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Current Medical Imaging

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ISSN (Print): 1573-4056
ISSN (Online): 1875-6603

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Research Article

Evaluation of Cardiac Scan in Diagnosing Coronary-artery Disease

Author(s): Zubaida Butaish, Masheal Alajmi, Arouba Elahi and Saeed M. Bafaraj*

Volume 16, Issue 8, 2020

Page: [1022 - 1028] Pages: 7

DOI: 10.2174/1573405616666200530211415

Abstract

Background: With the evaluation of focal epicardial coronary stenosis and non-obstructive atherosclerosis, the cardiac scans play a significant role in diagnosing coronary artery disease (CAD). Moreover, the advancements in the imaging techniques leading to improved risk assessment and timely therapies help in early diagnosis of CAD with greater accuracy.

Aims: To evaluate the role of cardiac scan in diagnosing CAD.

Methods: Recruited 100 individuals without any history of CAD that refers to the assessment of suspected angina, conducted the prospective study. Electrocardiogram (ECG) findings assisted in the evaluation of left bundle branch blockage, abnormalities of ST-segment, and pathological Q waves.

Results: The results depicted negative N.M findings among 38 respondents; whereas, ischemia and myocardial infarctions were diagnosed in 26% and 19% of the respondents, respectively. The majority of the males (59) were positive in contrast to 37 females with positive results. Similarly, 24 respondents were presented with mild dilated left atria (LA), 37 respondents suffered from impaired relaxation pattern of left ventricular (LV) diastolic filling; while, 40 of the respondents had normal global LV systolic function.

Conclusion: The study results have concluded that non-invasive, low-risk, and cost-effective technique like ECG is an important beneficial advancement in the diagnosis of CAD.

Keywords: Cardiac scan, diastole, electrocardiogram, ischemia, myocardial infarction, systole.

Graphical Abstract

[1]
Boudoulas KD, Triposciadis F, Geleris P, Boudoulas H. Coronary atherosclerosis: pathophysiologic basis for diagnosis and management. Prog Cardiovasc Dis 2016; 58(6): 676-92.[http://dx.doi.org/10.1016/j.pcad.2016.04.003] [PMID: 27091673]
[2]
Li X, Liu M, Sun R, Zeng Y, Chen S, Zhang P. Atherosclerotic coronary artery disease: The accuracy of measures to diagnose preclinical atherosclerosis. Exp Ther Med 2016; 12(5): 2899-902.[http://dx.doi.org/10.3892/etm.2016.3710] [PMID: 27882093]
[3]
Douglas PS, Hoffmann U, Patel MR, et al. PROMISE Investigators. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015; 372(14): 1291-300.[http://dx.doi.org/10.1056/NEJMoa1415516] [PMID: 25773919]
[4]
McCance KL, Huether SE. Pathophysiology-E-Book: The Biologic Basis for Disease in Adults and Children. Elsevier Health Sciences 2018.
[5]
Lipton MJ, Bogaert J, Boxt LM, Reba RC. Imaging of ischemic heart disease. Eur Radiol 2002; 12(5): 1061-80.[http://dx.doi.org/10.1007/s003300101131] [PMID: 11976848]
[6]
Sacco. An Updated Definition of Stroke for the 21st Century: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association (vol 44, pg 2064, 2013). Stroke 2019; 50(8): E239.[PMID: 31329531]
[7]
Shishido S, Asanuma H, Nakai H, et al. The impact of repeated subclinical acute rejection on the progression of chronic allograft nephropathy. J Am Soc Nephrol 2003; 14(4): 1046-52.[http://dx.doi.org/10.1097/01.ASN.0000056189.02819.32] [PMID: 12660340]
[8]
Gonçalves PdeA, Rodríguez-Granillo GA, Spitzer E, et al. Functional evaluation of coronary disease by CT angiography. JACC Cardiovasc Imaging 2015; 8(11): 1322-35.[http://dx.doi.org/10.1016/j.jcmg.2015.09.003] [PMID: 26563862]
[9]
Tanabe Y, Kurata A, Matsuda T, et al. Computed tomographic evaluation of myocardial ischemia. Jpn J Radiol 2020; 38(5): 411-33.[http://dx.doi.org/10.1007/s11604-020-00922-8] [PMID: 32026226]
[10]
Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol 2007; 49(21): 2105-11.[http://dx.doi.org/10.1016/j.jacc.2007.01.087] [PMID: 17531660]
[11]
Tonino PA, De Bruyne B, Pijls NH, et al. FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009; 360(3): 213-24.[http://dx.doi.org/10.1056/NEJMoa0807611] [PMID: 19144937]
[12]
Teo KK, Sedlis SP, Boden WE, et al. COURAGE Trial Investigators. Optimal medical therapy with or without percutaneous coronary intervention in older patients with stable coronary disease: a pre-specified subset analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial. J Am Coll Cardiol 2009; 54(14): 1303-8.[http://dx.doi.org/10.1016/j.jacc.2009.07.013] [PMID: 19778673]
[13]
Mordi IR, Badar AA, Irving RJ, Weir-McCall JR, Houston JG, Lang CC. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag 2017; 13: 427-37.[http://dx.doi.org/10.2147/VHRM.S106838] [PMID: 29200864]
[14]
Arasaratnam P, Ruddy TD. Noninvasive Imaging for the Assessment of Coronary Artery Disease. Coronary Artery Disease: Assessment, Surgery. Prevention 2015; 35[http://dx.doi.org/10.5772/61502]
[15]
Koskinas KC. Appropriate use of non-invasive testing for diagnosis of stable coronary artery disease. ESC J Fam 2014; p. 12.
[16]
Montalescot G, Sechtem U, Achenbach S, et al. Task Force Members; ESC Committee for Practice Guidelines; Document Reviewers. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013; 34(38): 2949-3003.[http://dx.doi.org/10.1093/eurheartj/eht296] [PMID: 23996286]
[17]
Cademartiri F, Seitun S, Clemente A, et al. Myocardial blood flow quantification for evaluation of coronary artery disease by computed tomography. Cardiovasc Diagn Ther 2017; 7(2): 129-50.[http://dx.doi.org/10.21037/cdt.2017.03.22] [PMID: 28540209]
[18]
Haase R, Schlattmann P, Gueret P, et al. COME-CCT Consortium. Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data. BMJ 2019; 365: l1945.[http://dx.doi.org/10.1136/bmj.l1945] [PMID: 31189617]
[19]
Meijboom WB, van Mieghem CA, Mollet NR, et al. 64-slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease. J Am Coll Cardiol 2007; 50(15): 1469-75.[http://dx.doi.org/10.1016/j.jacc.2007.07.007] [PMID: 17919567]
[20]
Sun Z, Ng CK, Xu L, Fan Z, Lei J. Coronary CT angiography in heavily calcified coronary arteries: improvement of coronary lumen visualization and coronary stenosis assessment with image postprocessing methods. Medicine (Baltimore) 2015; 94(48): e2148.[http://dx.doi.org/10.1097/MD.0000000000002148] [PMID: 26632895]
[21]
Korosoglou G, Giusca S, Gitsioudis G, Erbel C, Katus HA. Cardiac magnetic resonance and computed tomography angiography for clinical imaging of stable coronary artery disease. Diagnostic classification and risk stratification. Front Physiol 2014; 5: 291.[http://dx.doi.org/10.3389/fphys.2014.00291] [PMID: 25147526]
[22]
Nakazato R, Shalev A, Doh JH, et al. Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity. J Am Coll Cardiol 2013; 62(5): 460-7.[http://dx.doi.org/10.1016/j.jacc.2013.04.062] [PMID: 23727206]
[23]
Naya M, Murthy VL, Blankstein R, et al. Quantitative relationship between the extent and morphology of coronary atherosclerotic plaque and downstream myocardial perfusion. J Am Coll Cardiol 2011; 58(17): 1807-16.[http://dx.doi.org/10.1016/j.jacc.2011.06.051] [PMID: 21996395]
[24]
Loewe C, Stadler A. Computed tomography assessment of hemodynamic significance of coronary artery disease: CT perfusion, contrast gradients by coronary CTA, and fractional flow reserve review. J Thorac Imaging 2014; 29(3): 163-72.[http://dx.doi.org/10.1097/RTI.0000000000000073] [PMID: 24576836]
[25]
Kazakauskaitė E, Žaliaduonytė-Pekšienė D, Rumbinaitė E, Keršulis J, Kulakienė I, Jurkevičius R. Positron Emission Tomography in the Diagnosis and Management of Coronary Artery Disease. Medicina (Kaunas) 2018; 54(3): 47.[http://dx.doi.org/10.3390/medicina54030047] [PMID: 30344278]
[26]
Mieres JH, Shaw LJ, Arai A, et al. Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation 2005; 111(5): 682-96.[http://dx.doi.org/10.1161/01.CIR.0000155233.67287.60] [PMID: 15687114]
[27]
Pepine CJ, Ferdinand KC, Shaw LJ, et al. ACC CVD in Women Committee. Emergence of nonobstructive coronary artery disease: a woman’s problem and need for change in definition on angiography. J Am Coll Cardiol 2015; 66(17): 1918-33.[http://dx.doi.org/10.1016/j.jacc.2015.08.876] [PMID: 26493665]
[28]
Chou R, Arora B, Dana T, Fu R, Walker M, Humphrey L. Screening asymptomatic adults with resting or exercise electrocardiography: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2011; 155(6): 375-85.[http://dx.doi.org/10.7326/0003-4819-155-6-201109200-00006] [PMID: 21930855]
[29]
Jonas DE, Reddy S, Middleton JC, et al. Screening for cardiovascular disease risk with resting or exercise electrocardiography: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018; 319(22): 2315-28.[http://dx.doi.org/10.1001/jama.2018.6897] [PMID: 29896633]
[30]
Curry SJ, Krist AH, Owens DK, et al. US Preventive Services Task Force. Screening for cardiovascular disease risk with electrocardiography: US Preventive Services Task Force recommendation statement. JAMA 2018; 319(22): 2308-14.[http://dx.doi.org/10.1001/jama.2018.6848] [PMID: 29896632]
[31]
Auer R, Bauer DC, Marques-Vidal P, et al. Health ABC Study. Association of major and minor ECG abnormalities with coronary heart disease events. JAMA 2012; 307(14): 1497-505.[http://dx.doi.org/10.1001/jama.2012.434] [PMID: 22496264]
[32]
Carroll MD, Kit BK, Lacher DA. Total and high-density lipoprotein cholesterol in adults NHANES 2009-2010
[33]
Zwald ML, Akinbami LJ, Fakhouri TH, Fryar CD. Prevalence of low high-density lipoprotein cholesterol among adults, by physical activity: United States, 2011–2014. NCHS Data Brief 2017; 20(276): 1-8.[http://dx.doi.org/10.1001/jama.2012.13022] [PMID: 28282020]
[34]
Chu SY, Jung JH, Park MJ, Kim SH. Risk assessment of metabolic syndrome in adolescents using the triglyceride/high-density lipoprotein cholesterol ratio and the total cholesterol/high-density lipoprotein cholesterol ratio. Ann Pediatr Endocrinol Metab 2019; 24(1): 41-8.[http://dx.doi.org/10.6065/apem.2019.24.1.41] [PMID: 30943679]
[35]
Pant DC, Mowar AB, Chandra N. Co-relation Between Total Cholesterol, High Density Lipoprotein, Low Density Lipoprotein and Glycosylated Haemoglobin (HbA1c) in Diabetic Patients with Acute Coronary Syndrome (ACS). J Assoc Physicians India 2018; 66(7): 20-2.[PMID: 31325255]
[36]
Chou R. High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med 2015; 162(6): 438-47.[http://dx.doi.org/10.7326/M14-1225] [PMID: 25775317]
[37]
Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular testing and clinical outcomes in emergency department patients with chest pain. JAMA Intern Med 2017; 177(8): 1175-82.[http://dx.doi.org/10.1001/jamainternmed.2017.2432] [PMID: 28654959]
[38]
Smetana GW, Cutlip DE, Pinto DS. Should We Screen for Coronary Heart Disease in Asymptomatic Persons?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2016; 164(7): 479-87.[http://dx.doi.org/10.7326/M15-2910] [PMID: 27043981]
[39]
Bhatia RS, Dorian P. Screening for cardiovascular disease risk with electrocardiography. JAMA Intern Med 2018; 178(9): 1163-4.[http://dx.doi.org/10.1001/jamainternmed.2018.2773] [PMID: 29896637]
[40]
Sadeghian H, Majd-Ardakani J, Lotfi-Tokaldany M, Jahangiri C, Fathollahi MS. Comparison between dobutamine stress echocardiography and myocardial perfusion scan to detect viable myocardium in patients with coronary artery disease and low ejection fraction. Hellenic J Cardiol 2009; 50(1): 45-51.[http://dx.doi.org/10.1016/j.nuclcard.2006.12.287] [PMID: 19196620]
[41]
Roberts JD, So DY, Lambert AS, Ruel M. Successful surgical repair of ventricular double rupture. Can J Cardiol 2011; 27(6): 868.e5-7.[http://dx.doi.org/10.1016/j.cjca.2011.08.122] [PMID: 22118020]
[42]
Donoiu I, Istratoaie O, Ionescu DD. Ventricular septal rupture after acute myocardial infarction. Hellenic J Cardiol 2010; 51(4): 374-6.[PMID: 20650838]
[43]
Esmaeilzadeh M, Parsaee M, Maleki M. The role of echocardiography in coronary artery disease and acute myocardial infarction. J Tehran Heart Cent 2013; 8(1): 1-13.[PMID: 23646042]
[44]
Esmaeilzadeh M, Mirdamadi A, Kiavar M, Omrani G. Timely diagnosis of left ventricular posterior wall rupture by echocardiography: a case report. J Tehran Heart Cent 2010; 5(1): 36-8.[PMID: 23074566]
[45]
Ahn SG, Lim HS, Joe DY, et al. Relationship of epicardial adipose tissue by echocardiography to coronary artery disease. Heart 2008; 94(3): e7.[http://dx.doi.org/10.1136/hrt.2007.118471] [PMID: 17923467]
[46]
Sanders GD, Patel MR, Chatterjee R. AHRQ future research needs papers, no. 41. Noninvasive Technologies for the Diagnosis of Coronary Artery Disease in Women: Future Research Needs. Identification of Future Research Needs From Comparative Effectiveness. Review No. 58. Rockville, MD: AHRQ 2013.https://www.ncbi.nlm.nih.gov/books/NBK153207
[47]
Aggarwal NR, Bond RM, Mieres JH. The role of imaging in women with ischemic heart disease. Clin Cardiol 2018; 41(2): 194-202.[http://dx.doi.org/10.1002/clc.22913] [PMID: 29505091]
[48]
Sicari R, Cortigiani L. The clinical use of stress echocardiography in ischemic heart disease. Cardiovasc Ultrasound 2017; 15(1): 7.[http://dx.doi.org/10.1186/s12947-017-0099-2] [PMID: 28327159]
[49]
Steeds RP, Wheeler R, Bhattacharyya S, et al. Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2019; 6(2): G17-33.[http://dx.doi.org/10.1530/ERP-18-0068] [PMID: 30921767]
[50]
Opthof T, Sutton P, Coronel R, Wright S, Kallis P, Taggart P. The association of abnormal ventricular wall motion and increased dispersion of repolarization in humans is independent of the presence of myocardial infarction. Front Physiol 2012; 3: 235.[http://dx.doi.org/10.3389/fphys.2012.00235] [PMID: 22783201]
[51]
Suzuki K, Hirano Y, Yamada H, et al. Practical guidance for the implementation of stress echocardiography. J Echocardiogr 2018; 16(3): 105-29.[http://dx.doi.org/10.1007/s12574-018-0382-8] [PMID: 29876799]
[52]
Martins Dourado PM, Tsutsui Filho JM, de Almeida Dourado JP. Myocardial Contrast and Stress Echocardiography: New Frontiers Peertechz J Biomed Eng 2017; 3(1): 001-10.
[53]
Aye T, Graham R. Risk stratification in stable coronary artery disease. Continuing Cardiology Education 2017; 3(1): 37-43.[http://dx.doi.org/10.1002/cce2.49]
[54]
Fennich N, Ellouali F, Abdelali S, et al. Stress echocardiography: safety and tolerability. Cardiovasc Ultrasound 2013; 11(1): 30.[http://dx.doi.org/10.1186/1476-7120-11-30] [PMID: 23961806]
[55]
Botvinick EH. Current methods of pharmacologic stress testing and the potential advantages of new agents. J Nucl Med Technol 2009; 37(1): 14-25.[http://dx.doi.org/10.2967/jnmt.108.057802] [PMID: 19258260]
[56]
Chatzizisis YS, Murthy VL, Solomon SD. Echocardiographic evaluation of coronary artery disease. Coron Artery Dis 2013; 24(7): 613-23.[http://dx.doi.org/10.1097/MCA.0000000000000028] [PMID: 24077229]
[57]
Coulter SA. Echocardiographic Evaluation of Coronary Artery Disease. Coronary Artery Disease. London: Springer 2015; pp. 217-252.[http://dx.doi.org/10.1007/978-1-4471-2828-1_10]
[58]
Lim YC, Teo SG, Poh KK. ST-segment changes with exercise stress. Singapore Med J 2016; 57(7): 347-53.[http://dx.doi.org/10.11622/smedj.2016116] [PMID: 27440279]
[59]
Al-Shehri H, Small G, Chow BJ, Cardiac CT. MR, SPECT, ECHO, and PET: What test, when? Appl Radiol 2011; 40(5): 13.
[60]
Gilstrap LG, Bhatia RS, Weiner RB, Dudzinski DM. Dobutamine stress echocardiography: a review and update. Res Rep Clin Cardiol 2014; 5: 69-81.
[61]
Sicari R, Nihoyannopoulos P, Evangelista A, et al. European Association of Echocardiography. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2008; 9(4): 415-37.[http://dx.doi.org/10.1093/ejechocard/jen175] [PMID: 18579481]
[62]
Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on exercise testing). J Am Coll Cardiol 1997; 30(1): 260-311.[PMID: 9207652]
[63]
Usher BW Jr, O’Brien TX. Recent advances in dobutamine stress echocardiography. Clin Cardiol 2000; 23(8): 560-70.[http://dx.doi.org/10.1002/clc.4960230804] [PMID: 10941540]
[64]
Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104(14): 1694-740.[http://dx.doi.org/10.1161/hc3901.095960] [PMID: 11581152]
[65]
Xian Quah J, Greaves K, Thomas L, Stanton T. The clinical utility and enduring versatility of stress echocardiography. Heart Lung Circ 2019; 28(9): 1376-83.[http://dx.doi.org/10.1016/j.hlc.2019.02.188] [PMID: 31078426]
[66]
Cademartiri F, Nieman K, van der Lugt A, et al. Intravenous contrast material administration at 16-detector row helical CT coronary angiography: test bolus versus bolus-tracking technique. Radiology 2004; 233(3): 817-23.[http://dx.doi.org/10.1148/radiol.2333030668] [PMID: 15516601]
[67]
Kim EY, Yeh DW, Choe YH, Lee WJ, Lim HK. Image quality and attenuation values of multidetector CT coronary angiography using high iodine-concentration contrast material: a comparison of the use of iopromide 370 and iomeprol 400. Acta Radiol 2010; 51(9): 982-9.[http://dx.doi.org/10.3109/02841851.2010.509740] [PMID: 20849317]
[68]
Tatsugami F, Matsuki M, Inada Y, et al. Feasibility of low-volume injections of contrast material with a body weight-adapted iodine-dose protocol in 320-detector row coronary CT angiography. Acad Radiol 2010; 17(2): 207-11.[http://dx.doi.org/10.1016/j.acra.2009.09.010] [PMID: 19926497]
[69]
Hirai N, Horiguchi J, Fujioka C, et al. Prospective versus retrospective ECG-gated 64-detector coronary CT angiography: assessment of image quality, stenosis, and radiation dose. Radiology 2008; 248(2): 424-30.[http://dx.doi.org/10.1148/radiol.2482071804] [PMID: 18574140]
[70]
Knez A, Becker A, Leber A, et al. Relation of coronary calcium scores by electron beam tomography to obstructive disease in 2,115 symptomatic patients. Am J Cardiol 2004; 93(9): 1150-2.[http://dx.doi.org/10.1016/j.amjcard.2004.01.044] [PMID: 15110209]
[71]
LaMonte MJ, FitzGerald SJ, Church TS, et al. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol 2005; 162(5): 421-9.[http://dx.doi.org/10.1093/aje/kwi228] [PMID: 16076829]
[72]
Fernandez-Friera L, Garcia-Alvarez A, Bagheriannejad-Esfahani F, et al. Diagnostic value of coronary artery calcium scoring in low-intermediate risk patients evaluated in the emergency department for acute coronary syndrome. Am J Cardiol 2011; 107(1): 17-23.[http://dx.doi.org/10.1016/j.amjcard.2010.08.037] [PMID: 21146680]
[73]
Yoon YE, Chang SA, Choi SI, et al. The absence of coronary artery calcification does not rule out the presence of significant coronary artery disease in Asian patients with acute chest pain. Int J Cardiovasc Imaging 2012; 28(2): 389-98.[http://dx.doi.org/10.1007/s10554-011-9819-0] [PMID: 21347595]
[74]
Manghat NE, Morgan-Hughes GJ, Marshall AJ, Roobottom CA. Multidetector row computed tomography: imaging congenital coronary artery anomalies in adults. Heart 2005; 91(12): 1515-22.[http://dx.doi.org/10.1136/hrt.2005.065979] [PMID: 16287728]
[75]
Leschka S, Stolzmann P, Schmid FT, et al. Low kilovoltage cardiac dual-source CT: attenuation, noise, and radiation dose. Eur Radiol 2008; 18(9): 1809-17.[http://dx.doi.org/10.1007/s00330-008-0966-1] [PMID: 18392829]

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