138 e-Letters

published between 2014 and 2017

  • Chocolate intake and risk of atrial fibrillation

    Chocolate intake and risk of atrial fibrillation

    Dear Editor,

    We have read with great interest the paper “Chocolate intake and risk of clinically apparent atrial
    fibrillation: the Danish Diet, Cancer, and Health Study” by Elizabeth Mostofsky and coworkers [1] and we found their conclusion of importance with a view to clinical prevention.

    With reference to the findings reported in the paper, we would like to make the following contribution to the discussion. In a recent analysis performed on 650 healthy women in pre-menopausal age (age range 45-54 years) chocolate intake was higher in women in the low quartile of adherence to Mediterranean Diet (low Med Score). This subgroup of women showed a lower ABI index compared to women with higher Med Score. The analysis of sources of antioxidants showed a greater intake from fruit and vegetables in the higher quartiles of Med Score. Coffee and tea were similarly distributed among the quartiles of Med Score [2]. Analysis from diet recall had the major limitation of missing data regarding out-of-mealtime snacking and drinking.
    In Mediterranean countries, wine is a strong antioxidant source and the synergistic effect of drinking wine during meals and antioxidant bioavailability is well known. We clearly understand that nutritional habits in Northern Europe differ from Mediterranean ones. However, we would like to underline that in a Mediterranean lifestyle characterized by high intake of antioxidants,...

    Show More
  • Machine learning to predict death after cardiac surgery in patients with infective endacarditis: Why not! But, where are the (big) data please?

    The study of Olmos et al., on prediction of in-hospital mortality in patients with active infective endocarditis undergoing cardiac surgery, is of great interest.1
    Indeed, this topic is fascinating because it is complicated to make a choice in so dramatic and not so rare situation.
    To help with this decision-making, the authors proposed a model for predicting hospital mortality: a classic multivariate logistic regression model.
    However, the editorial published with this article evokes in the title a new method: machine learning.2 Machine learning, which is a field of artificial intelligence, has already been used for predicting hospital mortality after elective cardiac surgery.3 This study aimed at comparing a machine learning model, a classic logistic regression model and EuroSCORE II on a cohort including 6,520 patients. The comparison of these models was based on ROC curves and decision curve analysis (DCA).4 Whatever the method of comparison, machine learning model was more accurate than other models.
    Our experience in this area probably allows us to make some comments on this editorial. Considering, the increase of studies comparing machine learning with logistic regression, it is now known that supervised machine learning algorithms improve the prediction of post-operative mortality. However, the size of the cohort used in the present study makes it difficult to apply machine learning algorithms. Indeed, this cohort comprised 671 patients who...

    Show More
  • Liver injury with direct-acting anticoagulants: has the fog cleared?

    To the Editor,
    The timely retrospective US cohort study by Alonso et al.1 assessed the risk of hospitalisations for liver injury after initiation of oral anticoagulation in patients with non-valvular atrial fibrillation, an unresolved safety issue so far.
    This study has key merits. First, it demonstrates the importance of conducting analytical research following safety signals emerging from spontaneous reporting systems2, to confirm or refute the drug-related hypothesis; this allows actual risk assessment and avoids unnecessary alarm, sometimes generated by pharmacovigilance analyses which do not recognize the limits of detected signals.
    Second, it provides a significant contribution to the debate on targeted patients’ selection when prescribing DOACs. In fact, the authors found that hospitalization rates for liver injury were lower among DOAC initiators as compared to patients starting warfarin, with rivaroxaban and dabigatran associated with highest and lowest risk, respectively. They conclude that “dabigatran may be considered a safer option” in patients susceptible of liver complications. In this vulnerable population, our proposal when initiating DOAC administration is to early monitor hepatic enzymes (i.e., within the first month of therapy) and, subsequently, on a yearly basis, especially for rivaroxaban users.3
    Although this study contributes to allay concern on the hepatotoxicity potential of DOACs, a residual aspect deserves attention. The...

    Show More
  • Drowning in a 48-year-old man


    We congratulate McDowell et al. on their educational and interesting case report.1 However, we would like to comment on their use of the term ‘near-drowning’. This, and other confusing and older terms which caused inconsistencies in the literature, have been abandoned by organisations such as the International Liaison Committee on Resuscitation (ILCOR) and the World Health Organisation (WHO) who recommend a more structured and clearer way of reporting drowning incidents.2,3 For several years now, drowning has been defined as ‘a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident’. 2,3 We would thus recommend that the authors and readers of your journal follow ILCOR and WHO recommendations, and simply use the term ‘drowning’ irrespective of the patient outcome. While this may seem pedantic, we do believe that it will assist with standardisation in drowning research and literature.


    1. McDowell K, Carrick D, Weir R. Heart Published Online First: 18 may 2017. doi:10.1136/heartjnl-2016-311043.
    2. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe...

    Show More
  • The true value of the NICE guidance

    We read with interest the Editorial on the recently updated National Institute for Health and Care Excellence (NICE) guidance for the assessment of suspected stable angina (1). The authors raise some salient points regarding the importance of careful history taking, the vexed question of the exercise ECG and the relative merits of the myriad non-invasive tests for diagnosing coronary artery disease (CAD). However, we believe they have adopted an unnecessarily alarmist tone in their criticisms and feel obliged to respond to several issues.
    Although they suggest that the assessment of pretest probability (PTP) has been disregarded, this process has merely been made implicit rather than explicit. The guidelines emphasise the pivotal importance of the clinical history and, in the setting of suspected angina, the nature of the presenting symptoms is the dominant predictor of CAD. Existing risk tables (2) show that either typical or atypical angina essentially guarantees a PTP of CAD ≥ 10%, the threshold warranting further investigation in the earlier NICE guideline. The residual clinical risk seen in patients with non-anginal symptoms is best addressed through cardiovascular screening approaches with an emphasis of lifestyle modification and primary prevention.
    Second, in arguing against the cost-effectiveness of the new approach, the authors imply that NICE are recommending “universal CTCA” which is incorrect. Non-anginal chest pain occurs in 40-60% of patients pre...

    Show More
  • Presenting the results of a pharmacoeconomic study: incremental cost-effectiveness ratio vs net monetary benefit

    The article by Wouters and colleagues (1) presents an exhaustive overview on how QALYs can be used in cost-effectiveness analysis. In this framework, the authors also mention the incremental cost-effectiveness ratio (ICER), which is the parameter typically employed to express the results of a cost-effectiveness study. The article, however, does not discuss the net monetary benefit (NMB), which is another parameter employed to express the results of a cost-effectiveness study.

    The incremental cost (deltaC) and the incremental effectiveness (deltaE) are the two main parameters of pharmacoeconomics and cost-effectiveness analysis, along with the willingness-to-pay threshold (lambda). The decision rule (e.g. in the case of a favourable pharmacoeconomic result) is (deltaC/deltaE)<lambda (Equation 1), if based on the ICER, or (deltaE x lambda - deltaC) > 0 (Equation 2), if based on the NMB. Likewise, an unfavourable pharmacoeconomic result is when (deltaC/deltaE)>lambda or when (deltaE x lambda - deltaC) < 0; NMB is defined as deltaE x lambda - deltaC, while ICER is defined as deltaC/deltaE.

    Despite its apparent complexity, most part of pharmacoeconomic methodology is described by the two simple equations reported above (i.e. Equations 1 and 2), but whether the ICER or the NMB is the best parameter for the purposes of pharmacoeconomic decision-making remains on open question.

    The study by Cowper et al evaluating new versus old oral antic...

    Show More
  • Moderate Sedation in Cardiac Electrophysiology Laboratory: a retrospective safety analysis

    Sawhney et al. reported that nurse-led, physician-directed moderate sedation during cardiac electrophysiology procedures is safe (1). All of the patients undergoing cardiac electrophysiological (EP) procedures and cardiac implantable electronic device (CIED) implantation during the last 12 years were moderately sedated. Since this study is a retrospective study, we could not comprehend why all patients were sedated despite the fact that routine sedation during all cardiac EP procedures and all CIED implantation is not recommended.
    Moreover, as mentioned in the article, sedation is a continuum and it is not always possible to predict how individual patients will respond. Therefore, a gradual increase of doses of the sedatives during sedation may be needed which may possibly increase the procedure duration. Did authors ascertain any prolongation of the procedures due to sedative administration?
    Furthermore, sedation may diminish arrythmia induction during EP procedures, particularly in patients with catecholamine-sensitive ventricular tachycardias (2). Did authors have any data questioning this issue?
    As a conclusion, the aim of sedation is to diminish the anxiety and to relieve the pain during the procedure. Therefore, using moderate sedation selectively in patients with anxiety or hyperalgesia may be more practical and rational rather than its routine use due to the fact that as mentioned in the article, researches and audit demonstrate continued avoidabl...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More