Abstract
Background
Obesity is often considered a risk factor for cardiovascular disease, but recent studies have shown conflicting results regarding the effect of BMI on the prognosis of coronary artery disease (CAD). This study aimed to evaluate the relationship between BMI and clinical outcomes of CAD according to sex in a Korean population.
Methods
A total of 3476 patients with a significant CAD who underwent percutaneous coronary intervention (PCI) were enrolled. Patients were classified as follows according to BMI using the Asia–Pacific cutoff points: underweight (<18.5 kg/m2), normal weight (18.5–22.9 kg/m2), overweight (23.0–24.9 kg/m2) and obese (≥25 kg/m2) patients. Underweight and normal weight patients were further categorized into the lower BMI group, whereas overweight and obese patients were categorized into the higher BMI group. The primary endpoint was all-cause mortality.
Results
Among women, the higher BMI group showed poor clinical features in the prevalence of hypertension and chest pain presentation, and among men, the higher BMI group had a significantly lower rate of chronic renal failure. At the end of the follow-up period (median 53.5 months), the all-cause mortality rate was lower in the higher BMI group in men, and cardiovascular death and stroke rates were significantly lower in the higher BMI group in women.
Conclusion
In Korean CAD patients treated with PCI, inverse correlations were observed between the clinical outcomes and BMI, but there were differences between men and women.
Keywords: body mass index, coronary artery disease, mortality, sex difference
The incidence of coronary artery disease (CAD) has been increasing worldwide in the past few years, and cardiovascular (CV) events have been more severe in Asian countries than in Western countries [1]. Overweight and obesity, most commonly defined by BMI, are chronic diseases, leading to an increased risk for morbidity and mortality of CV disease [2,3]. However, recent studies of patients with CAD showed a beneficial effect of elevated BMI in reducing the risk of CV events or mortality, a phenomenon known as the obesity paradox. There is no broad consensus on the obesity paradox, as other studies have shown conflicting results for body weight on the prognosis of CAD [4–7]. However, previous studies investigating the association between body weight and CAD have been mainly conducted in Western countries. Moreover, despite the fact that body fat percentage and distribution differ according to sex, data on the prognosis of men and women regarding the relationship between BMI and CAD are limited. Hence, this study evaluated the correlation between BMI and long-term clinical outcomes according to sex in a real-world Korean population with CAD treated with percutaneous coronary intervention (PCI).
Methods
Study design and population
This retrospective observational study enrolled patients with CAD who consecutively underwent PCI with second-generation drug-eluting stents (DESs) at CHA Bundang Medical Center, Seongnam, Korea, between August 2008 and December 2018. The exclusion criteria were as follows: a history of coronary artery bypass graft surgery, a history of PCI, bifurcation lesions requiring a side-branch intervention, a mixture of different DES types, concomitant valvular or aortic surgery, cardiogenic shock, other comorbid conditions with a life expectancy of <12 months, and planned surgery necessitating the interruption of antiplatelet drug therapy within six postoperative months. The study conformed to the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of CHA Bundang Medical Center (approval number: CHAMC 2021-08-040). Considering the retrospective study design, the requirement for obtaining patients’ informed consent was waived.
Procedure and follow-up
PCI was performed according to the treatment guidelines at the discretion of the treating physician. As the study did not specify the PCI treatment type, the interventional cardiologists decided upon the application of predilatation, the use of intravascular ultrasound (IVUS) and the selection of a specific DES type. Periprocedural anticoagulation was administered following a standard protocol [8]. All patients undergoing PCI received a loading dose of aspirin and ADP receptor antagonists before or during the intervention. After the procedure, aspirin was continued indefinitely and ADP receptor antagonists were prescribed for at least 6–12 months [9]. Treatment beyond this duration was provided at the physician’s discretion. Specialized personnel collected data for all baseline characteristics and outcomes using a case report form.
The patients’ BMI was calculated by dividing the body mass (kg) by the square of the body height (m2) and then classified into four groups: underweight (<18.5 kg/m2), normal weight (18.5–22.9 kg/m2), overweight (23.0–24.9 kg/m2) and obesity (≥25 kg/m2). This classification was based on the Asia–Pacific cutoff points [10]. The underweight and normal weight patients were categorized into the lower BMI group, whereas the overweight and obese patients were categorized into the higher BMI group.
Endpoints
The study’s primary endpoint was all-cause mortality. The secondary endpoints were CV death, myocardial infarction (MI), stroke and repeat revascularization. Death was considered as cardiac unless an unequivocal noncardiac cause could be established. The protocol definition of MI was prespecified and based on the universal definition of MI [11]. Stroke was identified by neurological deficits and confirmed by a neurologist using imaging modalities. Repeat revascularization included percutaneous or surgical revascularization procedures after the index procedure, which was not planned at the time of the index procedure. All clinical events were based on the treating physician’s clinical diagnoses and determined by an independent group of clinicians using source documentation.
Statistical methods
Continuous data were expressed as means and standard deviations, and categorical data as n (%). Central estimates across the groups for normally and non-normally distributed variables were compared using independent t-tests and nonparametric tests, respectively. Proportions between groups were compared using chi-square tests.
Time-to-event data were graphically presented using Kaplan–Meier curves. Survival rates between the groups were compared using log-rank tests. Cumulative events of the clinical outcomes were assessed using Kaplan–Meier estimates and compared using the log-rank test. We used multivariable Cox proportional hazards regression models to examine the independent effect of BMI on clinical outcomes. After performing the initial unadjusted analyses, multivariate Cox regression analyses were performed to adjust for the potential confounders we had identified using a literature search and based on a priori clinical knowledge. We considered covariates including age >70 years, BMI (lower or higher), presence of diabetes, hypertension, or chronic renal failure, clinical presentation [stable angina, unstable angina, non-ST-elevation MI (NSTEMI) or ST-elevation MI (STEMI)], use of IVUS and complete revascularization. The proportional hazards assumption was tested by examining the log–log survival curves and partial Schoenfeld residuals, with no significant violations being found. All analyses were two-sided, with a significance level of P < 0.05. All statistical data were analyzed using SPSS (version 22.0; IBM Corp., Armonk, New York, USA) and R (version 3.6.3 software; R Foundation for Statistical Computing, Vienna, Austria).
Results
Baseline characteristics
A total of 3476 patients diagnosed with CAD who underwent PCI with second-generation DESs were enrolled; of these, 1121 were women, comprising 370 (33.0%) patients with lower BMI and 751 (67.0%) with higher BMI and 2355 were men, comprising 656 (27.9%) patients with lower BMI and 1699 (72.1%) with higher BMI.
Table 1 shows the patients’ demographic characteristics. Among women, the mean age of the higher BMI group was 68.0 years, which did not significantly differ from that of the lower BMI group. The prevalence of hypertension was significantly higher in the higher BMI group, and the proportion of patients with MI in the higher BMI group was 24.7% (n = 185), which was significantly lower than that of the lower BMI group [n = 130 (35.1%)]. Regarding the clinical presentation, in women, the ratio of lower BMI patients significantly increased as the clinical presentation progressed from stable angina to STEMI (P = 0.001, Fig. 1). Among men, the average age of the higher BMI group was 60.8 years, which was significantly lower than that of the lower BMI group (63.8 years). There were no significant differences in cardiac risk factors and chest pain presentation between the two groups, except that the prevalence of chronic renal failure in the higher BMI group was statistically low (3.0% vs. 5.0%, P = 0.024). In men, unlike women, there was no significant difference in the proportion of patients with lower and higher BMI according to the clinical presentation (P = 0.225, Fig. 1). Regarding the laboratory data, hemoglobin, albumin, and cholesterol levels were statistically significantly higher in the higher BMI group in men.
Table 1.
Demographic and clinical characteristics of study population between lower and higher body mass index groups
| Women | Men | |||||
|---|---|---|---|---|---|---|
| Variables | Lower BMI group (n = 370) | Higher BMI group (n = 751) | P value | Lower BMI group (n = 656) | Higher BMI group (n = 1699) | P value |
| Demographics | ||||||
| Age, years | 69.1 ± 10.3 | 68.0 ± 10.1 | 0.088 | 63.8 ± 11.4 | 60.8 ± 11.1 | <0.001 |
| Height, cm | 153.7 ± 6.1 | 153.0 ± 5.9 | 0.061 | 167.2 ± 6.1 | 167.8 ± 6.1 | 0.071 |
| Weight, kg | 49.7 ± 5.4 | 61.9 ± 7.6 | <0.001 | 59.0 ± 6.2 | 73.8 ± 9.0 | <0.001 |
| BMI, kg/m2 | 21.0 ± 1.6 | 26.4 ± 2.7 | <0.001 | 21.1 ± 1.5 | 26.2 ± 2.4 | <0.001 |
| Cardiac risk factors | ||||||
| Hypertension | 209 (56.5%) | 507 (67.5%) | <0.001 | 341 (52.0%) | 950 (55.9%) | 0.094 |
| Diabetes | 123 (33.2%) | 265 (35.3%) | 0.542 | 213 (32.5%) | 506 (29.8%) | 0.223 |
| Dyslipidemia | 28 (7.6%) | 67 (8.9%) | 0.515 | 47 (7.2%) | 142 (8.4%) | 0.384 |
| Peripheral artery disease | 2 (0.5%) | 2 (0.3%) | 0.848 | 12 (1.8%) | 15 (0.9%) | 0.086 |
| Chronic renal failure | 18 (4.9%) | 22 (2.9%) | 0.141 | 33 (5.0%) | 51 (3.0%) | 0.024 |
| Heart failure | 15 (4.1%) | 20 (2.7%) | 0.282 | 12 (1.8%) | 28 (1.6%) | 0.899 |
| Atrial fibrillation | 17 (4.6%) | 29 (3.9%) | 0.673 | 28 (4.3%) | 63 (3.7%) | 0.608 |
| Stroke | 24 (6.5%) | 52 (6.9%) | 0.883 | 46 (7.0%) | 86 (5.1%) | 0.081 |
| History of smoke | 0.303 | 0.225 | ||||
| Current smoker | 44 (11.9%) | 75 (10.0%) | 235 (35.8%) | 657 (38.7%) | ||
| Ex-smoker | 0 (0.0%) | 3 (0.4%) | 3 (0.5%) | 3 (0.2%) | ||
| Chest pain presentation | 0.001 | 0.058 | ||||
| Stable angina | 56 (15.1%) | 150 (20.0%) | 90 (13.7%) | 256 (15.1%) | ||
| Unstable angina | 184 (49.7%) | 416 (55.4%) | 278 (42.4%) | 800 (47.1%) | ||
| NSTEMI | 70 (18.9%) | 111 (14.8%) | 138 (21.0%) | 298 (17.5%) | ||
| STEMI | 60 (16.2%) | 74 (9.9%) | 150 (22.9%) | 345 (20.3%) | ||
| Laboratory data | ||||||
| Hemoglobin, g/dl | 12.4 ± 1.9 | 12.6 ± 1.7 | 0.130 | 13.7 ± 1.9 | 14.2 ± 1.7 | <0.001 |
| Albumin, g/dl | 4.0 ± 0.6 | 4.1 ± 0.5 | 0.023 | 4.1 ± 0.6 | 4.2 ± 0.5 | <0.001 |
| Cholesterol, mg/dl | 176.3 ± 46.4 | 180.5 ± 46.9 | 0.231 | 173.2 ± 44.4 | 178 ± 44.7 | 0.048 |
NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction.
Fig. 1.
Distribution of the lower and higher BMI groups stratified according to sex. NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction.
There was no statistically significant difference in the echocardiographic and lesion characteristics between the lower and higher BMI groups, except that the higher BMI group showed a statistically higher left ventricular (LV) ejection fraction in women (59.7 ± 13.2 vs. 55.3 ± 15.0, P < 0.001). In men, the LV ejection fraction was also significantly higher in the higher BMI group (57.1 ± 13.0 vs. 54.2 ± 14.4, P < 0.001), and there was a significant difference in the location of diseased vessels (left anterior descending artery; 55.7% vs. 60.5%, P = 0.040, left circumflex artery; 19.9% vs. 15.5%, P = 0.018, Table 2). In addition, the femoral approach was significantly less performed in the higher BMI group (39.6% vs. 48.3%, P < 0.001). Supplementary Tables 1 and 2, Supplemental digital content 1, http://links.lww.com/MCA/A652 show the detailed baseline characteristics of the enrolled patients classified into four groups based on BMI (underweight, normal weight, overweight and obesity).
Table 2.
Echocardiographic and lesion characteristics of study population between lower and higher body mass index groups
| Women | Men | |||||
|---|---|---|---|---|---|---|
| Variables | Lower BMI group (n = 370) | Higher BMI group (n = 751) | P value | Lower BMI group (n = 656) | Higher BMI group (n = 1699) | P value |
| LV ejection fraction | 55.3 ± 15.0 | 59.7 ± 13.2 | <0.001 | 54.2 ± 14.4 | 57.1 ± 13.0 | <0.001 |
| Extent of CAD | ||||||
| 1VD | 0.911 | 0.620 | ||||
| 2VD | 149 (40.3%) | 312 (41.5%) | 270 (41.2%) | 737 (43.4%) | ||
| 3VD | 111 (30.0%) | 223 (29.7%) | 212 (32.3%) | 530 (31.2%) | ||
| Left main | 110 (29.7%) | 216 (28.8%) | 174 (26.5%) | 432 (25.4%) | ||
| Diseased vessel | 13 (3.5%) | 28 (3.7%) | 0.991 | 24 (3.7%) | 58 (3.4%) | 0.869 |
| LAD | 230 (62.2%) | 450 (59.9%) | 0.511 | 397 (60.5%) | 947 (55.7%) | 0.040 |
| LCX | 52 (14.1%) | 128 (17.0%) | 0.232 | 102 (15.5%) | 338 (19.9%) | 0.018 |
| RCA | 114 (30.8%) | 222 (29.6%) | 0.719 | 199 (30.3%) | 551 (32.4%) | 0.353 |
| Number of diseased lesions | 2.1 ± 1.1 | 2.1 ± 1.1 | 0.561 | 2.1 ± 1.1 | 2.1 ± 1.1 | 0.768 |
| Number of treated lesions | 1.4 ± 0.6 | 1.4 ± 0.7 | 0.972 | 1.4 ± 0.7 | 1.4 ± 0.7 | 0.323 |
| Number of stents | 1.4 ± 0.6 | 1.4 ± 0.7 | 0.998 | 1.4 ± 0.7 | 1.4 ± 0.7 | 0.340 |
| Femoral approach | 164 (44.3%) | 287 (38.2%) | 0.058 | 317 (48.3%) | 673 (39.6%) | <0.001 |
| Use of IVUS | 253 (68.4%) | 505 (67.2%) | 0.754 | 461 (70.3%) | 1216 (71.6%) | 0.567 |
| Complete revascularization | 181 (48.9%) | 377 (50.2%) | 0.734 | 334 (50.9%) | 885 (52.1%) | 0.642 |
CAD, coronary artery disease; IVUS, intravascular ultrasound; LAD, left anterior descending artery; LCX, left circumflex artery; LV, left ventricle; RCA, right coronary artery; VD, vessel disease.
Clinical outcomes
During a median follow-up of 53.3 (interquartile range: 33.6–77.5) months, 113 (3.3%) patients died, and 53 (1.5%) had CV death. MI, stroke and repeat vascularization were noted in 36 (1.0%), 41 (1.2%) and 490 (14.1%) patients, respectively. Table 3 and Fig. 2 show the clinical outcomes for the different BMI groups. In women, CV death and stroke were significantly reduced in the higher BMI group than in the lower BMI group. However, there was no difference in the occurrence of all-cause death, MI and repeat revascularization (Supplementary Table 3, Supplemental digital content 1, http://links.lww.com/MCA/A652). After multivariable adjustment for traditional risk factors and potential confounders, the higher BMI group was associated with a significantly lower risk for cardiac death [adjusted hazard ratio (HR) = 0.352; 95% confidence interval (CI): 0.146–0.848; P = 0.020] and stroke (adjusted HR = 0.352; 95% CI: 0.129–0.953; P = 0.040). In men, all-cause death was significantly lower in the higher BMI group than in the lower BMI group. However, there was no difference in the occurrence of CV death, MI, stroke and repeat revascularization between the two groups. After adjustment, higher BMI was associated with a significantly lower risk of all-cause death (adjusted HR = 0.585; 95% CI: 0.351–0.976; P = 0.040). Supplementary Table 4, Supplemental digital content 1, http://links.lww.com/MCA/A652 shows that adverse prognosis in men and women were mainly driven by the fact that the lower BMI group among acute coronary syndrome patients have a poor prognosis than the higher BMI group, rather than the difference in patients with stable angina.
Table 3.
Clinical outcomes comparing between lower and higher body mass index groups
| Women | ||||||
|---|---|---|---|---|---|---|
| Lower BMI group (n = 370) | Higher BMI group (n = 751) | Unadjusted HR (95% CI) | P value | Adjusted HR (95% PI) | P value | |
| All-cause death | 17 (4.6) | 33 (4.4) | 0.875 (0.487–1.571) | 0.654 | 0.901 (0.499–1.630) | 0.731 |
| Cardiovascular death | 12 (3.2) | 9 (1.2) | 0.347 (0.146–0.824) | 0.016 | 0.352 (0.146–0.848) | 0.020 |
| Myocardial infarction | 7 (1.9) | 7 (0.9) | 0.461 (0.161–1.314) | 0.147 | 0.460 (0.159–1.329) | 0.151 |
| Stroke | 9 (2.4) | 7 (0.9) | 0.341 (0.127–0.916) | 0.033 | 0.351 (0.129–0.953) | 0.040 |
| Repeat revascularization | 56 (15.1) | 101 (13.4) | 0.804 (0.580–1.114) | 0.190 | 0.792 (0.569–1.101) | 0.165 |
| Men | ||||||
|---|---|---|---|---|---|---|
| Lower BMI group (n = 656) | Higher BMI group (n = 1699) | Unadjusted HR (95% CI) | P value | Adjusted HR (95% PI) | P value | |
| All-cause death | 26 (4.0) | 37 (2.2) | 0.519 (0.314–0.857) | 0.010 | 0.585 (0.351–0.976) | 0.040 |
| Cardiovascular death | 13 (2.0) | 19 (1.1) | 0.540 (0.267–1.094) | 0.087 | 0.614 (0.300–1.257) | 0.182 |
| Myocardial infarction | 8 (1.2) | 14 (0.8) | 0.642 (0.269–1.531) | 0.318 | 0.695 (0.288–1.679) | 0.419 |
| Stroke | 5 (0.8) | 20 (1.2) | 1.415 (0.531–3.771) | 0.488 | 1.308 (0.489–3.498) | 0.592 |
| Repeat revascularization | 90 (13.7) | 243 (14.3) | 0.981 (0.771–1.250) | 0.880 | 0.972 (0.762–1.240) | 0.818 |
CI, confidence interval; HR; hazard ratio.
Fig. 2.
Kaplan–Meier curves on the clinical outcomes of the lower and higher BMI groups stratified according to sex.
Discussions
Obesity is not only a clinical factor of the increased risk for CV disease, but also a high-risk factor for hypertension, type 2 diabetes and stroke. However, data regarding long-term clinical outcomes of CAD patients in Asia are limited. We evaluated the effects of BMI on clinical outcomes according to sex in a real-world Korean population with CAD treated with PCI. In this study, lower BMI, including being underweight and having a normal weight as defined by the Asia–Pacific cutoff points [10], was prevalent in patients with CAD and associated with a poor clinical outcome, although differences are observed according to sex. Although obesity is a known risk factor for CV disease, in this study, the lower BMI group showed a higher risk of all-cause death in men and cardiac death in women even after adjusting for traditional risk factors and potential confounders. Therefore, our data suggest that tailored therapy according to sex is needed for CAD patients with lower BMI after PCI.
In this study, 370 (33.0%) female patients and 656 (27.9%) male patients belonged to the lower BMI group. This shows that lower BMI is prevalent in patients receiving PCI for CAD. Among women, there was no difference in age or other risk factors, except that the patients with higher BMI were more likely to have hypertension than those with lower BMI. Contrarily, in the lower BMI patients, the proportion of patients treated for NSTEMI and STEMI was 45.1%, which was significantly higher than that of the higher BMI group (24.7%). Among men, there was no significant difference in the characteristics between the two groups, except for the fact that the higher BMI group was younger than the lower BMI group and the rate of chronic renal failure was lower in the higher BMI group. Unlike women, there was no significant difference between the higher and lower BMI groups in the rate of chest pain presentation in men. In previous studies, the incidence of risk factors, such as hypertension, diabetes, and hyperlipidemia, was high in obese patients [7,12]. Some obesity-related factors, such as mild chronic inflammation, insulin resistance and ectopic fat deposition, increase the myocardial load and cardiac metabolic stress and cause hemodynamic side effects, thereby increasing the atherothrombotic risk in overweight patients [13]. On the other hand, low body weight is also commonly reported in patients with advanced age, due to accompanying comorbidities and impaired cognitive or social status, thereby increasing the frailty and complexity in the conditions of these underweight patients [14].
Regarding the echocardiographic and lesion characteristics, LV ejection fraction was significantly higher in the higher BMI group in both men and women. Although there was a difference in the frequency of diseased vessels in men, there was no difference in the numbers of diseased lesions, treated lesions and stents between the two BMI groups in both men and women, indicating that there was no significant difference in lesion complexity. Previous studies have shown that there was no difference in lesion characteristics among their BMI groups [15]. There was also no difference in the frequency of IVUS use and complete revascularization rate, suggesting that PCI was performed regardless of the patent’s BMI.
Regarding clinical outcome, this study showed that a lower BMI in men was associated with a higher risk of all-cause death, even after adjusting for clinical factors. Contrarily, among women, lower BMI was not associated with all-cause death, but it was related to a higher risk of cardiac death after adjusting for potential confounders. Despite the fact that CV risk factors and comorbidities are more prevalent in the obese population, several studies have reported a lower CV mortality rate in these patients than in those with lower BMI, which is referred to as the obesity paradox [16,17]. However, only a limited number of studies on patients with CAD have investigated the association between BMI and CV outcomes and mortality in men and women separately. A Danish study of AMI patients reported that the risk of death was similar for normal, overweight and obese patients in men, but the mortality rate was lower in overweight women than in normal weight women [18]. A follow-up study of the CADILLAC trial observed that, among male AMI patients treated with PCI, the in-hospital and 1-year mortality rates were significantly lower in obese patients than in normal weight patients [19]. Another study conducted in Norway on stable angina patients showed a higher mortality rate in obese men [20]. These studies were conducted in Western countries, and to the best of our knowledge, this is the first study to compare the clinical outcomes according to BMI in Asian patients after undergoing PCI.
BMI is often used due to its convenience, but it is inaccurate for measuring body fat mass and does not take into account muscle mass, fat distribution and overall body composition. Excess visceral fat is associated with an increased risk of developing metabolic syndrome, whereas subcutaneous fat in the gluteal region may be associated with a favorable clinical condition [21]. Men have a tendency to store excess fat in visceral fat deposits, whereas women usually store fat through a peripheral subcutaneous distribution [22]. This difference in fat distribution might have an effect on the difference in clinical outcomes observed between men and women stratified according to BMI. Estrogen is known to have a protective effect on CV disease by inducing vasodilation, improving endothelial function of the arteries, reducing endothelin release and preventing atherosclerosis [23]. It is known that women with high BMI have significantly higher free estradiol levels due to excessive estrogen production of adipose tissue [24]. Considering that the women in this study were mostly in their late 60s, it is suggested that most of our study patients are menopausal women. This might be another explanation for the higher risk of CV death observed in women with lower BMI.
This study has some limitations that need to be acknowledged. First, the single-center and retrospective nature of the study design had disadvantages, and PCI was performed at the discretion of the attending physician, potentially resulting in selection bias. Therefore, its overall findings must be considered hypothetical and hypothesis-generating only. Second, the data were limited. For example, this study does not contain information on socioeconomic characteristics that may contribute to the differences in BMI. Moreover, information on muscle mass, bone density and overall body composition that could differ among patients with similar BMIs was not included. Third, nutritional assessments were performed only at the time of PCI; therefore, the relationships between BMI changes over time or nutritional support and clinical outcomes have not been investigated. Fourth, most patients in our registry were Asians and BMI was classified based on the Asia–Pacific cutoff points; therefore, it remains unclear whether these findings can be generalized to other ethnic or social groups with different patient and procedural characteristics.
Conclusion
In Korean CAD patients treated with PCI, lower BMI, including being underweight and having a normal weight, was associated with poor clinical outcomes, but sex differences are noted. Therefore, tailored medical management is required to improve the prognosis of these patients.
Acknowledgements
The authors would like to thank Kwang Min Lee for his assistance in statistical analysis.
Conflicts of interest
There are no conflicts of interest.
Supplementary Material
Footnotes
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com.
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