Gregory Y H Lip

University of Catania, Catania, Sicily, Italy

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Publications (999)6109.03 Total impact

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    ABSTRACT: Entidades de la ESC que han participado en el desarrollo de este documento:
    No preview · Article · Jan 2016
  • Pak-Hei Chan · Duo Huang · Chu-Pak Lau · Esther W. Chan · Ian CK. Wong · Gregory YH. Lip · Hung-Fat Tse · Chung-Wah Siu
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    ABSTRACT: Although dabigatran is one of the preferred agents for stroke prevention in atrial fibrillation (AF), warfarin remains the mainstay treatment in many publicly financed healthcare systems. Little is known about the net clinical benefit of switching patients on warfarin at different risk profiles and time in therapeutic range (TTR) to dabigatran. In this study, we aimed to investigate the net clinical benefit of switching warfarin to dabigatran in relation to CHA2DS2-VASc score and TTR.
    No preview · Article · Jan 2016 · The Canadian journal of cardiology
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    ABSTRACT: Background: Patients with nonvalvular atrial fibrillation (AF) who undergo electrical cardioversion (ECV) tend to be younger and have less comorbidity. Long-term anticoagulation after ECV should be based on thromboembolic risk. We sought to study the long-term incidence of thromboembolic events (TE), factors related to TE and compare the predictive value of the CHADS2and CHA2DS2-VASc scores in this particular population.Methods and Results:From January 2008 to June 2012, 571 ECV were performed in 406 consecutive patients with nonvalvular AF. Risk factors for TE and factors related to anticoagulation therapy after ECV were registered. During a follow-up of approximately 2 years, the annual incidence of TE was 1.9%. Factors associated with TE were: poor quality anticoagulation control (hazard ratio [HR]: 2.91; 95% confidence interval [CI]: 1.10-7.80; P=0.03), cessation of anticoagulation after ECV (HR: 8.80; 95% CI: 3.11-25.10; P<0.001), age ≥65 years (HR: 13.65; 95% CI: 1.74-107.16; P=0.01), CHADS2score (HR: 1.59; 95% CI: 1.10-2.29; P=0.01) and CHA2DS2-VASc score (HR: 1.67; 95% CI: 1.30-2.22; P<0.001). Both risk scores predicted TE [c-statistic for CHADS2: 0.68 (95% CI: 0.62-0.74; P=0.005), for CHA2DS2-VASc: 0.75 (95% CI: 0.70-0.80; P<0.001)]. Based on c-statistics, the predictive accuracy of CHA2DS2-VASc was superior (difference between areas: 0.064±0.031; P=0.0403). Conclusions: Important determinants of long-term occurrence of TE after ECV were related to anticoagulant therapy (poor quality anticoagulation and cessation of this therapy over follow-up). The CHA2DS2-VASc score successfully predicts TE after ECV, having better predictive accuracy than the CHADS2score.
    Full-text · Article · Jan 2016 · Circulation Journal
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    ABSTRACT: Objective: To compare intracerebral hemorrhage (ICH) volume and clinical outcome of non-vitamin K oral anticoagulants (NOAC)-associated ICH to warfarin-associated ICH. Methods: In this multicenter cross-sectional observational study of patients with anticoagulant-associated ICH, consecutive patients with NOAC-ICH were compared to those with warfarin-ICH selected from a population of 344 patients with anticoagulant-associated ICH. ICH volume was measured by an observer blinded to clinical details. Outcome measures were ICH volume and clinical outcome adjusted for confounding factors. Results: We compared 11 patients with NOAC-ICH to 52 patients with warfarin-ICH. The median ICH volume was 2.4 mL (interquartile range [IQR] 0.3-5.4 mL) for NOAC-ICH vs 8.9 mL (IQR 4.0-21.3 mL) for warfarin-ICH (p = 0.0028). In univariate linear regression, use of warfarin (difference in cube root volume 1.61; 95% confidence interval [CI] 0.69 to 2.53) and lobar ICH location (compared with nonlobar ICH; difference in cube root volume 1.52; 95% CI 2.20 to 0.85) were associated with larger ICH volumes. In multivariable linear regression adjusting for confounding factors (sex, hypertension, previous ischemic stroke, white matter disease burden, and premorbid modified Rankin Scale score [mRS]), warfarin use remained independently associated with larger ICH (cube root) volumes (coefficient 0.64; 95% CI 0.24 to 1.25; p = 0.042). Ordered logistic regression showed an increased odds of a worse clinical outcome (as measured by discharge mRS) in warfarin-ICH compared with NOAC-ICH: odds ratio 4.46 (95% CI 1.10 to 18.14; p = 0.037). Conclusions: In this small prospective observational study, patients with NOAC-associated ICH had smaller ICH volumes and better clinical outcomes compared with warfarin-associated ICH.
    Full-text · Article · Dec 2015 · Neurology
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    Full-text · Article · Dec 2015 · European Heart Journal
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    ABSTRACT: We aimed to assess the impact of L-carnitine on plasma Lp(a) concentrations through systematic review and meta-analysis of available RCTs. The literature search included selected databases up to 31st January 2015. Meta-analysis was performed using fixed-effects or random-effect model according to I2 statistic. Effect sizes were expressed as weighted mean difference (WMD) and 95% confidence interval (CI). The meta-analysis showed a significant reduction of Lp(a) levels following L-carnitine supplementation (WMD: -8.82 mg/dL, 95%CI: -10.09, -7.55, p<0.001). When the studies were categorized according to the route of administration, a significant reduction in plasma Lp(a) concentration was observed with oral (WMD: -9.00 mg/dL, 95%CI: -10.29, -7.72, p<0.001) but not intravenous L-carnitine (WMD: -2.91 mg/dL, 95%CI: -10.22, 4.41, p=0.436). The results of the meta-regression analysis showed that the pooled estimate is independent of L-carnitine dose (slope: -0.30; 95%CI: -4.19, 3.59; p=0.878) and duration of therapy (slope: 0.18; 95%CI: -0.22, 0.59; p=0.374). In conclusion, the meta-analysis suggests a significant Lp(a) lowering by oral L-carnitine supplementation. Taking into account the limited number of available Lp(a)-targeted drugs, L-carnitine might be an effective alternative to effectively reduce Lp(a). Prospective outcome trials will be required to fully elucidate the clinical value and safety of oral L-carnitine supplementation.
    Full-text · Article · Dec 2015 · Scientific Reports
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    George Ntaios · Gregory Y.H. Lip
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    ABSTRACT: Purpose of review: A significant proportion of stroke patients is treated with anticoagulants for secondary stroke prevention. Often, in such patients, stroke physicians are required to make difficult clinical decisions when confronted with the dilemma to choose between the risk of thromboembolism and the risk of bleeding. This article focuses on three common anticoagulant-related situations, where the stroke physician needs to find the delicate balance between the two risks. Recent findings: Three typical case vignettes are presented and the associated dilemmas are discussed: a patient with an anticoagulant-related intracranial hemorrhage: would you restart anticoagulation?, an anticoagulated patient with a previous stroke because of atrial fibrillation is scheduled for an elective polyp removal: how would you handle anticoagulation perioperatively?, and a patient presents with an ischemic stroke because of atrial fibrillation: how soon would you start anticoagulation for secondary stroke prevention? The article summarizes the related literature and discusses the pros and cons of each choice. Summary: The available evidence is limited; we need to individualize our approach according to the specific characteristics of our patients, and share the decision process with our patients and their proxies, taking strongly into consideration their values and preferences.
    Full-text · Article · Dec 2015 · Current Opinion in Neurology
  • Gregory Y.H. Lip · Deirdre A. Lane

    No preview · Article · Dec 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Autor para correspondencia:
    No preview · Article · Dec 2015
  • Mikhail S Dzeshka · Gregory Yh Lip
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    ABSTRACT: Introduction: Oral anticoagulation is central to the management of patients with atrial fibrillation (AF) and at least one additional stroke risk factor. For decades, the vitamin K antagonists (e.g. warfarin) remained the only oral anticoagulant available for stroke prevention in AF. The non-vitamin K oral anticoagulants (NOACs) are now available, and these drugs include the direct thrombin inhibitors and factor Xa inhibitors. The latter class includes edoxaban, which has recently been approved for stroke prevention in AF by the United States Food and Drug Administration and the European Medicine Agency. In line with other NOACs, edoxaban avoids the many limitations of warfarin associated with variability of anticoagulation effect and multiple food and drug interactions. Areas covered: In this review, the currently available evidence on edoxaban in patients with non-valvular AF is discussed. The pharmacology, efficacy and safety, and current aspects of use of edoxaban in patients with non-valvular AF for stroke and thromboembolism prevention are reviewed. Expert opinion: Phase III trials on edoxaban for stroke prevention in non-valvular AF confirms non-inferiority of edoxaban compared to well-managed warfarin both in terms of efficacy and safety. Currently ongoing and future trials as well as real-world data are warranted to confirm its effectiveness and safety for chronic anticoagulation and improve evidence in other areas which are lacking evidence where NOAC use remains controversial.
    No preview · Article · Nov 2015 · Expert Opinion on Pharmacotherapy
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    ABSTRACT: Oral anticoagulation therapy is essential in patients with atrial fibrillation and clinicians need guidance on decision-making between the vitamin K antagonists (VKA), e.g. warfarin, or non-vitamin K antagonist oral anticoagulants. Observational studies have shown that patients who receive VKA therapy spend a significant percentage of their time with INR values outside of the therapeutic range (time in therapeutic range, TTR <60%.) Recently, a clinical score has been developed with commonly-encountered clinical features, the SAMe-TT2R2 score, to help decision-making with regards to whether a patient is likely to do well, or not, with a VKA. Those with a SAMe-TT2R2 score 0-1 are likely to do well on a VKA, whilst those with a SAMe-TT2R2 score ≥2 are on probability going to achieve suboptimal TTR. In this article, we provide an overview of the main published retrospective and prospective studies that have validated the SAMe-TT2R2 score and its value for decision-making in daily clinical practice.
    No preview · Article · Nov 2015 · Expert Review of Cardiovascular Therapy
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    ABSTRACT: Background: Patients with systolic heart failure (HF) are at increased risk of both ischemic stroke and death. Currently, no risk scores are available to identify HF patients at high risk of stroke or death. The Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial studied 2305 HF patients, in sinus rhythm, followed for up to 6 years (3.5±1.5 years). This trial showed no overall difference in those treated with warfarin vs aspirin with regard to death or stroke. The present study develops the first prognostic model to identify patients at higher risk of stroke or death based on their overall risk profile. Methods and results: A scoring algorithm using 8 readily obtainable clinical characteristics as predictors, age, gender, hemoglobin, blood urea nitrogen, ejection fraction, diastolic blood pressure, diabetes status, and prior stroke or transient ischemic attack (C-index=0.65, 95% CI: 0.613-0.681), was developed. It was validated internally using a bootstrap method. In predicting 1-year survival for death alone, our 8-predictor model had an AUC of 0.63 (95% CI: 0.579-0.678) while the 14-predictor Seattle model had an AUC of 0.72. The Seattle model did not report stroke. Conclusions: This novel prognostic model predicts the overall risk of ischemic stroke or death for HF patients. This model compares favorably for death with the Seattle model and has the added utility of including stroke as an endpoint. Use of this model will help identify those patients in need of more intensive monitoring and therapy and may help identify appropriate populations for trials of new therapies. Clinical trial registration: http://www.Clinicatrials.govNCT00041938.
    No preview · Article · Nov 2015 · Journal of Cardiology
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    ABSTRACT: Background: Atrial fibrillation (AF) increases the risk of stroke and death. Data on the predictors for stroke and death in 'real-world' AF patients are limited, especially from large prospective Asian cohorts. Methods: The Fushimi AF Registry is a community-based prospective survey designed to enroll all AF patients who visited the participating medical institutions in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 3,304 patients (median follow-up period 741 days). We explored the predictors for 'death, stroke, and systemic embolism (SE)' during follow-up in 1,541 patients not receiving oral anticoagulants (OAC) at baseline. Results: The mean age was 73.1 ± 12.5 years, and 673 (44%) patients were female. The mean CHADS2 and CHA2DS2-VASc scores were 1.76 and 3.08, respectively. Cumulative events were as follows: stroke/SE in 61 (4%) and death in 230 (15%), respectively. On multivariate analysis, advanced age (hazard ratio (HR): 1.68, 95% confidence interval (CI): 1.24-2.29), underweight (body mass index <18.5 kg/m2) (HR: 1.71, 95% CI: 1.25-2.32), previous stroke/SE/transient ischemic attack (HR: 1.70, 95% CI: 1.25-2.30), heart failure (HR: 1.59, 95% CI: 1.17-2.15), chronic kidney disease (HR: 1.53, 95% CI: 1.16-2.02), and anemia (HR: 2.41, 95% CI: 1.78-3.28) were independent predictors for death/stroke/SE. Cumulative numbers of these 6 risk predictors could stratify the incidence of death/stroke/SE in patients without OAC, as well as those with OAC in our registry. Conclusions: Advanced age, underweight, previous stroke/SE/transient ischemic attack, heart failure, chronic kidney disease, and anemia were independently associated with the risk of death/stroke/SE in non-anticoagulated Japanese AF patients.
    Preview · Article · Nov 2015 · PLoS ONE
  • Andrew D. Blann · Ron Pisters · Gregory Y.H. Lip
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    ABSTRACT: The purpose of this study was to determine, in a model based on Europeans at risk of stroke by virtue of atrial fibrillation (AF), the net clinical benefit of edoxaban in the reduction of the risk of stroke, mortality, and of hemorrhage.
    No preview · Article · Nov 2015 · JACC Clinical Electrophysiology
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    ABSTRACT: Background: How the adoption of prediction models to decide which patient with atrial fibrillation (AF) to anticoagulate can affect prescription rates and outcomes is unclear. Methods: We retrospectively analyzed data from Danish registries on patients with a first-time recorded AF from 2005 to 2010. We simulated the adoption of a decisional model based on the individual absolute risk reduction of stroke and absolute risk increase of bleeding with warfarin, as expected from the patient CHA2DS2-VASc and HAS-BLED, adjusted for a 0.6 relative value for bleeding versus stroke. We studied 3 different model versions and calculated for each of them the net benefit associated with its adoption, measured as the value-adjusted reduction in stroke and bleeding events at 1year, compared with i) the actual practice, or ii) recommending warfarin consistently with the European Society of Cardiology (ESC) guidelines, irrespective of HAS-BLED. Results: We included 41,455 patients; 31.9% actually received warfarin. The expected treatment rate with the model ranged from 21% to 87% according to the version used. The model version resulting into the highest treatment rate (i.e. treating any patient with CHA2DS2-VASc ≥1) was associated with the greatest net benefit (0.98; 95% credible interval 0.72-1.23), compared with the actual practice, with a 1/3 reduction in overall mortality, as with the adoption of ESC guidelines. Conclusions: Preliminarily to a randomized impact study, our analysis suggests that individualizing anticoagulation for AF using a decisional model might have a clinical advantage over actual practice, and no added advantage over following ESC guidelines.
    No preview · Article · Nov 2015 · International journal of cardiology
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    ABSTRACT: Background: Stroke is the most serious clinical consequence of atrial fibrillation, which is the most common cardiac arrhythmia. Non-vitamin K antagonist oral anticoagulants (NOACs) have emerged as efficacious, safe and convenient stroke prevention agents. This updated network meta-analysis focused on the relative efficacy and safety of apixaban compared with dabigatran, rivaroxaban and edoxaban for stroke prevention in (i) patients with CHADS2 score ≥2, (ii) secondary stroke prevention, and (iii) patients with high quality anticoagulation control with warfarin. Methods and results: A fixed-effects network meta-analysis was conducted, including data from four Phase III randomised controlled trials (>70,000 patients with non-valvular atrial fibrillation). The results of the base-case analysis comparing NOACs with warfarin were broadly in line with the results from the individual trials. Results from the three subgroup analyses were broadly similar to the base case results. For example in patients with CHADS2 score ≥2, apixaban, high-dose dabigatran, rivaroxaban, and high-dose edoxaban had significantly lower hazards of stroke/systemic embolism compared with low-dose edoxaban. Apixaban and low-dose edoxaban were associated with significantly lower hazards of major bleeding compared with rivaroxaban and dabigatran 150mg. However, several treatment comparisons that were significant in the base-case analysis were not significant in the patient subgroups, due to the reduced sample size of the subgroups compared with the overall population. Conclusions: Among the NOACs, apixaban offered the most favourable efficacy and safety profile in the overall patient population as well as in the three subgroups investigated.
    No preview · Article · Nov 2015 · International journal of cardiology
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    ABSTRACT: Time in therapeutic range (TTR), albeit being the standard measure of quality of anticoagulation control for warfarin, is underutilized in everyday clinical practice due to its tedious calculation. In contrast, the Percentage of INR measurements in Range (PINRR) is a convenient alternative. Our objective is to investigate the correlation between PINRR and TTR, and whether PINRR has clinical utility for prediction of ischemic stroke and intracranial hemorrhage in a ‘real world’ atrial fibrillation (AF) cohort.
    No preview · Article · Nov 2015 · The Canadian journal of cardiology
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    ABSTRACT: Aims: Patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) and stenting require triple antithrombotic therapy according to current ESC guidelines. The purpose of this study was to assess guideline implementation and predictive factors of the prognosis related to ESC guideline adherence. Methods and results: We enrolled consecutive AF patients referred for PCI with stent from 2011 to 2014. Among 371 patients (72% male; mean age 76±11) followed up for 505±372days (median 391, interquartile range 550days), 118 (45%) undergoing elective coronary stenting and 41 (31%) among those with acute coronary syndrome were guideline adherent. Oral anticoagulation (OAC) before hospitalization was the only factor independently associated with guideline adherence (OR, 0.45; 95% CI 0.26-0.77; p=0.003). OAC underuse and antiplatelet therapy (APT) underuse were independently associated with increased risks of death (OR 5.55; 95% CI 2.42-13.47; p<0.0001 and OR 5.56; 95% CI, 2.17-14.65; p=0.0004, respectively) and major adverse cardiac events (MACE) (OR 4.18; 95% CI 2.05-8.79; p<0.0001 and OR 4.81; 95% CI, 2.09-11.18; p=0.0002, respectively). Conclusion: Guidelines for antithrombotic therapy in patients with AF who undergo PCI and stent implantation are still poorly followed in clinical practice. OAC and APT underuse were both associated with an increased risk of death and MACE in this population.
    No preview · Article · Nov 2015 · International journal of cardiology
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    ABSTRACT: Background: Oral anticoagulation is crucial for the prevention of stroke and thromboembolism in atrial fibrillation (AF). One of the comorbidities potentially affecting thromboembolic risk and anticoagulation effectiveness is obstructive sleep apnea (OSA). The objective of this study was to establish if presence of OSA is associated with poor expected benefit from vitamin K antagonist (VKA) therapy as assessed using the SAMe-TT2R2 score. Methods: We studied AF patients planned for invasive electrophysiological procedures. All patients had a whole night polygraphy performed for the diagnosis of OSA, and their SAMe-TT2R2 score was calculated. Results: We studied 211 AF patients (mean age=57.1±10.2years, 62.6% males). OSA with apnea-hypopnea index (AHI) ≥15/h was found in 48 (22.7%) patients. Mean SAMe-TT2R2 score in non-OSA patients was 1.4±0.9, compared to mild OSA patients, 1.5±0.9; moderate OSA patients, 1.9±1.1; and severe OSA patients, 2.8±0.6. A significantly higher percentage of patients with SAMe-TT2R2≥2, indicating poor predicted INR control on VKAs, was found with increasing AHI category (37% vs. 41% vs. 57% vs. 100%, respectively). Patients with poor predicted anticoagulation control (SAMe-TT2R2≥2) had a higher prevalence of OSA. There was a lower proportion of patients with TTR>70% among patients with moderate/severe OSA compared to no/mild OSA (13.6% vs. 29.6%, p=0.03). Conclusion: SAMe-TT2R2 scores in patients with OSA are substantially higher than in those without sleep-disordered breathing. The mean SAMe-TT2R2 score, as well as the percentage of patients with SAMe-TT2R2 score≥2, suggests poor predicted anticoagulation control on VKA rises along with the AHI. There was a lower proportion of patients with TTR>70% among patients with moderate/severe OSA, compared to no/mild OSA.
    No preview · Article · Nov 2015 · International journal of cardiology
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    ABSTRACT: Introduction: Increased plasma levels of von Willebrand factor Antigen (vWF:Ag) are associated with high risk of coronary artery disease. The effect of statin therapy on vWF:Ag levels remains uncertain. Therefore the aim of this meta-analysis was to evaluate the effect of statin therapy on vWF:Ag Levels. Methods: A systematic multiple-database search was carried out to identify RCTs that investigated the effect of statins on plasma vWF:Ag levels. Results: Random-effect meta-analysis of 21 treatment arms revealed a significant decrease in plasma vWF:Ag levels following statin therapy (SMD:-0.54, 95%CI: -0.87, -0.21, p=0.001). In subgroup analyses, the greatest effect was observed with simvastatin (SMD:-1.54, 95%CI: -2.92, -0.17, p=0.028) and pravastatin (SMD:-0.61, 95%CI: -1.18, -0.04, p=0.035), but not with fluvastatin (SMD:-0.34, 95%CI: -0.69, 0.02, p=0.065), atorvastatin (SMD:-0.23, 95%CI: -0.57, 0.11, p=0.179) and rosuvastatin (SMD:-0.20, 95% CI: -0.71, 0.30, p=0.431). The lowering effect of statins on plasma vWF:Ag levels was greater in the subset of studies lasting ≥12 weeks (SMD:-0.70, 95%CI: -1.19, -0.22, p=0.005) compared with that of studies lasting <12 weeks (SMD:-0.34, 95%CI: -0.67, 0.003, p=0.052). Finally, low-intensity statin therapy was not associated with a significant reduction in vWF:Ag levels (SMD:-0.28, 95%CI: -0.82, 0.27, p=0.320), but a significant effect was observed in high-intensity statin trials (SMD:-0.66, 95%CI: -1.07, -0.24, p=0.002). Conclusions: This meta-analysis of available RCTs demonstrates a significant reduction in plasma vWF:Ag levels following statin therapy.
    Full-text · Article · Oct 2015 · Thrombosis and Haemostasis

Publication Stats

31k Citations
6,109.03 Total Impact Points

Institutions

  • 2015
    • University of Catania
      Catania, Sicily, Italy
    • Birmingham City Council
      Birmingham, England, United Kingdom
  • 2012-2015
    • Aalborg University
      • Department of Clinical Medicine
      Ålborg, North Denmark, Denmark
    • University of Iowa
      Iowa City, Iowa, United States
  • 1996-2015
    • University of Birmingham
      • • Centre for Cardiovascular Sciences
      • • Department of Primary Care Clinical Sciences
      Birmingham, England, United Kingdom
    • Sandwell and West Birmingham Hospitals NHS Trust
      Birmingham, England, United Kingdom
    • Royal Brisbane Hospital
      Brisbane, Queensland, Australia
    • Shrewsbury and Telford Hospital NHS Trust
      Shrewsbury, England, United Kingdom
  • 2013
    • Hospital Universitario Virgen de la Arrixaca
      • Departamento de Cardiología
      Murcia, Murcia, Spain
    • Chinese PLA General Hospital (301 Hospital)
      Peping, Beijing, China
  • 2010-2013
    • Aston University
      • School of Life and Health Sciences
      Birmingham, England, United Kingdom
    • Academisch Medisch Centrum Universiteit van Amsterdam
      • Academic Medical Center
      Amsterdamo, North Holland, Netherlands
  • 1995-2013
    • University Hospitals Birmingham NHS Foundation Trust
      • Department of Medicine
      Birmingham, England, United Kingdom
    • University of Glasgow
      Glasgow, Scotland, United Kingdom
  • 2008-2012
    • University of Murcia
      • Faculty of Medicine
      Murcia, Murcia, Spain
  • 2007-2008
    • University Hospital of Heraklion
      Irákleio, Attica, Greece
    • University of Texas at San Antonio
      San Antonio, Texas, United States
    • Università degli Studi di Milano-Bicocca
      • Department of Statistics and Quantitative Methods
      Milano, Lombardy, Italy
  • 1996-2007
    • Birmingham City University
      Birmingham, England, United Kingdom
  • 2006
    • Saint Luke's Hospital (NY, USA)
      New York, New York, United States
  • 2004-2006
    • The Royal Orthopaedic Hospital NHS Foundation Trust
      Birmingham, England, United Kingdom
  • 1998-2006
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 2003
    • Hospital General Universitario de Alicante
      Alicante, Valencia, Spain
  • 2002
    • Harvard University
      Cambridge, Massachusetts, United States
    • McMaster University
      • Department of Medicine
      Hamilton, Ontario, Canada
  • 2001
    • Beaumont Hospital
      Dublin, Leinster, Ireland
  • 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