756 e-Letters

  • Cardiovascular manifestations of chronic helminthic infections: new aspects of an old disease

    Cardiovascular manifestations of helminthic infections: new aspects of an old disease
    To the Editor,
    We read with great interest the recent review article by Nunes et al (1) regarding cardiac manifestations of parasitic diseases. The authors adeptly reviewed direct and indirect manifestations of protozoan and helminthic infections on the heart function. However, we would like to make additional points on cardioprotective manifestations of chronic helminthic infections. It is well documented that chronic helminthiasis alter immune response toward T helper 2 (Th2) type immunity and anti-inflammatory responses. Also, chronic helminthiasis led to decline in atherogenic biomarkers and Body Mass Index (BMI) (2-3). Hence, chronic helminthiasis may lead to decrease the risk of atherosclerosis. In this regard, Wiria et al (2) performed a cross-sectional study in a highly endemic area of soil-transmitted helminths (STH) infections in Indonesia. They found that subjects with any STH infection had a lower BMI, waist to hip ratio (WHR), total cholesterol, and LDL-cholesterol than uninfected subjects. Moreover, subjects with high total immunoglobulin-E levels (which an index of helminthic infections) had significantly lower total cholesterol, HDL and fasting blood glucose levels than uninfected subjects (2). Magen et al (4) investigated the association between chronic Opisthorchis felineus infection with total cholesterol levels and aortic atherosclerosis in autopsy specimen...

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  • RE: Tea consumption and risk of ischaemic heart disease
    Dr.Rajiv Kumar

    This is good to read a research article on "Tea consumption and risk of ischaemic heart disease" This is the largest prospective study (cohort of Chinese adults) published to assess the association between tea consumption and incidence of IHD and showed that daily tea consumption is beneficial in reducing risk of IHD. Study has more limitations (although the investigators rightly said this).The is observational study,ma...

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  • Time metrics for reperfusion therapy and failure to achieve Guideline mandated times with P-PCI

    We read with interest the article by Varcoe et al (Heart Jan 15 th 20917) “Impact of call-to-balloon time on 30-day mortality in contemporary practice” We were not surprised by the results which indicate yet again that patients with delays to reperfusion suffer worse mortality rates - the concept of timely reperfusion in STEMI has been previously very well documented, and its importance recognised for some time. Thus de Lucca (1), Cannon (2) and others (3) reported data >10 years ago which supported the concept that mortality rates increase when important time metrics are not achieved. Time dependent infarct size is considered the cause (4)
    When the National Infarct Angioplasty Project (NIAP) was established in 2008 with the explicit aim of rolling out P-PCI in the UK, everyone involved in care of STEMI patients thought it was a good idea to go with a policy of one STEMI management strategy, for simplicity. No-one doubted that P-PCI should become the standard of care. Some (including the authors of this letter - one of whom served on NIAP) voiced concerns however that, based on the published data, achieving guideline mandated times was essential, and that this might be difficult to achieve with P-PCI in patients transferred from more rural regions. There was assurance from Department of Health that >95% of patients were “within distance” of a P-PCI centre. We tried to point out that being “within distance”, and being within the mandated times were very differe...

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  • Mechanical prosthetic heart valves in pregnancy are associated with a high risk of maternal and fetal morbidity and mortality

    We read with interest the paper by Bhagra and wish to add further information from two recent publications which emphasise the key points that ‘pregnancy in women with mechanical heart valves is high risk’ and that ‘a multidisciplinary team approach to the management of pregnant women with a mechanical prosthetic heart valve (MPHV) is necessary to ensure optimal outcomes’.
    A recent prospective observational national study of women in the UK with pregnancies between February 2013 and January 2015, estimated the incidence of MPHVs in pregnancy to be 3.7 per 100 000 and described high rates of maternal mortality (9%), serious maternal morbidity (41%) and poor fetal outcomes (47% of the cohort and 35% of those reaching the third trimester) . These complication rates are higher than previously described in the literature. This may be because the validated methodology resulted in less reporting bias; or because of variation in the quality of care women received; or the anticoagulation regime used. In this study 71% of women used low molecular weight heparin (LMWH) throughout pregnancy, whereas those in studies described by Bhagra mainly used warfarin, either throughout, or during the second and third trimesters of pregnancy. The UK study highlighted considerable variation in dosing and monitoring regimes, and that the recommended weight based starting dose of LMWH appeared to be insufficient.
    The 2016 MBRRACE maternal mortality report highlighted the increasing i...

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  • Sole reliance on I^2 may mislead

    We read the recommendations by Kiran and colleagues [1] on graphical displays to present meta-analysis results with great interest. Like the authors, we think that graphics play a major role to concisely summarize meta-analysis results and to evaluate heterogeneity between studies and small study effects. We agree with most recommendations [1] and actually forest plots generated with our R package meta (https://cran.r-project.org/web/packages/meta/) almost look like blueprints of Figure 2. However, in contrast to the authors, we would like to argue that solely relying on I^2 [2] to investigate heterogeneity might be misleading.

    Almost 10 years ago, we demonstrated analytically and using simulations that I^2 does not depend on the number of studies included in a meta-analysis, however, depends on the precision of included studies [3]. Accordingly, using I^2 to compare heterogeneity across different settings is typically misleading as precision of studies varies from meta-analysis to meta-analysis or subgroup to subgroup. We argued that the between-study variance tau^2 which does not depend on the precision of individual studies should be used instead of I^2 to compare heterogeneity across settings.

    Very recently, our assessment of I^2 was strongly supported in a publication [4] - including the main author of the original I^2 publication [2] as co-author - arguing that a prediction interval instead of...

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  • Re:A Case for Palliative PCI
    James Cockburn

    We would like to thank Sarah Blake et al, for their thoughtful and insightful comments.

    Firstly, we agree that "palliative PCI" can be a very useful treatment in this elderly patient population. Locally at our institution, via our heart team meeting, we can offer an elderly symptomatic patient with multiple co-morbidities percutaneous coronary intervention (PCI), which often fails to achieve complete re-vasculari...

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  • Cautious anticoagulation strategy in patients with dialysis-requiring end-stage kidney disease.
    Jonathan M Behar

    We read with interest this manuscript which demonstrated in a large clinical registry that patients with chronic kidney disease with indications for anticoagulation were often treated sub-therapeutically (1). A more aggressive approach was therefore advocated.

    We would like to point out that, while this study should be commended for including a large number of patients, it did not show data on the key clinical...

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  • Considering genomic variants for cardiovascular disease prediction
    Sherry-Ann N. Brown

    Dear Editor,

    I read with great interest the article by Morris et al entitled, "Marginal role for 53 common genetic variants in cardiovascular disease prediction" (1). The article analyzed a large sample of 11, 851 individuals from 7 prospective studies aimed at primary prevention of fatal or non-fatal coronary heart disease (CHD) or stroke.

    The study incorporated susceptibility variants for CHD and str...

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  • "Definite Diagnosis of Spontaneous Coronary Artery Dissection: An Unsettled Issue"
    Adriano Caixeta

    We read with great interest the manuscript by Faden et al. (1) entitled "A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium" when it was published online July 13. Using the Healthcare Cost and Utilization Project national database, the authors evaluated over 4 million pregnancy-related discharges, looking at the prevalence and outcomes of pregnancy-associated spontaneous cor...

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  • A Case for Palliative PCI
    Sarah R Blake

    Dear Editor

    On reading the review on coronary revascularisation in the elderly by Cockburn et al (1) I must agree that more trials are needed to focus on the benefit of PCI in elderly populations.

    When assessing these patients, clinicians should consider the impact of symptom relief versus procedural risk. If a patient is experiencing recurrent and debilitating chest pain requiring frequent hospital a...

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