XIENCE 90: A Safety Evaluation of 3-month DAPT After XIENCE Implantation for HBR Patients.

Not Applicable

Completed

Conditions: Coronary Artery Lesions

Interventions: Device: XIENCE
Drug: DAPT

Registration Number: NCT03218787

Lead Sponsor: Abbott Medical Devices

Brief Summary: XIENCE 90 study is a prospective, single arm, multi-center, open label trial to evaluate the safety of 3-month dual antiplatelet therapy (DAPT) in subjects at high risk of bleeding (HBR) undergoing percutaneous coronary intervention (PCI) with the approved XIENCE family of coronary drug-eluting stents.

The XIENCE family stent systems include commercially approved XIENCE Xpedition Everolimus Eluting Coronary Stent System (EECSS), XIENCE Alpine EECSS, XIENCE PRO\^X EECSS \[rebrand of the XIENCE Xpedition Stent System and is only available outside of the United States (OUS)\], XIENCE PRO\^A EECSS (rebrand of the XIENCE Alpine Stent System and is only available OUS) and XIENCE Sierra EECSS of coronary drug-eluting stents.

Detailed Description: A. Primary Objective:

To show non-inferiority of the primary endpoint of all death or all MI (modified ARC) from 3 to 12 months following XIENCE implantation in HBR subjects treated with 3-month DAPT compared to a historical control after propensity score adjustment.

B. Secondary Objective:

* To show superiority of the major secondary endpoint of major bleeding (Bleeding Academic Research Consortium \[BARC\] type 2-5) from 3 to 12 months following XIENCE implantation in HBR subjects treated with 3-month DAPT compared to a historical control after propensity score adjustment.

* To evaluate stent thrombosis (ARC definite/probable) from 3 to 12 months following XIENCE implantation in HBR subjects treated with 3-month DAPT against a performance goal (PG).

All registered subjects will be followed at 3, 6 and 12 months post index procedure.

The data collected from this study will be compared with the historical control of non-complex HBR subjects treated with standard DAPT duration of up to 12 months from the XIENCE V USA study, which is a US post-approval study to evaluate the safety of XIENCE V EECSS in "all-comer" population under real-world setting.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 2047

Inclusion Criteria

Subject is considered at high risk for bleeding (HBR), defined as meeting one or more of the following criteria at the time of registration and in the opinion of the referring physician, the risk of major bleeding with > 3-month DAPT outweighs the benefit:
1. ≥ 75 years of age.
2. Clinical indication for chronic (at least 6 months) or lifelong anticoagulation therapy.
3. History of major bleeding which required medical attention within 12 months of the index procedure.
4. History of stroke (ischemic or hemorrhagic).
5. Renal insufficiency (creatinine ≥ 2.0 mg/dl) or failure (dialysis dependent).
6. Systemic conditions associated with an increased bleeding risk (e.g. hematological disorders, including a history of or current thrombocytopenia defined as a platelet count <100,000/mm^3, or any known coagulation disorder associated with increased bleeding risk).
7. Anemia with hemoglobin < 11g/dl.
Subject must be at least 18 years of age.
Subject or a legally authorized representative must provide written informed consent as approved by the Institutional Review Board (IRB)/Ethics Committee (EC) of the respective clinical site prior to any study related procedure.
Subject is willing to comply with all protocol requirements, including agreement to stop taking P2Y12 inhibitor at 3 months, if eligible per protocol.
Subject must agree not to participate in any other clinical trial for a period of one year following the index procedure.

Angiographic Inclusion Criteria

Up to three target lesions with a maximum of two target lesions per epicardial vessel. Note:
- The definition of epicardial vessels means left anterior descending coronary artery (LAD), left circumflex coronary artery (LCX) and right coronary artery (RCA) and their branches. For example, the patient must not have >2 lesions requiring treatment within both the LAD and a diagonal branch in total.
- If there are two target lesions within the same epicardial vessel, the two target lesions must be at least 15 mm apart per visual estimation; otherwise this is considered as a single target lesion.
Target lesion ≤ 32 mm in length by visual estimation.
Target lesion must be located in a native coronary artery with visually estimated reference vessel diameter between 2.25 mm and 4.25 mm.
Exclusive use of XIENCE family of stent systems during the index procedure.
Target lesion has been treated successfully, which is defined as achievement of a final in-stent residual diameter stenosis of <20% with final TIMI-3 flow assessed by online quantitative angiography or visual estimation, with no residual dissection NHLBI grade ≥ type B, and no transient or sustained angiographic complications (e.g., distal embolization, side branch closure), no chest pain lasting > 5 minutes, and no ST segment elevation > 0.5 mm or depression lasting > 5 minutes.

General Exclusion Criteria

Subject with an indication for the index procedure of acute ST-segment elevation MI (STEMI).
Subject has a known hypersensitivity or contraindication to aspirin, heparin/bivalirudin, P2Y12 inhibitors (clopidogrel/prasugrel/ticagrelor), everolimus, cobalt, chromium, nickel, tungsten, acrylic and fluoro polymers or contrast sensitivity that cannot be adequately pre-medicated.
Subject with implantation of another drug-eluting stent (other than XIENCE) within 9 months prior to index procedure.
Subject has a known left ventricular ejection fraction (LVEF) <30%.
Subject judged by physician as inappropriate for discontinuation from P2Y12 inhibitor use at 3 months, due to another condition requiring chronic P2Y12 inhibitor use.
Subject with planned surgery or procedure necessitating discontinuation of P2Y12 inhibitor within 3 months following index procedure.
Subject with a current medical condition with a life expectancy of less than 12 months.
Subject intends to participate in an investigational drug or device trial within 12 months following the index procedure.
Pregnant or nursing subjects and those who plan pregnancy in the period up to 1 year following index procedure. Female subjects of child-bearing potential must have a negative pregnancy test done within 7 days prior to the index procedure per site standard test.

Note: Female patients of childbearing potential should be instructed to use safe contraception (e.g., intrauterine devices, hormonal contraceptives: contraceptive pills, implants, transdermal patches, hormonal vaginal devices, injections with prolonged release.) It is accepted, in certain cases, to include subjects having a sterilised regular partner or subjects using a double barrier contraceptive method. However, this should be explicitly justified in special circumstances arising from the study design, product characteristics and/or study population
Subject is part of a vulnerable population, defined as subject whose willingness to volunteer in a clinical investigation could be unduly influenced by the expectation, whether justified or not, of benefits associated with participation or of retaliatory response from senior members of a hierarchy in case of refusal to participate. Examples of populations which may contain vulnerable subjects include: individuals with lack of or loss of autonomy due to immaturity or through mental disability, persons in nursing homes, children, impoverished persons, subjects in emergency situations, ethnic minority groups, homeless persons, nomads, refugees, and those incapable of giving informed consent. Other vulnerable subjects include, for example, members of a group with a hierarchical structure such as university students, subordinate hospital and laboratory personnel, employees of the sponsor, members of the armed forces, and persons kept in detention.
Subject is currently participating in another clinical trial that has not yet completed its primary endpoint.

Angiographic Exclusion Criteria

Target lesion is in a left main location.
Target lesion is located within an arterial or saphenous vein graft.
Target lesion is restenotic from a previous stent implantation.
Target lesion is a total occluded lesion (TIMI flow 0).
Target lesion contains thrombus as indicated in the angiographic images (per SYNTAX score thrombus definition).
Target lesion is implanted with overlapping stents, whether planned or for bailout.

Note: If there is more than one target lesion, all target lesions must satisfy the angiographic eligibility criteria. Non-target lesion (i.e., lesions that do not meet the angiographic criteria listed above) treatments are not allowed during the index procedure.

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
XIENCE	XIENCE	Subjects will receive XIENCE family stents and if a subject was DAPT compliant and event free, then took 3 month DAPT, following with aspirin mono-therapy until 12 month
XIENCE	DAPT	Subjects will receive XIENCE family stents and if a subject was DAPT compliant and event free, then took 3 month DAPT, following with aspirin mono-therapy until 12 month

Primary Outcome Measures

Name	Time	Method
Percentage of Participants With Composite Rate of All Death or All Myocardial Infarction (MI)(Modified Academic Research Consortium [ARC]), by Propensity Score Quintiles	From 3 to 12 months	All death: All deaths are considered cardiac unless an unequivocal non-cardiac cause can be established. Specifically, any unexpected death even in patients with coexisting potentially fatal non-cardiac disease should be classified as cardiac. MI (Modified ARC): Patients present any of the following clinical or imaging evidence of ischemia: * Clinical symptoms of ischemia; * ECG changes indicative of new ischemia - new ST-T changes or new left bundle branch block, development of pathological Q waves; * Imaging evidence of a new loss of viable myocardium or a new regional wall motion abnormality) AND confirmed with elevated cardiac biomarkers per ARC criteria: * Periprocedural MI * Spontaneous MI: CK-MB \> URL or Troponin \> URL with baseline value \< UR The propensity score for each individual was calculated using a logistic regression model that included the study group as the outcome \& the baseline demographic, clinical and procedural covariates as the predictors

Secondary Outcome Measures

Name	Time	Method
Percentage of Participants With Major Bleeding Rate by Bleeding Academic Research Consortium (BARC) Type 2-5, by Propensity Score Quintiles	From 3 to 12 months	* Type 2: Any overt, actionable sign of hemorrhage * Type 3a: Overt bleeding plus Hb drop of 3 to \< 5g/dL;Any transfusion with overt bleeding * Type 3b: Overt bleeding plus Hb drop ≥ 5 g/dL;Cardiac tamponade;Bleeding requiring surgical intervention for control;Bleeding requiring IV vasoactive agents * Type 3c: ICH; Subcategories confirmed by autopsy/imaging/lumbar puncture;Intraocular bleed compromising vision * Type 4: CABG-related bleeding: Perioperative intracranial bleeding within 48h;Reoperation after closure of sternotomy for the purpose of controlling bleeding;Transfusion of ≥ 5 U whole blood or packed RBC within 48h;Chest tube output ≥ 2L within 24h * Type 5: Fatal bleeding The propensity score for each individual was calculated using a logistic regression model that included the study group as the outcome \& the baseline demographic, clinical and procedural covariates as the predictors.
Number of Participants With All Stroke, Ischemic Stroke and Hemorrhagic Stroke	From 3 to 12 months	An acute symptomatic episode of neurological dysfunction attributed to a vascular cause lasting more than 24 hours or lasting 24 hours or less with a brain imaging study or autopsy showing new infarction. * Ischemic Stroke: An acute symptomatic episode of focal cerebral, spinal, or retinal dysfunction caused by an infarction of central nervous system tissue. * Hemorrhagic Stroke: An acute symptomatic episode of focal or global cerebral or spinal dysfunction caused by a non-traumatic intraparenchymal, intraventricular, or subarachnoid hemorrhage. * Undetermined Stroke: A stroke with insufficient information to allow categorization as ischemic or hemorrhagic. * Pharmacologic, i.e., thrombolytic drug administration, or Non-pharmacologic, i.e., neurointerventional procedure (e.g., intracranial angioplasty)
Number of Participants With Clinically-indicated Target Lesion Revascularization (CI-TLR)	From 3 to 12 months	Target Lesion Revascularization (TLR) is defined as any repeat percutaneous intervention of the target lesion or bypass surgery of the target vessel performed for restenosis or other complication of the target lesion. All TLR should be classified prospectively as clinically indicated \[CI\] or not clinically indicated by the investigator prior to repeat angiography. Clinically Indicated \[CI\] Revascularization: A revascularization is considered clinically indicated if angiography at follow-up shows a percent diameter stenosis ≥ 50% and if one of the following occurs: * A positive history of recurrent angina pectoris, presumably related to the target vessel; * Objective signs of ischemia at rest (ECG changes) or during exercise test (or equivalent), presumably related to the target vessel; * Abnormal results of any invasive functional diagnostic test * A TLR/TVR with a diameter stenosis ≥70% in the absence of the above mentioned ischemic signs or symptoms.
Number of Participants With Clinically-indicated Target Vessel Revascularization (CI-TVR)	From 3 to 12 months	TVR is defined as any repeat percutaneous intervention or surgical bypass of any segment of the target vessel. The target vessel is defined as the entire major coronary vessel proximal and distal to the target lesion which includes upstream and downstream branches and the target lesion itself. A revascularization is considered clinically indicated if angiography at follow-up shows a percent diameter stenosis ≥ 50% and if one of the following occurs: * A positive history of recurrent angina pectoris, presumably related to the target vessel; * Objective signs of ischemia at rest (ECG changes) or during exercise test (or equivalent), presumably related to the target vessel; * Abnormal results of any invasive functional diagnostic test (e.g., Doppler flow velocity reserve, fractional flow reserve); * A TVR with a diameter stenosis ≥70% in the absence of the above mentioned ischemic signs or symptoms.
Number of Participants With Target Lesion Failure (TLF, Composite of Cardiac Death, TV-MI and CI-TLR)	From 3 to 12 months	TLF is defined as a composite of all cardiac death, myocardial infarction attributed to target vessel or clinically-indicated TLR.
Number of Participants With Stent Thrombosis (ARC Definite/Probable)	From 3 to 12 months	Definite stent thrombosis: Definite stent thrombosis is considered to have occurred by either angiographic or pathologic confirmation. Probable stent thrombosis: Clinical definition of probable stent thrombosis is considered to have occurred after intracoronary stenting in the following cases: * Any unexplained death within the first 30 days * Irrespective of the time after the index procedure, any MI that is related to documented acute ischemia in the territory of the implanted stent without angiographic confirmation of stent thrombosis and in the absence of any other obvious cause
Number of Participants With All Myocardial Infarction (MI) and MI Attributed to Target Vessel (TV-MI, Modified ARC)	From 3 to 12 months	All Myocardial Infarction (Modified ARC): Patients present any of the following clinical or imaging evidence of ischemia: * Clinical symptoms of ischemia; * ECG changes indicative of new ischemia - new ST-T changes or new left bundle branch block (LBBB), development of pathological Q waves; * Imaging evidence of a new loss of viable myocardium or a new regional wall motion abnormality) AND confirmed with elevated cardiac biomarkers per ARC criteria: * Periprocedural MI: * Within 48h after PCI: CK-MB \>3 x URL or Troponin \> 3 x URL with baseline value \< URL * Within 72h after CABG: CK-MB \>5 x URL or Troponin \> 5 x URL with baseline value \< URL * Spontaneous MI (\> 48h following PCI, \> 72h following CABG): CK-MB \> URL or Troponin \> URL with baseline value \< URL TV-MI: All infarcts that cannot be clearly attributed to a vessel other than the target vessel will be considered related to the target vessel.
Number of Participants With All Death, Cardiac Death, Vascular Death, Non-cardiovascular Death	From 3 to 12 months	All Death: All deaths are considered cardiac unless an unequivocal non-cardiac cause can be established. Specifically, any unexpected death even in patients with coexisting potentially fatal non-cardiac disease (e.g. cancer, infection) should be classified as cardiac. Cardiac death: Any death due to proximate cardiac cause (e.g. MI, low-output failure, fatal arrhythmia), unwitnessed death and death of unknown cause, all procedure related deaths including those related to concomitant treatment. Vascular death: Death due to non-coronary vascular causes such as cerebrovascular disease, pulmonary embolism, ruptured aortic aneurysm, dissecting aneurysm, or other vascular cause. Non-cardiovascular death: Any death not covered by the above definitions such as death caused by infection, malignancy, sepsis, pulmonary causes, accident, suicide or trauma.
Number of Participants With Target Vessel Failure (TVF, Composite of Cardiac Death, TV-MI and CI-TVR)	From 3 to 12 months	TVF is defined as a composite of cardiac death, MI attributed to target vessel, clinically-indicated TLR, or clinically-indicated TVR, non-TLR.
Number of Participants With Composite of Cardiac Death or MI (Modified ARC)	From 3 to 12 months	Cardiac death: Any death due to proximate cardiac cause (e.g. MI, low-output failure, fatal arrhythmia), unwitnessed death and death of unknown cause, all procedure related deaths including those related to concomitant treatment. MI (Modified ARC): Patients present any of the following clinical or imaging evidence of ischemia: * Clinical symptoms of ischemia; * ECG changes indicative of new ischemia - new ST-T changes or new left bundle branch block (LBBB), development of pathological Q waves; * Imaging evidence of a new loss of viable myocardium or a new regional wall motion abnormality) AND confirmed with elevated cardiac biomarkers per ARC criteria: * Periprocedural MI: * Within 48h after PCI: CK-MB \>3 x URL or Troponin \> 3 x URL with baseline value \< URL * Within 72h after CABG: CK-MB \>5 x URL or Troponin \> 5 x URL with baseline value \< URL * Spontaneous MI (\> 48h following PCI, \> 72h following CABG): CK-MB \> URL or Troponin \> URL with baseline value \< URL
Number of Participants With Major Bleeding Defined by the Bleeding Academic Research Consortium (BARC) Type 3-5	From 3 to 12 months	Bleeding per Bleeding Academic Research Consortium (BARC) adjudicated definitions are as follows: * Type 3a: Overt bleeding plus Hemoglobin(Hb) drop of 3 to \< 5 g/dL; Any transfusion with overt bleeding * Type 3b: Overt bleeding plus Hb drop ≥ 5 g/dL; Cardiac tamponade; Bleeding requiring surgical intervention for control; Bleeding requiring IV vasoactive agents * Type 3c: Intracranial hemorrhage;Subcategories confirmed by autopsy or imaging or lumbar puncture; Intraocular bleed compromising vision * Type 4: CABG-related bleeding: Perioperative intracranial bleeding within 48 h; Reoperation after closure of sternotomy for the purpose of controlling bleeding; Transfusion of ≥ 5 U whole blood or packed red blood cells within a 48-h period; Chest tube output ≥ 2L within a 24-h period * Type 5: Fatal bleeding * Type 5a: Probable fatal bleeding; no autopsy or imaging confirmation but clinically suspicious * Type 5b: Definite fatal bleeding;overt bleeding or autopsy or imaging confirmation

Trial Locations

Locations (101): MedStar Union Memorial Hospital
🇺🇸
Baltimore, Maryland, United States
Allegheny General Hospital
🇺🇸
Pittsburgh, Pennsylvania, United States
Baystate Medical Center
🇺🇸
Springfield, Massachusetts, United States
University Hospitals Cleveland Medical Center
🇺🇸
Cleveland, Ohio, United States
Beth Israel Deaconess Medical Center
🇺🇸
Boston, Massachusetts, United States
Franciscan Physician Network-Indiana Heart Physicians
🇺🇸
Indianapolis, Indiana, United States
St. Vincent Heart Center of Indiana
🇺🇸
Indianapolis, Indiana, United States
Memorial Hermann-Hermann Hospital/UTHealth
🇺🇸
Houston, Texas, United States
Sharp Grossmont Hospital (La Mesa Cardiac Center)
🇺🇸
San Diego, California, United States
Sharp Memorial Hospital / San Diego Cardiac Center
🇺🇸
San Diego, California, United States
Cedars-Sinai Medical Center
🇺🇸
Los Angeles, California, United States
Scripps Memorial Hospital/Prebys Cardiovascular Institute
🇺🇸
La Jolla, California, United States
McLaren Bay Region
🇺🇸
Bay City, Michigan, United States
St. Joseph Mercy Hospital (Michigan Heart)
🇺🇸
Ypsilanti, Michigan, United States
Clearwater Cardiovasular Consultants
🇺🇸
Clearwater, Florida, United States
Atlanta Veterans Affairs Medical Center
🇺🇸
Decatur, Georgia, United States
Kansas Heart Hospital (Cardiovascular Research Institute of Kansas)
🇺🇸
Wichita, Kansas, United States
North Georgia Heart Foundation, Inc.
🇺🇸
Gainesville, Georgia, United States
Traverse Heart and Vascular Munson Medical Center
🇺🇸
Traverse City, Michigan, United States
JFK Medical Center
🇺🇸
Atlantis, Florida, United States
Doylestown Hospital
🇺🇸
Doylestown, Pennsylvania, United States
Augusta Medical Center
🇺🇸
Augusta, Georgia, United States
Mount Sinai Medical Center
🇺🇸
New York, New York, United States
Elkhart General Hospital/Midwest Cardiology Research & Education Foundation
🇺🇸
Elkhart, Indiana, United States
University of Kentucky/Gill Heart and Vascular Institute
🇺🇸
Lexington, Kentucky, United States
St. John's Hospital
🇺🇸
Springfield, Illinois, United States
Morton Plant Mease Healthcare System
🇺🇸
Clearwater, Florida, United States
Lahey Clinic/Lahey Hospital and Medical Center
🇺🇸
Burlington, Massachusetts, United States
Boone Hospital Center (Missouri Cardiovascular Specialists)
🇺🇸
Columbia, Missouri, United States
NYU Langone Health
🇺🇸
New York, New York, United States
UPMC Hamot/Medicor Associates, Inc.,
🇺🇸
Erie, Pennsylvania, United States
Providence Regional Medical Center Everett
🇺🇸
Everett, Washington, United States
Wellmont Holston Valley Medical Center
🇺🇸
Kingsport, Tennessee, United States
Mary Washington Hospital/Virginia Cardiovascular Consultants
🇺🇸
Fredericksburg, Virginia, United States
St. Luke's Hospital/Mid America Heart Institute
🇺🇸
Kansas City, Missouri, United States
Morristown Medical Center
🇺🇸
Morristown, New Jersey, United States
Holy Spirit Hospital
🇺🇸
Camp Hill, Pennsylvania, United States
Harrisburg Hospital/Pinnacle Health Cardiovascular Institute, Inc.
🇺🇸
Harrisburg, Pennsylvania, United States
St Dominic-Jackson Memorial Hospital (Jackson Heart Clinic)
🇺🇸
Jackson, Mississippi, United States
Jersey Shore University Medical Center
🇺🇸
Neptune, New Jersey, United States
UPMC
🇺🇸
Pittsburgh, Pennsylvania, United States
Heart Hospital of Austin
🇺🇸
Austin, Texas, United States
St. Mary Medical Center
🇺🇸
Langhorne, Pennsylvania, United States
CentraCare
🇺🇸
Saint Cloud, Minnesota, United States
New York Presbyterian Hospital - Weill Cornell
🇺🇸
New York, New York, United States
NC Heart and Vascular Research
🇺🇸
Raleigh, North Carolina, United States
AnMed Health Clinical Research
🇺🇸
Anderson, South Carolina, United States
Lenox Hill Hospital (Northwell)/ Feinstein Institute
🇺🇸
New York, New York, United States
St. Joseph Medical Center
🇺🇸
Wyomissing, Pennsylvania, United States
East Texas Medical Center
🇺🇸
Tyler, Texas, United States
New York - Presbyterian Queens Lang Research Center
🇺🇸
Flushing, New York, United States
Penn Presbyterian Medical Center/Penn Heart and Vascular Pavilion,
🇺🇸
Philadelphia, Pennsylvania, United States
Sanford Health
🇺🇸
Sioux Falls, South Dakota, United States
Texas Tech University Health (University Medical Center)
🇺🇸
Lubbock, Texas, United States
Baptist Memorial Hospital
🇺🇸
Memphis, Tennessee, United States
Inova Fairfax Hospital/Inova Heart and Vascular Institute
🇺🇸
Falls Church, Virginia, United States
The University of Kansas Medical Center
🇺🇸
Kansas City, Kansas, United States
Cardiovascular Research Institute of Kansas/Via Christi Regional Medical
🇺🇸
Wichita, Kansas, United States
Englewood Hospital and Medical Center
🇺🇸
Englewood, New Jersey, United States
St John Hospital & Medical Center
🇺🇸
Detroit, Michigan, United States
Integris Baptist Medical Center/Integris Cardiovascular Physicians, LLC
🇺🇸
Oklahoma City, Oklahoma, United States
Centennial Medical Center (TriStar Centennial Medical Center)
🇺🇸
Nashville, Tennessee, United States
Providence St. Vincent Medical Center
🇺🇸
Portland, Oregon, United States
Rocky Mountain Regional VA Medical Center
🇺🇸
Aurora, Colorado, United States
Washington University School of Medicine Barnes Jewish Hospital
🇺🇸
Saint Louis, Missouri, United States
Hillcrest Medical Center (Oklahoma Heart Institute)
🇺🇸
Tulsa, Oklahoma, United States
Stony Brook University Medical Center
🇺🇸
Stony Brook, New York, United States
University of California Davis Medical Center
🇺🇸
Sacramento, California, United States
Eastern Maine Medical Center/One Northeast Drive
🇺🇸
Bangor, Maine, United States
Our Lady of Lourdes/Cardiovascular Associates of the Delaware Valley (The Heart House)
🇺🇸
Camden, New Jersey, United States
Western Michigan University Homer Stryker M.D. School of Medicine
🇺🇸
Kalamazoo, Michigan, United States
Scottsdale Healthcare Hospitals (d/b/a HonorHealth - HonorHealth Research Institute)
🇺🇸
Scottsdale, Arizona, United States
Huntsville Hospital (Heart Center Research LLC)
🇺🇸
Huntsville, Alabama, United States
Arkansas Heart Hospital
🇺🇸
Little Rock, Arkansas, United States
John Muir Health Concord
🇺🇸
Concord, California, United States
Santa Barbara Cottage Hospital/Sansum Clinic
🇺🇸
Santa Barbara, California, United States
Washington Hospital (Mission Cardiovascular Research Institute)
🇺🇸
Fremont, California, United States
Medstar Washington Hospital
🇺🇸
Washington, District of Columbia, United States
St. Vincent's Medical Center (St. Vincent's Healthcare)
🇺🇸
Jacksonville, Florida, United States
North Florida Regional / The Cardiac and Vascular Institute
🇺🇸
Gainesville, Florida, United States
University Health, INC/University Cardiology Associates, LLC
🇺🇸
Augusta, Georgia, United States
Massachusetts General Hospital
🇺🇸
Boston, Massachusetts, United States
Baptist Health Louisville/Louisville Cardiology
🇺🇸
Louisville, Kentucky, United States
Abbott Northwestern Hospital (Minneapolis Heart Institute Foundation)
🇺🇸
Minneapolis, Minnesota, United States
Genesys Regional Medical Center (Regional Cardiology Associates)
🇺🇸
Grand Blanc, Michigan, United States
MidMichigan Medical Center Midland
🇺🇸
Midland, Michigan, United States
North Mississippi Medical Center (Cardiology Associates Research)
🇺🇸
Tupelo, Mississippi, United States
St. Patrick Hospital International Heart Institute of Montana Foundation
🇺🇸
Missoula, Montana, United States
Bryan Local General Hospital (Bryan Medical Center East)
🇺🇸
Lincoln, Nebraska, United States
St. Joseph's Hospital Health Center
🇺🇸
East Syracuse, New York, United States
The Presbyterian Hospital (d/b/a Novant Health Heart and Vascular Institute) Novant Health Clinical Research
🇺🇸
Charlotte, North Carolina, United States
Wake Forest Baptist Medical Center (Wake Forest University Health Sciences)/Medical Center Boulevard
🇺🇸
Winston-Salem, North Carolina, United States
Cardiovascular Research Center, LLC (Mercy Health St. Vincent Medical Center LLC)
🇺🇸
Toledo, Ohio, United States
Baylor Heart and Vascular Hospital
🇺🇸
Dallas, Texas, United States
Turkey Creek Medical Center (Knoxville HMA Cardiology, LLC)
🇺🇸
Knoxville, Tennessee, United States
Erlanger Medical Center
🇺🇸
Chattanooga, Tennessee, United States
Charleston Area Medical Center Memorial Division
🇺🇸
Charleston, West Virginia, United States
Torrance Memorial Medical Center
🇺🇸
Torrance, California, United States
Tallahassee Memorial Hospital / Tallahassee Research Institute, Inc.
🇺🇸
Tallahassee, Florida, United States
The University of Vermont Medical Center
🇺🇸
Burlington, Vermont, United States
Rhode Island Hospital
🇺🇸
Providence, Rhode Island, United States