The prognostic utility of the pulmonary artery pulsatility and aortic pulsatility index in patients with heart failure: A systematic review

Abstract

Heart failure (HF) continues to pose a major burden worldwide, and risk stratification is important to guide management. Hemodynamic indices such as the pulmonary artery pulsatility index (PAPI) and aortic pulsatility index (API) have gained attention as potential prognostic tools, but their role is still not well established. We conducted a systematic review to assess the prognostic role of PAPI and API in HF patients. We systematically searched PubMed, Web of Science, Scopus, and Cochrane Library for studies assessing PAPI and API in adults (≥18 years) with HF. We included cohort studies and randomized trials reporting outcomes such as mortality, hospitalization, left ventricular assist device implantation, or heart transplantation. Of 601 studies identified, 12 met the inclusion criteria, comprising 3681 patients. Across different HF populations, lower PAPI values were consistently associated with worse outcomes, with reported cutoffs ranging from ≤1.9 in cardiogenic shock to around ≤2.8–2.95 in broader HF populations, and up to ≤3.65 in advanced HF. Aortic pulsatility index showed a similar pattern, but with more consistent performance: values <1.45 were linked to mortality or rapid progression to advanced therapies, while values >2.9 were associated with better event-free survival. In studies that evaluated both indices, API generally showed stronger prognostic value. Overall, PAPI and API provide clinically useful prognostic information, particularly in advanced HF patients undergoing invasive hemodynamic assessment, though further large-scale prospective studies are needed to better define their role.

Keywords

Heart failure mortality prognosis pulmonary artery pulsatility index aortic pulsatility index

Introduction

Heart failure (HF) continues to pose a major public health concern, contributing significantly to morbidity, mortality, and healthcare costs. Despite variation in reported incidence, a clear upward trend in the prevalence of HF has been observed, owing to aging populations and the increasingly vital role played by cardiovascular risk factors.¹ The estimated global prevalence stands at around 1–2%, with over 6.5 million Americans living with HF.^2,3 Advancements in pharmacological and device-based therapies have proven effective in HF treatment; nevertheless, the 5-year absolute mortality rate of end-stage HF is estimated at around 50%.³ This underscores the importance of early risk stratification as a valuable adjunct in the clinical management of HF.

Hemodynamic assessment plays a central role in guiding interventions and predicting outcomes of HF patients, where evidence has shown a substantially improved quality of life and a reduction in hospitalization.⁴ In spite of benefits over clinical prediction, traditional hemodynamic measures have inherent limitations, including variability and incomplete assessment of ventricular-arterial interactions.⁵ Therefore, there is a growing interest in the use of novel hemodynamic indices in the prediction of future outcomes and the guidance of HF treatment plans.

Pulmonary artery (PA) pulsatility index (PAPI), calculated as [PA pulse pressure/right atrial pressure (RAP)], initially emerged as a promising indicator, particularly for predicting right ventricular failure in acute inferior myocardial infarction and post-left ventricular assist device (LVAD) surgery.⁶ Several studies have since demonstrated that low PAPI values are associated with increased cardiac mortality risk, increased HF hospitalization, and serve as a relevant indicator for identifying high-risk individuals.^7,8

In contrast, aortic pulsatility index (API), defined as [pulse pressure/pulmonary capillary wedge pressure (PCWP)], is a new hemodynamic indicator proposed as a valuable marker of left ventricular function and has shown association with RAP due to the biventricular nature of advanced HF.² Multiple studies, including a subanalysis of the ESCAPE trial, have shown API to be superior to established hemodynamic indices in the prediction of clinical outcomes in HF.^2,9

Although PAPI and API have shown promise as emerging hemodynamic indicators in the assessment of HF prognosis, their clinical usage and prognostic implications remain unclear. Current literature includes heterogeneous studies examining the use of PAPI and API across varying patient populations and with differing outcomes, which necessitates a comprehensive review of available evidence. The objective of this systematic review is to evaluate the existing literature on the prognostic significance and potential applications of PAPI and API in the management of HF. This will allow the possible integration of PAPI and API into existing guidelines and solidify their role as independent hemodynamic indicators.

Materials and methods

Protocol and registration

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration ID CRD42024616250.

Search strategy

We developed a comprehensive search strategy to identify all studies evaluating PAPI and API as a prognostic tool in patients with HF. We conducted the search across four major databases: PubMed, Embase, MEDLINE, and Cochrane Library. Studies published up until 26 November 2024 were included. Our search strategy incorporated both MeSH (Medical Subject Headings) and non-MeSH terms related to HF, along with additional keywords such as mortality, hospitalization, heart transplantation, LVAD, and major adverse cardiovascular events. A description of the search terms and methodology is provided in Appendix 1. Since this study is based on publicly available data, ethical approval was not required.

Study selection and data extraction

Two independent authors screened the titles, abstracts, and full-text articles using Rayyan.ai, a web-based tool designed to facilitate systematic reviews. Studies were assessed based on predefined inclusion and exclusion criteria, with disagreements resolved through discussion and a third author consulted when necessary. The selection process was documented using a PRISMA flow diagram (Figure 1). A standardized form was used to collect key information, including study details, patient population, hemodynamic parameters, primary outcomes, and follow-up duration.

Figure 1.

Study selection process.

Data from included studies were synthesized descriptively, focusing on reported associations between PAPI, API, and clinical outcomes. A meta-analysis was not performed due to substantial clinical and methodological heterogeneity across studies, including differences in patient populations (HFrEF, HFpEF, cardiogenic shock), follow-up duration, and effect measures reported (hazard ratios vs. odds ratios). Exploratory pooled analyses using random-effects models confirmed high statistical heterogeneity (I² > 85% for both indices), supporting the decision to pursue a narrative synthesis.

Study eligibility

This review examined the prognostic value of PAPI and API in HF patients. We included cohort studies and post hoc analyses of randomized trials involving adults (≥18 years) that monitored key outcomes such as mortality, LVAD, hospitalization, or heart transplantation. Eligible studies needed to provide detailed hemodynamic data and analyze PAPI or API as primary markers. We excluded studies lacking sufficient data, as well as case reports, reviews, and editorials. To ensure quality and relevance, only full-text, peer-reviewed articles in English were included. Systemic arterial pulsatility index, which is mathematically equivalent to the API, was considered equivalent and included in the analysis.

Risk-of-bias assessment

The risk of bias was evaluated using assessment tools tailored for prognostic studies. Specifically, the six-domain Quality in Prognostic Studies tool, as recommended by the Cochrane Prognosis Methods Group,¹⁰ was used to assess potential biases in study design and execution. Further details can be found in Table 1 and Supplementary Table 1.

Table 1.

Risk of bias using Quality in Prognostic Studies (QUIPS) tool.

	Study participation	Study attrition	Prognostic factor measurement	Outcome measurement	Study confounding	Statistical analysis and reporting
Omar et al.¹¹	Low	Low	Low	Low	Moderate	Low
Koyun and Sahin¹²	Low	Low	Low	Low	Moderate	Low
Yildiz and Baydar¹³	Low	Low	Low	Low	Moderate	Low
Kochav et al.¹⁴	Low	Low	Low	Low	Moderate	Low
Bayram et al.¹⁵	Low	Low	Low	Low	Low	Low
Baldetti et al.¹⁶	Low	Low	Low	Low	Moderate	Low
Cyrille-Superville et al.¹⁷	Low	Low	Low	Low	Low	Low
Deis et al.²	Low	Low	Low	Low	Low	Low
Jain et al.¹⁸	Low	Low	Low	Low	Moderate	Low
Belkin et al.⁹	Low	Low	Low	Low	Moderate	Low
Belkin et al.¹⁹	Low	Low	Low	Low	Moderate	Low
Mazimba et al.²⁰	Low	Low	Low	Low	Moderate	Low

Results

Study characteristics

After a full-text screening, twelve studies comprising 3681 patients were included in this review, consisting of eight retrospective cohort studies and four post hoc ESCAPE trial analyses. Table 2 provides an overview of the included studies. These studies spanned across the USA, Canada, Turkey, Italy, the Netherlands, and Denmark, offering a diverse population sample. The studies primarily focused on the PAPI, with some also evaluating the API. Hemodynamic measurements were typically taken at admission, with PAPI calculated as (systolic PA pressure diastolic PA pressure) / RAP, and API calculated as (systolic arterial pressure – diastolic arterial pressure) / PCWP.

Table 2.

Overview of included studies.

Author name, year	Design	Country	Sample size	Follow-up duration	Inclusion criteria	Outcomes	Time of hemodynamic measurement
Omar et al.¹¹	Post hoc analysis of randomized trial (ESCAPE)	USA & Canada	167	6 months	LVEF ≤30%, NYHA class IV	Death, rehospitalization, HT	Final day of admission
Koyun and Sahin¹²	Retrospective cohort	Turkey	86	69.1 months	HFpEF	Death	At admission
Yildiz and Baydar¹³	Retrospective cohort	Turkey	129	52 months	LVEF ≤35%, NYHA class II–IV	Death, LVAD, HT	At admission
Kochav et al.¹⁴	Post hoc analysis of randomized trial (ESCAPE)	USA & Canada	190	6 months	LVEF ≤30%	Death, rehospitalization	At admission
Bayram et al.¹⁵	Retrospective cohort	Turkey	416	503.5 days	LVEF ≤25%, NYHA functional class II–IV	Death, HT, LVAD	At admission
Baldetti et al.¹⁶	Retrospective cohort	Italy, Netherlands	127	10 days	Cardiogenic shock due to HF	Death	At admission
Cyrille-Superville et al.¹⁷	Retrospective cohort	USA	846	6 months	Any HF patient	Death, HT, LVAD	At admission
Deis et al.²	Retrospective cohort	Denmark	453	9.1 years	LVEF ≤45%	Death, HT, LVAD	At admission and final day of admission
Jain et al.¹⁸	Retrospective cohort	USA	712	Hospital stay	Cardiogenic shock due to HF	Death	At admission
Belkin et al.⁹	Post hoc analysis of randomized trial (ESCAPE)	USA	189	6 months	LVEF ≤30%	Death, HT, LVAD	At admission
Belkin et al.¹⁹	Retrospective cohort	USA	224	30 days	Any HF patient	Death, rehospitalization, LVAD, HT	At admission
Mazimba et al.²⁰	Post hoc analysis of randomized trial (ESCAPE)	USA & Canada	142	6 months	LVEF ≤30%	Death, HT, LVAD, rehospitalization	Prior to removal of PAC

LVEF = left ventricular ejection fraction; LVAD = left ventricular assist device; HF = Heart failure; HFpEF = heart failure with preserved ejection fraction; HT = heart transplant; PAC = pulmonary artery catheter.

Sample sizes ranged from 86 patients to 846 patients. One study assessed outcomes within 10 days, while another had a median follow-up of over 9 years. Primary outcomes included mortality, rehospitalization, LVAD implantation, and urgent heart transplantation. Most studies focused on patients with HFrEF. One study exclusively included HFpEF patients, and two studies included both HFrEF and HFpEF populations. Two studies only included HF patients with cardiogenic shock, offering insights into how PAPI and API behave in patients with advanced HF.

Patient demographics and baseline characteristics

Patient age varied across studies, ranging from 48.6 ± 10.5 years in the youngest study population to a median age of 69 years (66–75) in the oldest. Male patients predominated, accounting for approximately 67.7% of total patients. LVEF differed by HF subtype, with markedly reduced values reported in HFrEF (as low as 18%) and preserved values in HFpEF (mean around 56%).

Endpoint achievement varied across studies, with the highest reported rates reaching up to 92.6%, followed by others reporting 80.8%. Pulmonary artery pulsatility index values were higher among survivors compared to nonsurvivors across most studies. For instance, in one cohort, survivors had a mean PAPI of 3.7 versus 3.1 in nonsurvivors; in another, the mean PAPI was 4.8 in survivors compared to 2.28 in nonsurvivors. Reported median API values ranged from 1.18 in nonsurvivor groups to 3.2 in other lower risk or survivor patient populations.

Prognostic value of PAPI

Table 3 summarizes the prognostic value of PAPI across the included studies. The studies demonstrated consistent evidence that lower PAPI values are associated with adverse outcomes in HF patients, though optimal cutoff values and effect sizes varied across populations.

Table 3.

Summary of PAPI findings.

Author name	PAPI cutoff value	Outcome predicted	Hazard/Odds ratio (95% CI)	AUC	Key finding
Omar et al.¹¹	2	Death or rehospitalization	HR: 0.890 (0.819–0.967)	0.631	Discharge PAPI was strongly associated with reaching endpoint; values increased with decongestion during hospitalization.
Koyun and Sahin¹²	2.84	Mortality	OR: 0.177 (0.072–0.439)	0.843	PAPI was found to be independent predictor of mortality in HFpEF
Yildiz and Baydar¹³	2.82	Cardiac death	HR: 0.73 (0.53–0.99)	0.76	A PAPI was an independent predictor of cardiac death in patients with HFrEF.
Kochav et al.¹⁴	3.65	Death, rehospitalization	HR: 0.91 (0.84–0.99)	NR	Lower PAPI was associated with increased risk of death or hospitalization in advanced HF
Bayram et al.¹⁵	2.56	Death or rehospitalization	HR: 0.75 (0.55–0.95)	NR	Lower PAPI was associated with increased risk of adverse cardiac events in advanced HF
Baldetti et al.¹⁶	2.95	Death, HT, LVAD	OR: 0.77 (0.62–0.92)	NR	PAPI was independently associated with higher in-hospital mortality in acute decompensated HF with cardiogenic shock
Cyrille-Superville et al.¹⁷	1.3	Death, HT, LVAD	OR: 1.02 (1.00–1.03)	NR	Both API (p < .001) and PAPI (p = .027) independently predicted combined endpoint in advanced HF patients, with API showing stronger prognostic value and higher API linked to better survival.
Jain et al.¹⁸	NR	Mortality	OR: 0.70 (0.60–0.82)	NR	Lower PAPI was associated with higher in hospital mortality in HF patients with cardiogenic shock.
Belkin et al.⁹	2.6	Death, HT, LVAD	OR: 0.85 (0.72–1.01)	0.634	API was the strongest predictor of death, transplant, or LVAD at 6 months; PAPI showed an association with outcomes but had weaker prognostic performance

PAPI = pulmonary artery pulsatility index; API = aortic pulsatility index; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HR = hazard ratio; OR = odds ratio; NR = not reported; LVAD = left ventricular assist device; HT = heart transplant.

In acute decompensated HF, Omar et al.¹¹ analyzed data from the ESCAPE trial and found that discharge PAPI ≤2 was strongly associated with death or rehospitalization; notably, higher PAPI values were associated with lower risk (HR per unit increase: 0.89), with PAPI rising during hospitalization as patients underwent decongestion. Similarly, Baldetti et al.¹⁶ demonstrated that PAPI ≤2.95 was independently associated with higher in-hospital mortality in acute decompensated HF complicated by cardiogenic shock (OR: 1.33). Jain et al.¹⁸ further confirmed that higher PAPI predicted lower hospital mortality in cardiogenic shock patients (OR: 0.70).

The prognostic utility of PAPI extended across ejection fraction phenotypes. Koyun and Sahin¹² reported that lower PAPI (≤2.84) independently predicted mortality in HFpEF, with higher PAPI associated with reduced risk (OR: 0.177). Similarly, Yildiz and Baydar¹³ found that higher PAPI was associated with lower cardiac mortality in HFrEF (HR: 0.73). In advanced HF populations being evaluated for mechanical circulatory support, Kochav et al.¹⁴ reported that PAPI ≤3.65 was associated with increased risk of death or rehospitalization, while higher PAPI values were protective (HR: 0.91). Similarly, Bayram et al.¹⁵ found that PAPI ≤2.56 predicted adverse cardiac events, with increasing PAPI associated with reduced risk (HR: 0.75).

In studies directly comparing both API and PAPI, Cyrille-Superville et al.¹⁷ found that while lower PAPI was associated with the combined endpoint of death, heart transplantation, or LVAD implantation, its prognostic performance was weaker compared to API. Similarly, Belkin et al.⁹ observed that although PAPI ≤2.6 was associated with adverse outcomes, its predictive performance was inferior to API.

Prognostic value of API

Table 4 summarizes the prognostic value of API across the included studies. Across all studies, lower API values were linked to worse outcomes in advanced HF, and in the studies that directly compared both indices, API outperformed PAPI as a prognostic marker.

Table 4.

Summary of API findings.

Author name	API cutoff value	Outcome predicted	Hazard/Odds ratio (95% CI)	AUC	Key finding
Cyrille-Superville et al.¹⁷	2.3	Death, HT, LVAD	HR: 0.33 (0.22–0.49)	NR	Both API (p < .001) and PAPI (p = .027) independently predicted combined endpoint in advanced HF patients, with API showing stronger prognostic value and higher API linked to better survival.
Deis et al.²	1.9	Death, HT, LVAD	HR: 0.33 (0.20–0.56)	0.694	API predicted freedom from the combined endpoint and all-cause mortality even when correcting for known variables associated with a worse outcome in HF
Belkin et al.⁹	2.9	Death, HT, LVAD	OR: 0.47 (0.32–0.70)	0.71	API was the strongest predictor of death, transplant, or LVAD at 6 months; PAPI showed an association with outcomes but had weaker prognostic performance
Belkin et al.¹⁹	1.45	Death, HT, LVAD	OR: 0.38 (0.22–0.65)	0.73	Lower baseline API predicted progression to advanced therapies or death within 30 days
Mazimba et al.²⁰	NR	Death, HT, LVAD, rehospitalization	HR: 0.81 (0.69–0.95)	NR	Lower API was associated with higher risk of death, LVAD, heart transplant, and HF hospitalization in advanced HF

PAPI = pulmonary artery pulsatility index; API = aortic pulsatility index; HF = heart failure; HR = hazard ratio; OR = odds ratio; NR = not reported; LVAD = left ventricular assist device; HT = heart transplant.

In advanced HF patients, Cyrille-Superville et al.¹⁷ found that API ≤2.3 strongly predicted the combined endpoint of death, heart transplant, or LVAD implantation with higher API values associated with improved survival (HR: 0.33) When compared directly with PAPI in the same cohort, API had superior prognostic strength (p < .001) compared to PAPI (p = .027), with higher API values were associated with better survival. Deis et al.² first described API as a hemodynamic tool for evaluating decompensated HF and showed that API ≤1.9 predicted freedom from the combined endpoint and all-cause mortality, while higher API values were protective (HR: 0.33).

Belkin et al.^9,19 evaluated API in two separate analyses. In the first, API ≤2.9 was associated with increased risk of death, transplant, or LVAD at 6 months, with higher API values linked to lower risk (OR: 0.47), with PAPI showing a weaker association. In the second analysis, a lower baseline API (≤1.45) predicted progression to advanced therapies or death within 30 days, with increasing API associated with reduced risk (OR: 0.38), supporting its role in short-term risk stratification.

Additionally, Mazimba et al.²⁰ also found that lower API was tied to a higher risk of death, LVAD, heart transplant, and HF rehospitalization (HR: 0.81), though no specific cutoff was reported. Overall, these results suggest PAPI and API are useful prognostic markers in advanced HF, with API potentially outperforming PAPI in risk prediction.

Discussion

This systematic review evaluated the prognostic utility of pulsatility-based hemodynamic indices, including PAPI and API in HF patients. It spanned 12 studies involving 3681 HF patients. Both indices were consistently predictive of adverse events, including mortality, rehospitalization, and the need for advanced mechanical support. Despite the variety of cutoff values, the overall trend was clear, with lower PAPI correlating with a higher risk of adverse outcomes, even among patients with preserved LVEF, while lower API was associated with worse survival and an increased likelihood of LVAD or heart transplantation. These findings highlight the potential role of PAPI and API as relatively underutilized indices in the clinical appraisal of HF.

The prognostic performance of PAPI varied considerably depending on the underlying HF phenotype. Most studies in this review focused on patients with HFrEF, where right ventricular dysfunction is common, and PAPI consistently distinguished between high- and low-risk patients. However, one study¹² that focused exclusively on HFpEF patients reported higher PAPI values overall, with the lowest odds ratio for adverse outcomes among all included studies. This suggests that PAPI has less discriminatory value in HFpEF, likely because right ventricular involvement is less prominent compared to HFrEF or cardiogenic shock. As a result, PAPI thresholds should be interpreted in the context of the underlying HF phenotype, as values derived from HFrEF populations may not directly apply to HFpEF patients.

The severity of hemodynamic compromise at the time of measurement also influenced the reported cutoff values. Two studies^16,18 examined patients with cardiogenic shock due to HF rather than stable advanced HF. These studies reported relatively lower PAPI and API values, reflecting the profound hemodynamic instability inherent to cardiogenic shock. In contrast, studies of stable ambulatory patients evaluated for advanced therapies reported higher thresholds.

Moreover, the timing of hemodynamic assessment, whether at admission or discharge, also contributed to the variability in cutoff values. Admission measurements capture a decompensated state, while discharge values reflect posttreatment stabilization. For example, one study¹¹ specifically examined discharge PAPI and found that values increased with decongestion during hospitalization, and that discharge PAPI was strongly associated with outcomes. Studies with shorter follow-up periods tended to report lower cutoff values, while longer-term studies reported higher thresholds. This suggests that the prognostic utility of PAPI may depend not only on the absolute value but also on when it is measured relative to the patient's clinical trajectory.

A key consideration is that most studies in this review included patients with advanced HF who were already undergoing right heart catheterization for clinical reasons such as LVAD evaluation, transplant candidacy, or assessment of cardiogenic shock. In that setting, the invasive nature of PAPI and API is less of a limitation and more inherent to their intended use. They are not meant for routine screening but rather as additional tools to help with risk stratification in high-risk patients. When these measurements are already available, calculating PAPI and API does not add any extra burden and can provide useful prognostic information to guide clinical decisions.

Pulsatility indices may add value by capturing ventricular vascular interactions not reflected by other hemodynamic measures. For example, cardiac power output (CPO) is a well-established predictor of mortality in cardiogenic shock, but it mainly reflects left ventricular function and may miss right-sided dysfunction.²¹ Similarly, the RAP to PCWP ratio captures right left ventricular imbalance but does not account for pulsatility or vascular compliance.²² Despite this, none of these, including PAPI and API, are formally recommended in the 2022 AHA/ACC/HFSA guidelines, which continue to emphasize conventional parameters such as cardiac index and filling pressures.²²

More recently, the American Heart Association highlighted API as a potentially superior prognostic marker in advanced HF, demonstrating the ability to predict myocardial recovery and weaning from temporary mechanical support.²³ In the ESCAPE subanalysis, API outperformed CPO and cardiac index in predicting death, LVAD implantation, or transplantation at 6 months.⁹ Similarly, in the PREDICT-HF registry, both PAPI and API were independent predictors of adverse outcomes, with API demonstrating stronger overall prognostic performance.¹⁷ These findings suggest that API adds meaningful prognostic information beyond traditional hemodynamic measures in advanced HF.

This study has several limitations that should be considered. Some heterogeneity was present across studies in several aspects, including differences in effect measures (hazard and odds ratios), patient populations (such as advanced HF, HFpEF, cardiogenic shock, or patients evaluated for advanced therapies). While some studies evaluated mortality alone, others reported composite outcomes including death, LVAD implantation, heart transplantation, or rehospitalization. Differences in the reported cutoff values for PAPI and API further limit the ability to establish standardized thresholds for clinical use. These findings highlight the need for larger prospective studies with more standardized methodologies to better define the prognostic role of these indices.

In summary, PAPI and API are emerging hemodynamic markers that offer a different perspective on risk in HF by capturing aspects of ventricular vascular interaction that are not reflected by traditional measures such as cardiac output or filling pressures. Their role is more relevant in patients who are already undergoing invasive hemodynamic assessment, where these indices can be obtained from existing data without added burden. That said, their clinical use is still limited by the lack of standardized cutoff values and their absence from current guidelines. Larger prospective studies across different HF populations are needed to better define how and when to use them. If validated, these indices could help refine risk stratification and support more individualized decision-making in advanced HF.

Supplemental Material

sj-docx-1-cvd-10.1177_20480040261444452 - Supplemental material for The prognostic utility of the pulmonary artery pulsatility and aortic pulsatility index in patients with heart failure: A systematic review

Supplemental material, sj-docx-1-cvd-10.1177_20480040261444452 for The prognostic utility of the pulmonary artery pulsatility and aortic pulsatility index in patients with heart failure: A systematic review by Zain Albdour, Mohannad Qadri, Zaid Abdulraheem AlAbed, Zeid Mohannad Jarrar, Ahmad Fawzi Bayadreh, Oun Mohammad Abu-Shattal and Karam Albdour in JRSM Cardiovascular Disease

Footnotes

ORCID iDs

Zain Albdour

Mohannad Qadri

Zeid Mohannad Jarrar

Ahmad Fawzi Bayadreh

Oun Mohammad Abu-Shattal

Karam Albdour

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

All data analyzed in this systematic review are included in the paper. No additional data were generated or used.

Supplemental material

Supplemental material for this article is available online.

Appendix 1

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