Mihai Gheorghiade

Emory University, Atlanta, Georgia, United States

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Publications (703)4014.56 Total impact

  • Stephen J Greene, Mihai Gheorghiade
    Journal of the American College of Cardiology 10/2014; 64(15):1599-601. · 14.09 Impact Factor
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    ABSTRACT: Heart failure (HF) is a public health problem of global proportions afflicting more than 25 million patients worldwide. Despite stable or declining per capita hospitalization rates in the USA and several European countries, there are over one million hospitalizations for HF annually in the USA, with similar numbers in Europe, accounting for 6.5 million hospital days and the majority of the approximately $40 billion spent each year on HF-related care. Moreover, clinical trial data suggest that post-discharge survival and readmissions have largely remained unchanged. Thus, understanding geographic and ethnic variations in HF is essential to formulating public policy at the local, national, regional, and international levels and setting the agenda for basic, translational, and clinical research endeavors. This paper aims to describe regional and ethnic variations in patient characteristics, management, and outcomes in hospitalized HF.
    Current Heart Failure Reports 09/2014;
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    ABSTRACT: The objective of this study was to evaluate the clinical presentation, inpatient management, and in-hospital outcome of patients hospitalized for acute heart failure syndromes (AHFS) and classified as pulmonary edema (PE).
    Journal of Cardiovascular Medicine 09/2014; · 2.66 Impact Factor
  • JACC: Heart Failure. 09/2014;
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    ABSTRACT: We investigated the clinical profiles associated with serum uric acid (sUA) levels in a large cohort of patients hospitalized for worsening chronic heart failure with ejection fraction (EF) ≤40%, with specific focus on gender, race, and renal function based interactions. In 3,955 of 4,133 patients (96%) with baseline sUA data, clinical characteristics and outcomes were compared across sUA quartiles. The primary end points were all-cause mortality and a composite of cardiovascular mortality or heart failure hospitalization. Interaction analyses were performed for gender, race, and baseline renal function. Median follow-up was 9.9 months. Mean sUA was 9.1 ± 2.8 mg/dl and was higher in men than in women (9.3 ± 2.7 vs 8.7 ± 3.0 mg/dl, p <0.001) and in blacks than in whites (10.0 ± 2.7 vs 9.0 ± 2.8 mg/dl, p <0.001). Higher sUA was associated with lower systolic blood pressure and EF, higher natriuretic peptides, and more impaired renal function. After accounting for 24 baseline covariates, in patients with enrollment estimated glomerular filtration rate ≥30 ml/min/1.73 m(2), sUA was strongly associated with increased all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.22 to 1.69, p <0.001) and the composite end point (hazard ratio 1.44, 95% confidence interval 1.26 to 1.64, p <0.001). However, in patients with estimated glomerular filtration rate <30 ml/min/1.73 m(2), sUA was not related with either end point (both p >0.4). Adjusted interaction analyses for gender, race, and admission allopurinol use were not significant. In conclusion, sUA is commonly elevated in patients hospitalized for worsening chronic heart failure and reduced EF, especially in men and blacks. The prognostic use of sUA differs by baseline renal function, suggesting different biologic and pathophysiologic significance of sUA among those with and without significant renal dysfunction.
    The American journal of cardiology. 09/2014;
  • Muthiah Vaduganathan, Mihai Gheorghiade
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    ABSTRACT: Heart failure (HF) accounts for over 1 million primary hospitalizations in the USA each year and carries a tremendous burden on costs and patient outcomes. The clinical syndrome of HF is not a single disease, but represents the complex interplay between various cardiac and non-cardiac processes, each of which need to be individually addressed. This review provides an updated, contemporary roadmap for inpatient worsening chronic HF management with a focus on identifying and addressing initiating mechanisms, amplifying factors, and cardiac structural abnormalities. Inpatient risk stratification should guide patient education, team structuring, disposition, and post-discharge monitoring.
    Journal of cardiology. 09/2014;
  • Javed Butler, Eugene Braunwald, Mihai Gheorghiade
    JAMA The Journal of the American Medical Association 08/2014; 312(8):789-790. · 29.98 Impact Factor
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    ABSTRACT: Background Clinical trials have demonstrated benefit for cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillator (ICD) therapies in patients with heart failure with reduced ejection fraction (HFrEF); yet, questions have been raised with regard to the benefit of device therapy for minorities. Objectives The purpose of this study was to determine the clinical effectiveness of CRT and ICD therapies as a function of race/ethnicity in outpatients with HFrEF (ejection fraction ≤35%). Methods Data from IMPROVE HF (Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting) were analyzed by device status and race/ethnicity among guideline-eligible patients for mortality at 24 months. Multivariate Generalized Estimating Equations analyses were conducted, adjusting for patient and practice characteristics. Results The ICD/cardiac resynchronization defibrillator (CRT-D)–eligible cohort (n = 7,748) included 3,391 (44%) non-Hispanic white, 719 (9%) non-Hispanic black, and 3,638 (47%) other racial/ethnic minorities or race-not-documented patients. The cardiac resynchronization pacemaker (CRT-P)/CRT-D–eligible cohort (n = 1,188) included 596 (50%) non-Hispanic white, 99 (8%) non-Hispanic black, and 493 (41%) other/not-documented patients. There was clinical benefit associated with ICD/CRT-D therapy (adjusted odds ratio: 0.64, 95% confidence interval: 0.52 to 0.79, p = 0.0002 for 24-month mortality), which was of similar proportion in white, black, and other minority/not-documented patients (device–race/ethnicity interaction p = 0.7861). For CRT-P/CRT-D therapy, there were also associated mortality benefits (adjusted odds ratio: 0.55, 95% confidence interval: 0.33 to 0.91, p = 0.0222), and the device–race/ethnicity interaction was not significant (p = 0.5413). Conclusions The use of guideline-directed CRT and ICD therapy was associated with reduced 24-month mortality without significant interaction by racial/ethnic group. Device therapies should be offered to eligible heart failure patients, without modification based on race/ethnicity.
    Journal of the American College of Cardiology 08/2014; 64(8):797–807. · 14.09 Impact Factor
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    ABSTRACT: MD for the ASTRONAUT Investigators and Coordinators I NHIBITION OF THE RENIN-ANGIOTEN-sin-aldosterone system (RAAS) has long been recognized as a life-prolonging therapy for patients with chronic heart failure (HF) with reduced left ventricular ejection fraction (LVEF), 1 and angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and mineralocorticoid receptor antago-nists (MRAs) are recommended by all major national guidelines. 2,3 How-ever, although the benefits of these treatments are undisputed, these agents induce a compensatory increase in re-nin and downstream RAAS intermedi-aries that may partially offset RAAS blocking effects. Based on this patho-physiological concept of "RAAS es-cape," multiple trials have
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    ABSTRACT: The management of heart failure with reduced ejection fraction (HF-REF) has improved significantly over the last two decades. In contrast, little or no progress has been made in identifying evidence-based, effective treatments for heart failure with preserved ejection fraction (HF-PEF). Despite the high prevalence, mortality, and cost of HF-PEF, large phase III international clinical trials investigating interventions to improve outcomes in HF-PEF have yielded disappointing results. Therefore, treatment of HF-PEF remains largely empiric, and almost no acknowledged standards exist. There is no single explanation for the negative results of past HF-PEF trials. Potential contributors include an incomplete understanding of HF-PEF pathophysiology, the heterogeneity of the patient population, inadequate diagnostic criteria, recruitment of patients without true heart failure or at early stages of the syndrome, poor matching of therapeutic mechanisms and primary pathophysiological processes, suboptimal study designs, or inadequate statistical power. Many novel agents are in various stages of research and development for potential use in patients with HF-PEF. To maximize the likelihood of identifying effective therapeutics for HF-PEF, lessons learned from the past decade of research should be applied to the design, conduct, and interpretation of future trials. This paper represents a synthesis of a workshop held in Bergamo, Italy, and it examines new and emerging therapies in the context of specific, targeted HF-PEF phenotypes where positive clinical benefit may be detected in clinical trials. Specific considerations related to patient and endpoint selection for future clinical trials design are also discussed.
    European heart journal. 08/2014;
  • Journal of cardiac failure. 08/2014; 20(8S):S103-S104.
  • Circulation Heart Failure 07/2014; 7(4):680-91. · 6.68 Impact Factor
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    ABSTRACT: AimsThe clinical outcomes for patients with worsening chronic heart failure (WCHF) remain exceedingly poor despite contemporary evidence-based therapies, and effective therapies are urgently needed. Accumulating evidence supports augmentation of cyclic guanosine monophosphate (cGMP) signalling as a potential therapeutic strategy for HF with reduced or preserved ejection fraction (HFrEF and HFpEF, respectively). Direct soluble guanylate cyclase (sGC) stimulators target reduced cGMP generation due to insufficient sGC stimulation and represent a promising method for cGMP enhancement.Methods The phase II SOluble guanylate Cyclase stimulatoR in heArT failurE Study (SOCRATES) programme consists of two randomized, parallel-group, placebo-controlled, double-blind, multicentre studies, SOCRATES-REDUCED (in patients with LVEF <45%) and SOCRATES-PRESERVED (in those with LVEF ≥45%), that will explore the pharmacodynamic effects, safety and tolerability, and pharmacokinetics of four dose regimens of the once-daily oral sGC stimulator vericiguat (BAY 1021189) over 12 weeks compared with placebo. These studies will enrol patients stabilized during hospitalization for HF at the time of discharge or within 4 weeks thereafter. The primary endpoint in SOCRATES-REDUCED is change in NT-proBNP at 12 weeks. The primary endpoints in SOCRATES-PRESERVED are change in NT-proBNP and left atrial volume at 12 weeks.PerspectivesSOCRATES will be the first programme to enrol specifically both inpatients and outpatients with WCHF and patients with reduced or preserved ejection fraction. Results will inform the benefits of pursuing subsequent event-driven clinical outcome trials with sGC stimulators in this patient population.Trial registrationNCT01951625 (SOCRATES-REDUCED) and NCT01951638 (SOCRATES-PRESERVED)
    European Journal of Heart Failure 07/2014; · 5.25 Impact Factor
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    ABSTRACT: Despite the well-established benefits of mineralocorticoid receptor agonists (MRAs) in heart failure with reduced ejection fraction, safety concerns remain in patients with concomitant diabetes mellitus (DM) because of common renal and electrolyte abnormalities in this population. We analyzed all-cause mortality and composite cardiovascular mortality and HF hospitalization over a median 9.9 months among 1,998 patients in the placebo arm of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial by DM status and discharge MRA use. Of the 750 patients with DM, 59.2% were receiving MRAs compared with 62.5% in the non-DM patients. DM patients not receiving MRAs were older, more likely to be men, with an ischemic heart failure etiology and slightly worse renal function compared with those receiving MRAs. After adjustment for baseline risk factors, among DM patients, MRA use was not associated with either mortality (hazard ratio [HR] 0.93; 95% confidence interval [CI] 0.75 to 1.15) or the composite end point (HR 0.94; 95% CI 0.80 to 1.10). Similar findings were seen in non-DM patients (mortality [HR 1.01; 95% CI 0.84 to 1.22] or the composite end point [HR 0.98; 95% CI 0.85 to 1.13] [p >0.43 for DM interaction]). In conclusion, in-hospital initiation of MRA therapy was low (15% to 20%), and overall discharge MRA use was only 60% (with regional variation), regardless of DM status. There does not appear to be clear, clinically significant in-hospital hemodynamic or even renal differences between those on and off MRA. Discharge MRA use was not associated with postdischarge end points in patients hospitalized for worsening heart failure with reduced ejection fraction and co-morbid DM. DM does not appear to influence the effectiveness of MRA therapy.
    The American Journal of Cardiology 06/2014; · 3.21 Impact Factor
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    ABSTRACT: Despite all available therapies, the rates of hospitalization and death from heart failure (HF) remain unacceptably high. The most common reasons for hospital admission are symptoms related to congestion. During hospitalization, most patients respond well to standard therapy and are discharged with significantly improved symptoms. Post-discharge, many patients receive diligent and frequent follow-up. However, rehospitalization rates remain high. One potential explanation is a persistent failure by clinicians to adequately manage congestion in the outpatient setting. The failure to successfully manage these patients post-discharge may represent an unmet need to improve the way congestion is both recognized and treated. A primary aim of future HF management may be to improve clinical surveillance to prevent and manage chronic fluid overload while simultaneously maximizing the use of evidence-based therapies with proven long-term benefit. Improvement in cardiac function is the ultimate goal and maintenance of a "dry" clinical profile is important to prevent hospital admission and improve prognosis. This paper focuses on methods for monitoring congestion, and strategies for water and sodium management in the context of the complex interplay between the cardiac and renal systems. A rationale for improving recognition and treatment of congestion is also proposed.
    Heart Failure Reviews 06/2014; · 4.45 Impact Factor
  • Sadiya S Khan, Javed Butler, Mihai Gheorghiade
    JAMA The Journal of the American Medical Association 06/2014; 311(23):2379-80. · 29.98 Impact Factor
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    ABSTRACT: A quarter of patients hospitalized for heart failure are readmitted within 30 days, perhaps related to ineffective decongestion. Limited data exist guiding the extent and duration of diuresis in patients hospitalized for heart failure. The objective of this review was to determine the prognostic value of hemoconcentration, or the relative increase in the cellular elements in blood, in patients hospitalized for heart failure and to clarify its role in guiding inpatient diuretic practices. Six post-hoc retrospective studies from 2010-2013 were available for review. Hemoconcentration was consistently associated with markers of aggressive fluid removal including increased diuretic dosing and reduced body weight, but increased risk of in-hospital worsening renal function. Despite this, hemoconcentration was associated with improved short-term mortality and rehospitalization. Hemoconcentration is a practical, readily available, non-invasive, economically feasible strategy to help guide diuresis and monitor congestion relief in patients hospitalized for worsening heart failure. Clinicians should strongly consider utilizing changes in hemoglobin and hematocrit as an adjunct to other available measures of decongestion and clinical acumen in inpatient heart failure care.
    The American journal of medicine. 06/2014;
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    ABSTRACT: Amino acids play a key role in multiple cellular processes. Amino acids availability is reduced in patients with heart failure (HF) with deleterious consequences on cardiac and whole-body metabolism. Several metabolic abnormalities have been identified in the failing heart, and many of them lead to an increased need of amino acids. Recently, several clinical trials have been conducted to demonstrate the benefits of amino acids supplementation in patients with HF. Although they have shown an improvement of exercise tolerance and, in some cases, of left ventricular function, they have many limitations, namely small sample size, differences in patients' characteristics and nutritional supplementations, and lack of data regarding outcomes. Moreover recent data suggest that a multi-nutritional approach, including also antioxidants, vitamins, and metals, may be more effective. Larger trials are needed to ascertain safety, efficacy, and impact on prognosis of such an approach in HF.
    Heart Failure Reviews 06/2014; · 4.45 Impact Factor
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    ABSTRACT: Background Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management.Objectives The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five-point absolute Likert scale, 10-cm visual analog scale [VAS], or seven-point relative Likert scale).Methods This was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement.ResultsOf the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five-point Likert scale (c-index ranged from 0.708 to 0.831 for each scale).Conclusions Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.ResumenAntecedentesLa disnea es el síntoma más frecuente en la insuficiencia cardiaca aguda (ICA), sin embargo no ha sido bien definida la mejor manera de medirla. Estudios previos demuestran diferencias en la mejoría de la disnea a través de varias escalas de medida, sin embargo estos estudios suelen reclutar pacientes bastante después de la fase de manejo en el SU.ObjetivosEl objetivo de este estudio fue determinar los predictores precoces de mejoría de la disnea para tres escalas de disnea diferentes frecuentemente utilizadas (escala Likert absoluta de 5 puntos, escala visual analógica [EVA] de 10 cm o escala Likert relativa de 7 puntos).MétodosSe trata de un análisis post hoc del estudio observacional Disnea URGENTE, que reclutó 776 pacientes dentro de la primera hora tras la primera valoración médica en 17 países. Los criterios de inclusión fueron amplios para reflejar la práctica clínica en el mundo real. La literatura previa documentó la definición a priori de la mejoría significativa de disnea. Se crearon modelos multivariables basados en el remuestreo para determinar las características de los pacientes significativamente asociadas con la mejoría de la disnea.ResultadosDe los 524 pacientes con ICA, aproximadamente un 40% de los pacientes no documentaron una mejoría sustancial de la disnea en las 6 primeras horas. Las características basales fueron similares entre los que mejoraron y los que no, aunque hubo diferencias en la historia de insuficiencia cardiaca, enfermedad coronaria y presión arterial sistólica inicial. Para aquéllos que mejoraron, las características del paciente difirieron en las tres escalas, con la excepción de la gravedad de la disnea basal para la EVA y en la escala Likert de 5 puntos (el índice-c varió desde 0,708 hasta 0,831 para cada escala).ConclusionesLos predictores de la mejoría precoz de disnea difieren dependiendo de la escala, con la excepción de la disnea basal. Los intentos para utilizar una sola escala para categorizar la totalidad del síntoma disnea pueden ser insuficientes.
    Academic Emergency Medicine 06/2014; 21(6). · 1.76 Impact Factor
  • Bertram Pitt, Mihai Gheorghiade
    European Journal of Heart Failure 05/2014; · 5.25 Impact Factor

Publication Stats

17k Citations
4,014.56 Total Impact Points


  • 2011–2014
    • Emory University
      • Division of Cardiology
      Atlanta, Georgia, United States
    • Institute for Cardiovascular Diseases
      Socola, Iaşi, Romania
    • Thomas Jefferson University
      Philadelphia, Pennsylvania, United States
    • Wilford Hall Ambulatory Surgery Center
      Lackland Air Force Base, Texas, United States
    • University of Chicago
      Chicago, Illinois, United States
  • 1993–2014
    • Northwestern University
      • • Division of Cardiology (Dept. of Medicine)
      • • Department of Emergency Medicine
      • • Feinberg School of Medicine
      • • Department of Medicine
      • • Division of General Internal Medicine and Geriatrics
      • • Department of Preventive Medicine
      Evanston, Illinois, United States
    • University of Illinois at Chicago
      • Section of Cardiology
      Chicago, Illinois, United States
  • 2013
    • Stanford Medicine
      • Department of Medicine
      Stanford, CA, United States
    • New York Medical College
      • Department of Medicine
      New York City, New York, United States
    • University of Groningen
      • Department of Cardiology
      Groningen, Province of Groningen, Netherlands
    • University at Buffalo, The State University of New York
      • Department of Medicine
      Buffalo, New York, United States
  • 2012–2013
    • Centre Hospitalier Universitaire de Poitiers
      • Department of Cardiology
      Poitiers, Poitou-Charentes, France
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • Harvard Medical School
      • Department of Medicine
      Boston, MA, United States
    • Massachusetts General Hospital
      • Department of Medicine
      Boston, MA, United States
    • University of Cologne
      Köln, North Rhine-Westphalia, Germany
    • Stanford University
      • Department of Medicine
      Stanford, CA, United States
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
  • 2011–2013
    • Vanderbilt University
      • Department of Emergency Medicine
      Nashville, Michigan, United States
  • 2010–2013
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
    • Brescia University
      Chicago, Illinois, United States
    • Sahlgrenska University Hospital
      Goeteborg, Västra Götaland, Sweden
    • Wayne State University
      • Department of Emergency Medicine
      Detroit, MI, United States
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 2006–2013
    • Unité Inserm U1077
      Caen, Lower Normandy, France
    • University of Colorado
      Denver, Colorado, United States
    • Biomedical Research Institute, Rockville
      Maryland, United States
    • Ospedale Pediatrico Bambino Gesù
      • Division of Cardiac Surgery
      Roma, Latium, Italy
  • 2004–2013
    • University of Alabama at Birmingham
      • Department of Medicine
      Birmingham, AL, United States
    • Johns Hopkins Medicine
      • Department of Medicine
      Baltimore, MD, United States
    • Ochsner
      New Orleans, Louisiana, United States
  • 2001–2013
    • Duke University
      Durham, North Carolina, United States
  • 1998–2013
    • University of California, San Francisco
      • • Division of Cardiology
      • • Division of Hospital Medicine
      San Francisco, CA, United States
    • St. George's School
      • Department of Cardiological Sciences
      Middletown, Rhode Island, United States
  • 2002–2012
    • Duke University Medical Center
      • • Division of Cardiology
      • • Duke Clinical Research Institute
      • • Department of Medicine
      Durham, NC, United States
    • Medical City Hospital, Dallas
      Dallas, Texas, United States
  • 1987–2012
    • Henry Ford Hospital
      • Department of Internal Medicine
      Detroit, Michigan, United States
  • 2009–2011
    • National Research Council
      • Institute of Clinical Physiology IFC
      Roma, Latium, Italy
    • University of Maryland, Baltimore
      • Division of Cardiology
      Baltimore, MD, United States
    • University of South Florida
      Tampa, Florida, United States
    • San Francisco VA Medical Center
      San Francisco, California, United States
    • Kerckhoff Klinik
      Stadt Bad Nauheim, Hesse, Germany
    • Baylor Hamilton Heart and Vascular Hospital
      Dallas, Texas, United States
  • 2007–2011
    • Tufts Medical Center
      • Division of Cardiology
      Boston, Massachusetts, United States
    • University of California, San Diego
      San Diego, California, United States
    • University of South Carolina
      Columbia, South Carolina, United States
    • University of Texas Southwestern Medical Center
      • Department of Internal Medicine
      Dallas, TX, United States
    • Louisiana State University Health Sciences Center Shreveport
      Shreveport, Louisiana, United States
    • Athens State University
      Athens, Alabama, United States
  • 2003–2011
    • Università degli Studi di Brescia
      • Department of Clinical and Experimental Sciences
      Brescia, Lombardy, Italy
    • Advocate Illinois Masonic Medical Center
      Chicago, Illinois, United States
  • 1998–2011
    • University of California, Los Angeles
      • • Department of Medicine
      • • Division of Cardiology
      Los Angeles, CA, United States
  • 2008–2010
    • University of Cincinnati
      • Department of Emergency Medicine
      Cincinnati, OH, United States
    • Northwestern Memorial Hospital
      • Bluhm Cardiovascular Institute
      Chicago, Illinois, United States
    • Baylor Health Care System
      • Baylor Heart and Vascular Institute (BHVI)
      Dallas, Texas, United States
    • Attikon University Hospital
      • Department of Cardiology
      Athens, Attiki, Greece
    • The Ohio State University
      • Division of Cardiovascular Medicine
      Columbus, OH, United States
    • University of Texas Medical School
      • Department of Internal Medicine
      Houston, TX, United States
    • University of Southern California
      Los Angeles, California, United States
  • 2007–2010
    • Harbor-UCLA Medical Center
      Torrance, California, United States
  • 2005–2010
    • University of Michigan
      Ann Arbor, Michigan, United States
    • Hennepin County Medical Center
      Minneapolis, Minnesota, United States
  • 1993–2010
    • Sapienza University of Rome
      • Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences
      Roma, Latium, Italy
  • 2008–2009
    • Paris Diderot University
      Lutetia Parisorum, Île-de-France, France
  • 2006–2008
    • European Hospital
      Roma, Latium, Italy
  • 2001–2006
    • North Carolina Clinical Research
      Raleigh, North Carolina, United States
  • 2002–2005
    • University of North Carolina at Chapel Hill
      • Department of Medicine
      Chapel Hill, NC, United States
  • 1997
    • Northeastern University
      Boston, Massachusetts, United States
    • Northeastern Illinois University
      Chicago, Illinois, United States
  • 1995
    • Henry Ford Health System
      Detroit, Michigan, United States
  • 1984
    • Providence Hospital
      Mobile, Alabama, United States