This is invaluable work in a very complex clinical situation. The
scenario of increasing shortness of breath and chest tightness is a common
occurance in people with chronic obstructive pulmonary disorder. This
usually leads to a clinical suspicion of a cardiac event and in quite a
few cases the tropnin levels are done and found to be high. The correct
interpretation in these cases is of paramount significance as manageme...
This is invaluable work in a very complex clinical situation. The
scenario of increasing shortness of breath and chest tightness is a common
occurance in people with chronic obstructive pulmonary disorder. This
usually leads to a clinical suspicion of a cardiac event and in quite a
few cases the tropnin levels are done and found to be high. The correct
interpretation in these cases is of paramount significance as management
can be quite challenging. Also a wrong presumption of acute coronary
syndrome will lead to unnecessary investigations. Furthermore management
options can be limited because of the respiratory condition. This study
highlights the importance of good clinical assessment in these cases
rather than using the troponin assay as a base for diagnosis.
It seems that every time COURAGE is discussed, its shortcomings fade
further into the little-mentioned background. It is vital to recognise
the marked limitations of the study before suggesting, as the editorial
appears to do, that we use it as a benchmark for our management decsion
making in stable angina.
1) the recruitment in the study was only 2287 out of 35539 screened:
astonishingly low, s...
It seems that every time COURAGE is discussed, its shortcomings fade
further into the little-mentioned background. It is vital to recognise
the marked limitations of the study before suggesting, as the editorial
appears to do, that we use it as a benchmark for our management decsion
making in stable angina.
1) the recruitment in the study was only 2287 out of 35539 screened:
astonishingly low, suggesting (as do the reasons for non recruitment
including over 6500 for "logistic" reasons) that this was a a very highly
selected and polished-up group, and may well have been unrepresentative
if many of these exclusions were for patient or cardiologist preference.
2) All the patients had angiography which allowed major anatomical
risk disease (eg left main stem disease) to be excluded: extolling optimal
medical treatment as first line on the basis of COURAGE in the UK is
likely to delay referral for angiography whilst OMT is tried in general
practice settings: this is certainly not supported by COURAGE data.
3) many of the patients in COURAGE were virtually asymptomatic: 42%
were in class 0 or 1: yet all these got angiography: these patients
rarely even get hospital referral in the UK, and their risk of events is
low enough to make any benefit very unlikely in a trial of only 2287
patients over 5 years or so
4) of the patients in the angioplasty group, 8% had either balloon-
only angioplasty or no lesions could be crossed at all; 975 patinets had
bare metal stents and only 31 patients (approx 2%) had drug-eluting
stents.
5) approx 1/3rd of patients in the medical group 'crossed over' to
intervention: of course the outcome data rightly includes these in the
medical group under the intention to treat principle, but the trial is
clearly not actually comparing outcome of PCI against OMT
So in essence the only acceptable conclusion from COURAGE is that:
In a very highly selected group of patients, many with minimal or
negligible symptoms, it appeared to be reasonable to delay older-style
revascularisation with balloon angioplasty or bare metal stents for a
short while, providing all patients had angiography and there were
facilities for rapid cross-over to intervention.
I don't believe this is adequete informaton to change practice,
particularly that of ischaemia guided PCI.
Mark Signy
Conflict of Interest:
Perform PCI
Have personally had a PCI for stable angina
I read with interest the recent paper by Kim and co-authors on "Mild-
to-moderate functional tricuspid regurgitation (TR) in patients undergoing
valve replacement for rheumatic mitral valve (MV) disease".1 The authors,
reporting on 236 patients divided into two groups, concluded that compared
with MV replacement alone, concomitant TV repair was associated with
better postoperative TV function that ma...
I read with interest the recent paper by Kim and co-authors on "Mild-
to-moderate functional tricuspid regurgitation (TR) in patients undergoing
valve replacement for rheumatic mitral valve (MV) disease".1 The authors,
reporting on 236 patients divided into two groups, concluded that compared
with MV replacement alone, concomitant TV repair was associated with
better postoperative TV function that may help to improve long-term
clinical outcomes. The authors should be congratulated on their work,
which added more insight into the treatment of this pathology.
However, a point should be underlined: In patients with rheumatic MV
disease, TV regurgitation is not always only functional. It is true that
in patients with rheumatic MV disease, tricuspid involvement is usually
secondary to pulmonary hypertension and right ventricular volume overload,
however, TV may be directly involved in the rheumatic inflammatory process
in up to 8% of cases.2,3 Nonetheless, a recent imaging study aiming to
analyze the prevalence of TV involvement in rheumatic heart disease
reported 18.3% with organic TV disease.4 Three-dimensional
echocardiography has been proposed to better study the TV morphology,
since with this methodology all three leaflets are simultaneously
visualized and seen from both atrial and ventricular aspects.3 However, I
did not find in Kim's study population any patient with definite organic
TV disease from rheumatic endocarditis. Cardiovascular practice in western
countries has changed over the years, reflecting the decreased incidence
of acute rheumatic fever (RF). However, in countries that still have a
high incidence of RF, it is not unusual to see during surgery Aschoff's
nodules on the TV. Rheumatic TV inflammation causes scarring and fibrosis
with retraction of valve leaflets and/or fusion of its commissures. An
organic rheumatic TV involvement would result in organic valve
regurgitation and/or stenosis. Nevertheless, annular TV dilatation may
also coexist with organic disease. Functional TV regurgitation due to
annular dilatation from right ventricular volume overload is usually
treated by annular reduction or valve bicuspidalization. Instead,
rheumatic leaflet involvement may require more challenging surgical
reparative procedures whose uncertain results are probably underreported
in the literature. TV organic involvement at the time of surgery would
influence short and long term results. In 2008, Bernal et al, reporting on
328 consecutive patients that underwent TV valve surgery for rheumatic
disease, concluded that "organic tricuspid valve disease associated with
rheumatic mitral or aortic lesions increases hospital and late
mortality."5 In addition, in a recent work Naqshband et al analyzed their
follow-up results of TV repair and reported that deterioration in
regurgitation grade occurred only in those patients having some organic
involvement of TV.6 In conclusion, preoperative imaging studies aiming to
carefully visualize TV leaflets, together with intraoperative data on TV
leaflet morphology from institutions dealing with a high volume of
rheumatic heart valve disease would in the future help to provide more
insight into the treatment of this condition.
References
1. Kim JB, Yoo DG, Kim GS, et al. Mild-to-moderate functional
tricuspid regurgitation in patients undergoing valve replacement for
rheumatic mitral disease: the influence of tricuspid valve repair on
clinical and echocardiographic outcomes. Heart. 2012;98(1):24-30
2. Hauck AJ, Freeman DP, Ackermann DM, et al. Surgical pathology of
the tricuspid valve: a study of 363 cases spanning 25 years. Mayo Clin
Proc. 1988;63(9):851-63.
3. Anwar AM, Geleijnse ML, Soliman OI, et al. Evaluation of rheumatic
tricuspid valve stenosis by real-time three-dimensional echocardiography.
Heart. 2007;93(3):363-4
4. Arora R, Sattur A, Ambar S, et al. Prevalence of tricuspid valve
disease in rheumatic heart disease. J Am Coll Cardiol. 2012;59(13s1):E1263
-E1263. doi:10.1016/S0735-1097(12)61264-9
5. Bernal JM, Pont?n A, Diaz B, et al. Surgery for rheumatic
tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg.
2008;136(2):476-81
6. Naqshband MS, Abid AR, Akhtar RP, et al. Functional tricuspid
regurgitation in rheumatic heart disease: surgical options. Ann Thorac
Cardiovasc Surg. 2010;16(6):417-25
I was intrigued to read the editorial of Calum MacRae,1 where he
leads with the provocative statement that "The sinoatrial node,
atrioventricular (AV) node and proximal His-Purkinje system can each be
seen with the naked eye in humans". I am sure that cardiac surgeons
worldwide will be delighted at this news. It is, therefore, unfortunate
that MacRae does not share with us the means of achieving the
v...
I was intrigued to read the editorial of Calum MacRae,1 where he
leads with the provocative statement that "The sinoatrial node,
atrioventricular (AV) node and proximal His-Purkinje system can each be
seen with the naked eye in humans". I am sure that cardiac surgeons
worldwide will be delighted at this news. It is, therefore, unfortunate
that MacRae does not share with us the means of achieving the
visualisation of these crucial structures. I have spent most of my career
seeking to establish landmarks to help in determining their location, but
never have I been fortunate enough, with certainty, to see them with "the
naked eye". It is the case that, with the eye of faith, it is possible to
discern the likely site of the sinus node, but the atrioventricular node
is buried within the floor of the triangle of Koch, while the proximal His
-Purkinje system is insulated within the central fibrous body. Would it
not be appropriate if MacRae shared with all your readers the technique he
used in observing these entities with his "naked eye"?
References
1. MacRae CA. Pattern recognition: combining informatics and genetics to
re-evaluate conduction disease. Heart 2012;98:1263-1264
We read with great interest the article titled "Contemporary clot
busting in ST-elevation myocardial infarction: beware of the embolus"(1).
Since the publication of the TAPAS trial(2) in 2008 thrombus aspiration
has become a useful part of the paradigm for treatment of ST elevation
myocardial infarction. As demonstrated in the report by Rawlins et al
great care needs to be taken during the use of any a...
We read with great interest the article titled "Contemporary clot
busting in ST-elevation myocardial infarction: beware of the embolus"(1).
Since the publication of the TAPAS trial(2) in 2008 thrombus aspiration
has become a useful part of the paradigm for treatment of ST elevation
myocardial infarction. As demonstrated in the report by Rawlins et al
great care needs to be taken during the use of any aspiration catheter.
By its very nature this device is removing thrombus from a vascular bed
and exposing the rest of the circulation to the risk of embolization.
Aspiration devices themselves have a relatively small internal lumen
diameter and the risk of occlusive thrombus from large occluded coronary
arteries is potentially understated.
The journal has demonstrated occlusion of the aspiration catheter
preventing flow back into the aspiration syringe. We have also seen an
occurrence of occlusion of the guide catheter itself during thrombus
aspiration from a right coronary artery. As stated by Rawlins et al lack
of flow into the aspiration syringe should raise suspicion of an occluded
aspiration catheter, but of equal importance is the monitoring of the
guiding catheter pressure trace. If the guide catheter becomes damped
during aspiration then the possibility of thrombus in the catheter should
be considered. It is vitally important to maintain suction on the
aspiration catheter while it is withdrawn, and should the guide catheter
become damped, this too should be withdrawn from the circulation whilst
applying negative pressure.
Large thrombotic burdens potentially may be better treated by the use
of the angiojet device(3) with the potential to break up the thrombus in
situ.
References
1. Rawlins J, Shah N, O'Kane P. Contemporary clot busting in ST-elevation myocardial infarction: beware of the embolus. Heart 2012;98(16):1259-60.
2. Svilaas T, Vlaar PJ, van der Horst IC, et al.
Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358(6):557-67.
3. Migliorini A, Stabile A, Rodriguez AE, et al.
Comparison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. J Am Coll Cardiol 2010;56(16):1298-306.
"Time to act"1 - a message which resonates with the
team on our metropolitan Delivery Suite, who this week managed an acute
myocardial infarction in a postnatal lady. Our patient has two of the risk
factors mentioned in the editorial, her being 36 years old and a smoker.
In addition she had an important risk factor which can be missed, as
demonstrated by our recent experience. Since most women with acu...
"Time to act"1 - a message which resonates with the
team on our metropolitan Delivery Suite, who this week managed an acute
myocardial infarction in a postnatal lady. Our patient has two of the risk
factors mentioned in the editorial, her being 36 years old and a smoker.
In addition she had an important risk factor which can be missed, as
demonstrated by our recent experience. Since most women with acute
coronary syndrome (ACS) in pregnancy and the puerperium have no symptoms
before pregnancy2, risk factor stratification is important.
Our patient, who has a history of heroin addiction and was on
methadone, arrived by ambulance in preterm labour (35+ weeks gestation)
and bleeding per vaginam. She had an uncomplicated vaginal delivery of a
growth restricted baby soon after arrival. The total intrapartum blood
loss was 540 millilitres.
One hour after delivery the patient was noted to be profoundly
hypotensive with bradycardia. There was no evidence of vaginal bleeding.
Physical examination was unremarkable and the hypotension responded to
fluid resuscitation. An electrocardiogram (ECG) showed ST elevation on the
inferior leads. A diagnosis of acute myocardial infarction was made. She
was stabilised with morphine, aspirin and nitrates and was transferred for
Primary Percutaneous Coronary Intervention. Angiography revealed gross
spasm of the Right Coronary Artery and a 50-60% occlusion thereof. After
stenting, the ECG changes normalised. She made a good recovery within 24
hours.
Urine toxicology subsequently revealed recent abuse with cocaine and
other illicit substances.
Substance misuse amongst women of childbearing age is increasing3.
The United States National Survey on Drug Use and Health 2005 estimates a
4% prevalence of illicit drug use in pregnant women4. Research into the
effects of the various drugs of abuse on the physiology of pregnancy and
on the myocardium is ongoing. Coronary spasm is a recognised adverse
effect of cocaine. Accelerated atherosclerosis can be attributed in part
to the smoking of tobacco and drugs.
We feel that there should be a high index of suspicion for ACS in
patients with a history of substance misuse, even if they are on a
supervised treatment programme. Women with a history of substance misuse
are a high-risk group, and the antenatal period offers a precious
opportunity to screen for cardiovascular disease and current drug use,
when these women might be more likely to engage. Patients on methadone are
managed as part of a multidisciplinary team, providing scope for
cardiovascular risk assessment and preconception counseling as part of
this process.
References
1. Nelson-Piercy C, Adamson D, Knight M. Acute coronary Syndrome in
pregnancy: time to act. Heart 2012 ;98:760-761
2. Royal College of Obstetricians and Gynaecologists (RCOG). Cardiac
Disease in Pregnancy (Good Practice No. 13) (2011)
http://www.rcog.org.uk/files/rcog-
corp/GoodPractice13CardiacDiseaseandPregnancy.pdf (accessed 29 May 2012)
3. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers' Lives:
Reviewing maternal deaths to make motherhood safer: 2006-2008. The eighth
report of Confidential Enquiries into Maternal Deaths in the United
Kingdom. BJOG 2011;118(suppl 1):1-203
4. US Dept Health Human Services, Substance Abuse and Mental Health
Services Administration, Office of Applied Studies. Results from the 2005
National Survey on Drug Use and Health: National Findings. Rock-ville, Md:
US Dept Health Human Services;
2006.http://www.oas.samhsa.gov/nsduh/2k5nsduh/2k5Results.pdf (accessed 31
May 2012)
Recently, our article entitled 'Effect of smoke-free legislation on
the incidence of sudden circulatory arrest in the Netherlands' was
published in Heart, in which we investigated sudden circulatory arrest
(SCA) incidence trends before and after introduction of smoke-free
legislation (1). We found a significant decrease in incidence trend after
introduction of a nationwide workplace smoking ban....
Recently, our article entitled 'Effect of smoke-free legislation on
the incidence of sudden circulatory arrest in the Netherlands' was
published in Heart, in which we investigated sudden circulatory arrest
(SCA) incidence trends before and after introduction of smoke-free
legislation (1). We found a significant decrease in incidence trend after
introduction of a nationwide workplace smoking ban.
Because (changes in) trends are difficult to interpret, we
illustrated our study results by estimating the absolute reduction of SCA
cases after 1 year of smoke-free legislation in our study population
(inhabitants of South Limburg between 20 and 75 years of age). In the
discussion section of our article we additionally extrapolated our
regional findings to the Netherlands as a whole and over a longer period
of time. Although this was only a minor issue in the paper, we feel that
we have not adequately addressed the assumptions underlying this
extrapolation. With this response we would like to put things into
perspective.
First, the South Limburg population may not be representative for the
whole Dutch population. Second, we erroneously extrapolated to the entire
Dutch population, while we should have taken into account only Dutch
citizens between 20 and 75 years of age. This would have led to a lower
estimate of prevented SCA cases. Third, calculating the absolute reduction
of SCA cases over a longer period (4.5 years; the period between
introduction of the first (2004) and second (2008) smoking ban) may have
resulted in a less precise estimate. For these reasons, the extrapolation
should be interpreted with caution. We hope to have clarified this matter
sufficiently with this response.
On behalf of all co-authors,
Dianne de Korte-de Boer
Maastricht University, the Netherlands
Reference
1. De Korte-de Boer D, Kotz D, Viechtbauer W, et al. Effect of smoke-free
legislation on the incidence of sudden circulatory arrest in the
Netherlands. Heart 2012;98:995-9.
I was impressed to read the results of Mulders et al. (1), who provided evidence that first-degree relatives of patients with premature coronary artery disease had increased arterial stiffness (measured by pulse-wave velocity) in the absence of coronary artery disease. The authors also found a relation between arterial stiffness and coronary artery calcification.
As a physician, I wonder about ways to prevent the devel...
I was impressed to read the results of Mulders et al. (1), who provided evidence that first-degree relatives of patients with premature coronary artery disease had increased arterial stiffness (measured by pulse-wave velocity) in the absence of coronary artery disease. The authors also found a relation between arterial stiffness and coronary artery calcification.
As a physician, I wonder about ways to prevent the development of coronary artery disease in these individuals who seem to have this disposition. I found it interesting that patients with premature coronary artery disease had elevated triglyceride levels at baseline measurements. These results match well with recent findings by De Caterina et al. (2) on the APOA5-1131T>C gene variant and its association with premature coronary artery disease. According to these results, the APOA5-1131C allele is not only associated with higher triglyceride levels, but also with the risk of premature coronary artery disease when adjusting for the influence of elevated triglyceride levels (2).
Another study that can be linked well to the results of Mulders et al. (1) is recent evidence on aortic relaxation (3), which is the opposite of arterial stiffness. It has just been shown experimentally by Liu et al. (3) that the use of fibrates causes aortic relaxation and goes along with decreased intracellular calcium levels in cultured vascular smooth muscle cells, suggesting an anti-atherosclerotic effect. Fibrates have also been known for their reduction in low density lipoprotein and triglyceride levels.
Combining the findings of Mulders et al. (1) with the results of the two recent studies (2)-(3) might have a clinical application in terms of preventing arterial stiffness and atherosclerosis in people with a disposition to develop coronary artery disease. In the future, it would probably be necessary to confirm the link between the APOA5-1131C allele (and possible other alleles) and the emergence of atherosclerosis in carriers of the alleles, and to transfer the experimental evidence on aortic relaxation (3) to clinical studies. Given that fibrate drugs can cause a number of adverse side reactions, I would still find it difficult to prescribe them to (healthy) individuals who seem to have a disposition to develop arterial stiffness, as it is not certain that they will actually develop coronary artery disease. In addition, the APOA5-1131C allele also increased the risk of coronary artery disease independent of triglyceride levels (2), so factors other than elevated triglyceride levels also seem to play a role. In any case, more research is needed to offer individuals at risk a good estimate what they can do to prevent coronary artery disease.
1. Mulders TA, van den Bogaard B, Bakker A et al. Arterial stiffness is increased in families with premature coronary artery disease. Heart 2012;98:490-4.
2. De Caterina R, Talmud PJ, Merlini PA, et al. Strong association of the APOA5-1131T>C gene variant and early-onset acute myocardial infarction. Atherosclerosis 2011;214:397-403.
3. Liu A, Yang J, Huang X, et al. Relaxation of rat thoracic aorta by fibrate drugs correlates with their potency to disturb intracellular calcium of VSMCs. Vascul Pharmacol 2012; Epub ahead of print Jan 21.
We are writing in regards to the paper entitled "Quantitative
myocardial perfusion analysis using multi-row detector CT in acute
myocardial infarction" that is recently published in the April 2012 issue
of Heart. We would like to congratulate the authors for a very interesting
study that has used all the advanced techniques available in the GE
Healthcare CT Perfusion research version software. We a...
We are writing in regards to the paper entitled "Quantitative
myocardial perfusion analysis using multi-row detector CT in acute
myocardial infarction" that is recently published in the April 2012 issue
of Heart. We would like to congratulate the authors for a very interesting
study that has used all the advanced techniques available in the GE
Healthcare CT Perfusion research version software. We are the core
laboratory that develop and validate the techniques in that version of the
software and are very pleased that they are being used successfully in
their work. Instead of references #13-16 in their paper, the correct
references that detail our work implemented in the software are as
follows:
1. So A et al. Beam hardening correction in CT myocardial perfusion
measurement. Phys Med Biol 2009;54(10):3031-3050
2. So A et al. Quantitative myocardial perfusion measurement using CT
Perfusion: a validation study in a porcine model of reperfused acute
myocardial infarction. Int J Cardiovasc Imaging. Epub 2011 Jul 29
3. So A et al. Non-invasive assessment of functionally relevant
coronary artery stenoses with quantitative CT perfusion: preliminary
clinical experiences. Eur Radiol 2012;22(10):39-50 Epub 2011 Sep 21
In particular, the beam hardening correction method in the CT
Perfusion research version software is based on our work previously
published in 2009 (see #1 above) rather than the work of Kitagawa et al as
referenced in the paper.
We hope this clarification would prevent confusion in the mind of
readers who read the paper and are stimulated to pursue quantitative
myocardial perfusion research.
Best regards,
Aaron So, PhD,
Associated Scientist,
Lawson Health Research Institute,
London, Ontario, Canada
Ting-Yim Lee, PhD, FCCPM,
CIHR-GE Healthcare Chair in Functional Imaging;
Director, PET/CT Research,
Lawson Health Research Institute;
Scientist, Robarts Research Institute;
Professor, Medical Biophysics, Oncology,
Medical Imaging, Western University,
London, Ontario, Canada
Conflict of Interest:
T.-Y. Lee has a CT Perfusion software licensing agreement with GE Healthcare, and receives research grant support from GE Healthcare, Astra Zeneca and Celgene. A. So has no disclosure.
The potential cost-effectiveness (CE) of adopting innovative
procedures within a publically funded healthcare system is a recurring
issue.[1] Trans-catheter aortic valve insertion (TAVI) is not currently
provided by the devolved National Health Service (NHS) in Scotland,
although a single high quality randomised controlled clinical trial (RCT)
has demonstrated that TAVI is a clinically effective intervention for
reducin...
The potential cost-effectiveness (CE) of adopting innovative
procedures within a publically funded healthcare system is a recurring
issue.[1] Trans-catheter aortic valve insertion (TAVI) is not currently
provided by the devolved National Health Service (NHS) in Scotland,
although a single high quality randomised controlled clinical trial (RCT)
has demonstrated that TAVI is a clinically effective intervention for
reducing the risk of death in older patients with severe aortic stenosis
considered unfit for standard surgery.[2] The recently published CE
analysis of TAVI reports an incremental CE ratio (ICER) of 16,000 [pounds
sterling] per quality adjusted life year (QALY) gained, which falls below
the ICER thresholds applied by the National Institute for Health and
Clinical Excellence (NICE) in the UK.[1]
The science-consultancy company 'Oxford Outcomes' constructed their
CE model based on New York Heart Association (NYHA) category data obtained
in the original RCT.[2] This involved adopting a rather convoluted
approach of indirectly estimating EQ-5D (EuroQol) values ('utilities')
based on data concerning the relationship between NHYA categories and EQ-
5D in patients with heart failure, and on UK population norms that are now
almost 20 years old.[1] Given that individual patients in the original RCT
had their EQ-5D values measured directly (at baseline, one, six and 12
months) it is not clear why 'Medtronic' (the TAVI-device manufacturer who
funded both the original RCT and the CE analysis) did not release the ED-
5D data to 'Oxford Outcomes'. Other important clinical values are derived
from a 'literature review' and estimates made by a 'clinical steering
group'. Unfortunately making an informed judgement about the validity of
these values is difficult as the literature search strategy is not
described and membership of the 'steering group' is not reported.
Historically the assessment of CE in the cardiovascular arena has
predominantly related to drug therapies, but the approach is now
increasingly being applied to cardiovascular devices.[3] Unfortunately CE
studies, with their heavy reliance on statistical modelling based on
multiple assumptions, have a poor track record of providing unbiased
information for healthcare decision making. In a previous systematic
review of almost 500 CE studies, industry-sponsored studies were 2-3 times
more likely to report favourable results compared to non-industry funded
analyses.[4] This may be because the biomedical industry regards the
undertaking and reporting of CE analyses as a marketing tool, rather than
as an independent scientific endeavour.[3] Consequently clinicians and
policy-makers need to be both cautious and critical in assessing this type
of study. In our opinion a further replication of these CE findings are
required using the EQ-5D data from the original trial.
[1] Watt M, Mealing S, Eaton J, et al. Cost-effectiveness of
transcatheter aortic valve replacement in patients ineligible for
conventional aortic valve replacement. Heart 2012;98:370-6.
[2] Leon MB, Smith CR, Mack M, et al. PARTNER Trial Investigators.
Transcatheter aortic-valve implantation for aortic stenosis in patients
who cannot undergo surgery. N Engl J Med 2010;363:1597-607.
[3] Tarricone R, Drummond M. Challenges in the clinical and economic
evaluation of medical devices: the case of transcatheter aortic valve
implantation. J Med Marketing 2011;11:221-229.
[4] Bell CM, Urbach DR, Ray JG, Bayoumi A, Rosen AB, Greenberg D,
Neumann PJ. Bias in published cost effectiveness studies: systematic
review. BMJ 2006;332:699-703.
This is invaluable work in a very complex clinical situation. The scenario of increasing shortness of breath and chest tightness is a common occurance in people with chronic obstructive pulmonary disorder. This usually leads to a clinical suspicion of a cardiac event and in quite a few cases the tropnin levels are done and found to be high. The correct interpretation in these cases is of paramount significance as manageme...
Sir
It seems that every time COURAGE is discussed, its shortcomings fade further into the little-mentioned background. It is vital to recognise the marked limitations of the study before suggesting, as the editorial appears to do, that we use it as a benchmark for our management decsion making in stable angina.
1) the recruitment in the study was only 2287 out of 35539 screened: astonishingly low, s...
Dear Editor,
I read with interest the recent paper by Kim and co-authors on "Mild- to-moderate functional tricuspid regurgitation (TR) in patients undergoing valve replacement for rheumatic mitral valve (MV) disease".1 The authors, reporting on 236 patients divided into two groups, concluded that compared with MV replacement alone, concomitant TV repair was associated with better postoperative TV function that ma...
Dear Editor,
I was intrigued to read the editorial of Calum MacRae,1 where he leads with the provocative statement that "The sinoatrial node, atrioventricular (AV) node and proximal His-Purkinje system can each be seen with the naked eye in humans". I am sure that cardiac surgeons worldwide will be delighted at this news. It is, therefore, unfortunate that MacRae does not share with us the means of achieving the v...
Dear Editor,
We read with great interest the article titled "Contemporary clot busting in ST-elevation myocardial infarction: beware of the embolus"(1). Since the publication of the TAPAS trial(2) in 2008 thrombus aspiration has become a useful part of the paradigm for treatment of ST elevation myocardial infarction. As demonstrated in the report by Rawlins et al great care needs to be taken during the use of any a...
Dear Editor
"Time to act"1 - a message which resonates with the team on our metropolitan Delivery Suite, who this week managed an acute myocardial infarction in a postnatal lady. Our patient has two of the risk factors mentioned in the editorial, her being 36 years old and a smoker. In addition she had an important risk factor which can be missed, as demonstrated by our recent experience. Since most women with acu...
Dear editor,
Recently, our article entitled 'Effect of smoke-free legislation on the incidence of sudden circulatory arrest in the Netherlands' was published in Heart, in which we investigated sudden circulatory arrest (SCA) incidence trends before and after introduction of smoke-free legislation (1). We found a significant decrease in incidence trend after introduction of a nationwide workplace smoking ban....
I was impressed to read the results of Mulders et al. (1), who provided evidence that first-degree relatives of patients with premature coronary artery disease had increased arterial stiffness (measured by pulse-wave velocity) in the absence of coronary artery disease. The authors also found a relation between arterial stiffness and coronary artery calcification.
As a physician, I wonder about ways to prevent the devel...
Dear Editors:
We are writing in regards to the paper entitled "Quantitative myocardial perfusion analysis using multi-row detector CT in acute myocardial infarction" that is recently published in the April 2012 issue of Heart. We would like to congratulate the authors for a very interesting study that has used all the advanced techniques available in the GE Healthcare CT Perfusion research version software. We a...
The potential cost-effectiveness (CE) of adopting innovative procedures within a publically funded healthcare system is a recurring issue.[1] Trans-catheter aortic valve insertion (TAVI) is not currently provided by the devolved National Health Service (NHS) in Scotland, although a single high quality randomised controlled clinical trial (RCT) has demonstrated that TAVI is a clinically effective intervention for reducin...
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