT01882114.
    Chest 11/2014; · 7.13 Impact Factor

Publication Stats

18k Citations
5,026.99 Total Impact Points

Institutions

  • 2013–2015
    • Aalborg University
      • Faculty of Medicine
      Ålborg, North Denmark, Denmark
    • Aalborg University Hospital
      • Department of Cardiology
      Aalborg, Region North Jutland, Denmark
    • Attikon University Hospital
      Athínai, Attica, Greece
    • Queen Mary, University of London
      • Centre for Primary Care and Public Health
      London, ENG, United Kingdom
    • Aston University
      • School of Life and Health Sciences
      Birmingham, ENG, United Kingdom
    • Azienda Ospedaliera Santa Maria della Misericordia
      Udine, Friuli Venezia Giulia, Italy
  • 1996–2014
    • University of Birmingham
      • • Centre for Cardiovascular Sciences
      • • School of Sport and Exercise Sciences
      Birmingham, England, United Kingdom
  • 2012–2013
    • Chinese PLA General Hospital (301 Hospital)
      Peping, Beijing, China
    • Hospital General Universitario Morales Meseguer
      Murcia, Murcia, Spain
    • Karolinska Institutet
      • Institutionen för klinisk forskning och utbildning, Södersjukhuset
      Stockholm, Stockholm, Sweden
    • Boehringer Ingelheim
      Ingelheim, Rheinland-Pfalz, Germany
    • Università di Pisa
      Pisa, Tuscany, Italy
    • University of Murcia
      • Faculty of Medicine
      Murcia, Murcia, Spain
    • Copenhagen University Hospital Gentofte
      • Department of Dermato-Allergology
      Hellebæk, Capital Region, Denmark
    • Vilnius University Hospital Santariškių Klinikos
      Vil'nyus, Vilniaus Apskritis, Lithuania
    • Universität Heidelberg
      • Department of Clinical Pharmacology and Pharmacoepidemiology
      Heidelberg, Baden-Wuerttemberg, Germany
    • University of Belgrade
      • Chair of Pharmacology, Clinical Pharmacology and Toxicology
      Beograd, Central Serbia, Serbia
    • University of Oxford
      • Department of Primary Care Health Sciences
      Oxford, ENG, United Kingdom
  • 2011–2013
    • Klinički centar Srbije
      • Institute for Cardiovascular Diseases
      Beograd, Central Serbia, Serbia
    • Sapienza University of Rome
      • Department of Experimental Medicine
      Roma, Latium, Italy
    • Centre Hospitalier Universitaire de Tours
      Tours, Centre, France
    • University of Bologna
      • Institute of Cardiology
      Bologna, Emilia-Romagna, Italy
    • Oulu University Hospital
      • Department of Surgery
      Oulu, Oulu, Finland
    • East Coast Community Healthcare CIC
      Beccles, England, United Kingdom
    • Universitätsklinikum Münster
      Muenster, North Rhine-Westphalia, Germany
  • 1995–2013
    • University Hospitals Birmingham NHS Foundation Trust
      • Department of Medicine
      Birmingham, ENG, United Kingdom
  • 2010–2011
    • Maastricht Universitair Medisch Centrum
      • Central Diagnostic Laboratory
      Maestricht, Limburg, Netherlands
    • Turku University Hospital
      • Turku PET Centre
      Turku, Province of Western Finland, Finland
    • Baker IDI Heart and Diabetes Institute
      Melbourne, Victoria, Australia
    • Academisch Medisch Centrum Universiteit van Amsterdam
      • Department of Vascular Medicine
      Amsterdam, North Holland, Netherlands
  • 2005–2011
    • Sandwell and West Birmingham Hospitals NHS Trust
      Birmingham, England, United Kingdom
    • Hospital Universitario San Juan De Alicante
      Alicante, Valencia, Spain
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom
  • 2008–2009
    • Justus-Liebig-Universität Gießen
      Gieben, Hesse, Germany
    • Ospedale Maggiore Carlo Alberto Pizzardi di Bologna
      • Department of Cardiology
      Bolonia, Emilia-Romagna, Italy
    • Royal College of Physicians
      Londinium, England, United Kingdom
    • Maastricht University
      • Cardiologie
      Maastricht, Provincie Limburg, Netherlands
  • 2007–2009
    • Hospital General Universitario de Alicante
      • Departamento de Cardiología
      Alicante, Valencia, Spain
  • 1995–2009
    • Birmingham City University
      Birmingham, England, United Kingdom
  • 2007–2008
    • University Hospital of Heraklion
      Irákleio, Attica, Greece
  • 2004
    • St. George's School
      Middletown, Rhode Island, United States
  • 2003
    • The University of Edinburgh
      • Division of Clinical Neurosciences
      Edinburgh, SCT, United Kingdom
  • 2002
    • McMaster University
      • Department of Medicine
      Hamilton, Ontario, Canada
  • 2001
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 1999
    • Birmingham Children's Hospital NHS Foundation Trust
      Birmingham, England, United Kingdom
  • 1997
    • University Hospital Of South Manchester NHS Foundation Trust
      Manchester, England, United Kingdom