To the editor:
I read with great interest the report by Dr. Todiere and colleagues1)
discussed the right ventricular hypertrophy in patients with systemic
hypertension. Although they reported that there was no difference in
systolic pulmonary artery pressure between hypertensive patients with and
without left ventricular hypertrophy, Lam and colleagues2) previously
reported the age-associated elevation of pulmonary arter...
To the editor:
I read with great interest the report by Dr. Todiere and colleagues1)
discussed the right ventricular hypertrophy in patients with systemic
hypertension. Although they reported that there was no difference in
systolic pulmonary artery pressure between hypertensive patients with and
without left ventricular hypertrophy, Lam and colleagues2) previously
reported the age-associated elevation of pulmonary artery systolic
pressure, which was related to increasing systemic vascular stiffening, in
the general population. Thus, I want to know the difference of the
pulmonary artery pressure between hypertensive patients and controls.
Moreover, Lam and colleagues reported that one of the independent
predictors of pulmonary artery systolic pressure was the ratio of early
transmitral flow velocity to early mitral annular (medial) tissue
velocity, which had been shown to reliably detect the elevated left
ventricular diastolic pressure. Thus, the data concerning the relationship
between systolic pulmonary artery pressure and the peak filling rate index
of left ventricle could also attract the interest of readers.
These two reports prove that the elevation of systemic blood
pressure, which is inevitable with aging, results in the increase of load
to right heart system. The hypertension induces the left ventricular
hypertrophy, and the left ventricular morphological and functional changes
cause the right ventricular hypertrophy. Without right ventricle, the
systemic hypertension will directly elevate the central venous pressure,
and induce congestion of the systemic venous system. Thus, the elevation
of systemic blood pressure could be one of the most serious problems for
the patients after Fontan type operation, because they don't have right
ventricle. In order to hold the damage due to hypertension to a minimum in
patients after Fontan type operation, we must educate them about the
prevention of hypertension and cardiovascular diseases from youth.
REFERENCES
1. Todiere G, Neglia D, Ghione S, et al. Right ventricular remodeling
in systemic hypertension: a cardiac MRI study. Heart 2011;97:1257-1261.
2. Lam CSP, Borlaug BA, Kane GC, Enders FT, Rodeheffer RJ, Redfield
MM. Age-associated increases in pulmonary artery systolic pressure in the
general population. Circulation 2009;119:2663-2670.
In light of recent clinical trials, number of guidelines about the
drug treatment in the management of hypertension has amended their
strategies. Among many of those, use of diuretics hopefully has been
placed at the highest rank. The concept of using a diuretic, an "innocent"
agent as the initial drug in the management of hypertension has changed
radically e.g. went to as a "third drug" for its number of biochemical and...
In light of recent clinical trials, number of guidelines about the
drug treatment in the management of hypertension has amended their
strategies. Among many of those, use of diuretics hopefully has been
placed at the highest rank. The concept of using a diuretic, an "innocent"
agent as the initial drug in the management of hypertension has changed
radically e.g. went to as a "third drug" for its number of biochemical and
metabolic adverse effects. Either CCB or RAS modulating agents have
occupied the higher places. More ever, if required for specific
indications, choosing a diuretic is also a big job. Most physicians still
follow the old strategy e.g. thiazide diuretic; either HCTZ or
bendroflumethiazide but time has changed. We need to go for better
thiazide-type (without benzothiadiazine ring in the molecule) diuretic
preferably chlortalidone or indapamide as the next choice. This is a very
good article and should be read by all physician involved in the
management of hypertension.
To the Editor:
We appreciate the work by Hermanides et al, which reported that routine
prehospital treatment with high-dose tirofiban (HDT) significantly reduced
the use of blinded bail-out study medication (20% vs.29%). The need for
bail-out therapy was associated with a less favourable outcome (major
adverse cardiac events (MACE) at 30 days 12.2% vs 5.6%). This analysis
suggests that routine pretreatment is superior to...
To the Editor:
We appreciate the work by Hermanides et al, which reported that routine
prehospital treatment with high-dose tirofiban (HDT) significantly reduced
the use of blinded bail-out study medication (20% vs.29%). The need for
bail-out therapy was associated with a less favourable outcome (major
adverse cardiac events (MACE) at 30 days 12.2% vs 5.6%). This analysis
suggests that routine pretreatment is superior to provisional use of HDT
in patients with ST-segment elevation myocardial infarction (STEMI).1
However, when we estimate the MACE rates in those without using bail-out
medication, the paradoxical results of tirofiban arm and the placebo arm
are 6.9% and 5.3% respectively.2 Therefore, prehospital treatment with
HDT should be emphasized for patients who have high risk to develop
reinfarction and death after primary angioplasty such as Killip's
classifications >1 to avoid unwanted bleeding.3,4 Of note, this is a
practical way to educate the emergency medical technicains to classify the
seveirty of myocardial infarction in the ambulance and can give early
antiplatelet agents and tirofiban.
In addition, there may have two biases to affect the death rates leading
to a favorable outcome in the tirofiban arm in the On-TIME2 trial.
Previously, we have stated that there may be a procedure selection bias
when urgent target vessel revascularization occurred during
hospitalization.5 Another one may be caused by patients died or lost,
whose written consents were not available by themselves or their families.
We noticed that there were 8 from 491 persons died in the tirofiban arm
more than 4 from 493 persons in the placebo arm on Day 0 and their
informed consents could not be obtained. Therefore, after excluding these
patients, only 3 persons were estimated to die in the tirofiban arm but 15
persons to die in the placebo arm in the next 30 days.2
In summary, we believe that the benefit of prehospital treatment with HDT
to reduce MACE may outweigh the hazard of bleeding for STEMI patients who
have high risk to develop reinfarction and death according to the result
of On-TIME2. However, whether there has a benefit of prehospital treatment
with HDT to reduce the death rate should be further evaluated.
Reference
1. Hermanides RS, Heestermans AA, Ten Berg JM, Gosselink AT,
Ottervanger JP, van Houwelingen KG, Kolkman JJ, Stella PR, Dill T, Hamm C,
van 't Hof AW. High-dose tirofiban pretreatment reduces the need for bail-
out study medication in patients with ST-segment elevation myocardial
infarction: results of a subgroup analysis of the On-TIME 2 trial. Heart.
2011; 97:106-111.
2. Van't Hof AW, Ten Berg J, Heestermans T, Dill T, Funck RC, van Werkum
W, Dambrink JH, Suryapranata H, van Houwelingen G, Ottervanger JP, Stella
P, Giannitsis E, Hamm C; Ongoing Tirofiban In Myocardial infarction
Evaluation (On-TIME) 2 study group. Prehospital initiation of tirofiban in
patients with ST-elevation myocardial infarction undergoing primary
angioplasty (On-TIME 2): a multicentre , double-blind, randomized
controlled trial. Lancet 2008; 372: 537-546.
3. Smit JJ, van 't Hof AW, de Boer MJ, Hoorntje JC, Dambrink JH, Gosselink
AT, Ottervanger JP, Kolkman JJ, Suryapranata H. Incidence and predictors
of subacute thrombosis in patients undergoing primary angioplasty for an
acute myocardial infarction. Thromb Haemost. 2006; 96:190-195.
4. Kernis SJ, Harjai KJ, Stone GW, Grines LL, Boura JA, Yerkey MW, O'Neill
W, Grines CL. The incidence, predictors, and outcomes of early
reinfarction after primary angioplasty for acute myocardial infarction. J
Am Coll Cardiol. 2003; 42:1173-1177.
5. Lin GM, Han CL. Risk profile and benefits from Gp IIb-IIIa inhibitors
among patients with ST-segment elevation myocardial infarction treated
with primary angioplasty: a meta-regression analysis of randomized trials.
Eur Heart J 2010; 31 753-754
In the excellent paper by Strauss et al,[1] the ECG utility as a
screening tool for risk stratification for Chagas' disease is highlighted.
ECG is widely available and inexpensive and may be properly interpreted by
primary care and clinical physicians.
It should be added that trypanocide treatment in chronic chagasic
adults is becoming a standard of care.[2] Although drugs for treatment of...
In the excellent paper by Strauss et al,[1] the ECG utility as a
screening tool for risk stratification for Chagas' disease is highlighted.
ECG is widely available and inexpensive and may be properly interpreted by
primary care and clinical physicians.
It should be added that trypanocide treatment in chronic chagasic
adults is becoming a standard of care.[2] Although drugs for treatment of
Chagas disease are poorly tolerated, benznidazole is associated with
parasitological and serological negativization even in latent and chronic
phases.[3]
It was observed that specific trypanocide treatment is linked to a
significant reduction of ECG alterations in patients with chronic chagasic
cardiomyopathy.[3] Persistence of T. cruzi in chronic cardiac lesions can
explain these treatment benefits. Calculation of QRS score in the 12-lead
ECG may be considered an inexpensive instrument to control anti-parasite
treatment progression in chronic patients. Future observational research
may validate this hypothesis in the everyday practice.
[1] Strauss DG et al. ECG scar quantification correlates with cardiac
magnetic resonance scar size and prognostic factors in Chagas' disease.
Heart 2011 97:357-361.
[2] Viotti R, Vigliano C, Lococo B, Bertocchi G, Petti M et al.
Mejoria de la Evolucion Clinica y Serologica de Pacientes con Enfermedad
de Chagas Cronica Tratados con Benznidazol. Salud(i)Ciencia 2009;16(8):855
-9.
[3] Fabbro DL, Bizai ML, Streiger ML, Del Barco ML, Amicone NA, Arias
ED. Confirman la Utilidad de la Quimioterapia Especifica en la Enfermedad
de Chagas Cronica. Salud(i)Ciencia 2010;17(8):786-8.
We read with great interest the recent article by Patterson and Foale
relating to access site selection for cardiac procedures(1). The authors
discuss a series of published trials comparing the use of radial and
femoral access sites, and conclude that there is not sufficient evidence
to justify a shift from femoral to radial access for most cardiac
procedures.
The radial artery access site was introduced into c...
We read with great interest the recent article by Patterson and Foale
relating to access site selection for cardiac procedures(1). The authors
discuss a series of published trials comparing the use of radial and
femoral access sites, and conclude that there is not sufficient evidence
to justify a shift from femoral to radial access for most cardiac
procedures.
The radial artery access site was introduced into contemporary
cardiac practice over 20 years ago. Over this time period considerable
effort has been put into comparing radial and femoral access in
observational and randomised trials. The observational studies suggest
that radial access can be employed with safety, reduces costs, is
preferred by patients, and may reduce mortality. Meta analysis of the
randomised studies confirms unequivocally that employing radial access
results in a reduction in vascular and bleeding complications(2). Since
bleeding rates are highest in acute coronary syndrome patients undergoing
PCI who are exposed to arterial punctures in the context of potent
antithrombotic regimes, the beneficial influence of employing radial
access is likely to be maximised in this subpopulation. This is supported
by a meta-analysis of randomised and observational trials in STEMI
patients which demonstrates a reduction in mortality and MACE with no
significant effect on procedural duration or door to balloon time(3). The
recently published RIVAL study provides welcome additional information
from a large randomised trial of over 7000 ACS patients. This confirms
that the use of radial access in STEMI is associated with a significant
and clinically important reduction in mortality(4). The study also
provides evidence that experienced radial operators can reduce mortality
in a broader population of ACS and stable patients.
The authors raise a number of issues relating to technical aspects of
performing radial procedures. Initially, operators had limited knowledge
relating to anatomical and technical issues that are pertinent to the use
of the radial access, and equipment was primitive. Over the last 20 years
extensive procedural and technical development has occurred and success
rates for well trained skilled radial operators in contemporary practice
are comparable to those achieved by femoral operators(5). Experienced
operators routinely employ radial access for haemodynamically unstable
patients, re-puncture the same site on multiple occasions, access the
right heart from a simultaneous upper limb venous puncture, image bypass
grafts, overcome anatomical obstacles with ease and achieve comparable
procedure duration. The reported increase in radiation exposure is a
learning curve phenomenon that has no relevance to established
practitioners(6). In 2011 use of the radial access site does not impose
technical limitations in interventional practice.
In common with other aspects of catheterisation procedures, arterial
access site practice has evolved over the last 50 years. In the UK the
most recent national PCI audit demonstrates that radial access is now
utilised in almost 50% of PCI procedures. The rate of change is rapid (in
2005 the rate was 10%) and shows no sign of slowing. Internationally this
trend is occurring in many countries. This change in practice is driven
by cardiologists (and increasingly patients) evaluation of the large
volume of safety data that exists. We endorse the recent comments by Di
Mario et al, and recommend that interventional cardiologists ensure that
they are well trained in all access sites, but employ the radial artery
for most procedures(7).
1. Patterson T, and Foale RA. If the radial artery is the new
standard of care in primary percutaneous coronary intervention, why is
most intervention done by the femoral approach? Heart. 2011, Apr;97(7):521
-2.
2. Jolly SS, Amlani S, Hamon M, Yusuf S, and Mehta SR. Radial versus
femoral access for coronary angiography or intervention and the impact on
major bleeding and ischemic events: a systematic review and meta-analysis
of randomized trials. Am Heart J. 2009, Jan;157(1):132-40.
3. Vorobcsuk A, K?nyi A, Aradi D, Horv?th IG, Ungi I, Louvard Y, and
Kom?csi A. Transradial versus transfemoral percutaneous coronary
intervention in acute myocardial infarction Systematic overview and meta-
analysis. Am Heart J. 2009, Nov;158(5):814-21.
4. Jolly SS, Yusuf S, Cairns J, Niemel? K, Xavier D, Widimsky P, et
al. Radial versus femoral access for coronary angiography and intervention
in patients with acute coronary syndromes (RIVAL): a randomised, parallel
group, multicentre trial [Internet]. The Lancet. 2011, Apr 2011;Available
from: http://linkinghub.elsevier.com/retrieve/pii/S0140673611604042
5. Freestone B, and Nolan J. Transradial cardiac procedures: the
state of the art. Heart. 2010, Jun;96(11):883-91.
6. Lo TS, Zaman AG, Stables R, Fraser D, Oldryod KG, Hildick-Smith
D, and Nolan J. Comparison of operator radiation exposure with optimized
radiation protection devices during coronary angiograms and ad hoc
percutaneous coronary interventions by radial and femoral routes. Eur
Heart J. 2008, Jun 17;(29):2180-2187.
7. Di Mario C, and Viceconte N. Radial angioplasty: worthy RIVAL,
not undisputed winner [Internet]. The Lancet. 2011, Apr 4;Available from:
http://linkinghub.elsevier.com/retrieve/pii/S0140673611604698
Letter regarding the article "If the radial artery is the new
standard of care in primary percutaneous coronary intervention, why is
most intervention done by the femoral approach?"
Because things take some time to change, but we're on the right lane.
I must disagree however with the conclusions of this recently published
point of view, where T Patterson and RA Foale comment on the performance
of trans-radial pr...
Letter regarding the article "If the radial artery is the new
standard of care in primary percutaneous coronary intervention, why is
most intervention done by the femoral approach?"
Because things take some time to change, but we're on the right lane.
I must disagree however with the conclusions of this recently published
point of view, where T Patterson and RA Foale comment on the performance
of trans-radial primary percutaneous coronary interventions (PCI) (1).
After a brief history of the technique and an overview of the enormous
advantages derived by its use (fewer bleedings, lower incidence of
composite endpoint of death, stroke and myocardial infarction), they hit
and stab and snap. In conclusion, they say that urgent PCI should not be
performed via the transardial route.
That's weird. In our opinion, the advantages of this route of
intervention unfold just during primary PCI. We'll try to prove that:
-Any coronary intervention (especially if emergent) can be performed with
a 6 Fr introducer, so the radial route is practicable in >90% of cases.
-During primary PCI, it is common to use more potent antithrombotic drugs
(i.e., abciximab, prasugrel), that are associated with an higher bleeding
risk.
-In this journal, SL Heterington et al recently published the results of a
study performed in a single high-volume centre and involving 1051 patients
undergoing primary PCI (2). Procedures performed with the transradial
route, apart from warranting fewer bleedings if compared to the
transfemoral one, was discovered to reduce in-hospital major adverse
cardio and cerebrovascular events, door-to-balloon and symptom-to-balloon
time, contrast load and radiation dose. Interestingly, if operators at the
beginning of the study preferred the transfemoral route in the 80% of
cases, at the end only 20% of them were treated with the big artery!
-In case of cardiogenic shock, the transradial route should be preferred
because it avoids dual femoral puncture and interference with the balloon
counterpulsation.
We radialists are well aware that this route of intervention requires
a big expertise and a steep learning curve. After a good level of
expertise however, it is plain how this technique does not increase
procedural and fluoroscopy time and access site crossover rate is very
low. Moreover costs for the healthcare system are lower and, importantly,
patient outcome is similar or superior without any inconvenience (3).
Patients are happy to "walk" outside the cath lab, if undergone elective
procedures. But the real advantages do occur in case of primary PCI!
References
(1) Patterson T, Foale RA. If the radial artery is the new standard
of care in primary percutaneous coronary intervention, why is most
intervention done by the femoral approach? Heart 2011;97:521-22.
(2) Hetherington SL, Adam Z, Morley R et al. Primary percutaneous coronary
intervention for acute ST-segment elevation myocardial infarction:
changing patterns of vascular access, radial versus femoral artery. Heart
2009;95:1612-18.
(3) Amoroso G, Kiemeneij F. Transradial access for primary percutaneous
coronary intervention: the next standard of care? Heart 2010;96:1341-44.
To the Editor.
It was with great interest that we read the article by Borgia et al. [1] on their experience with an Adenosine-induced asystole to facilitate the grasping of the mitral valve leaflets during a MitraClip procedure. We would like to comment on our experience with an Adenosine-induced asystole and describe an alternative method using ventilation manoeuvres to ease the grasping of the mitral valve leaflets.
Borgia et al...
To the Editor.
It was with great interest that we read the article by Borgia et al. [1] on their experience with an Adenosine-induced asystole to facilitate the grasping of the mitral valve leaflets during a MitraClip procedure. We would like to comment on our experience with an Adenosine-induced asystole and describe an alternative method using ventilation manoeuvres to ease the grasping of the mitral valve leaflets.
Borgia et al. described their method in a situation, where the first clip had already been placed and grasping of the leaflets for the second clip appeared to be difficult.
We have also attempted to facilitate leaflet grasping using an Adenosine-induced asystole when the positioning of the first clip proved difficult. Unfortunately this method did not lead to the desired outcome, because, in our experience, the position of the valve leaflets during the induced asystole cannot be predicted and may not be appropriate for grasping. This appears to be different in the case described by Borgia et al., where the first clip may have limited leaflet movement during the induced asystole.
Currently we anaesthetists facilitate the grasping of the leaflets by implementing various ventilation manoeuvres. Because all patients undergoing a MitraClip procedure are intubated and ventilated, the position of the heart is highly dependent on the actual ventilation phase. A lateral shift of the heart can be observed in the transoesophageal echocardiography during inspiration and a corresponding medial shift during expiration.
By decreasing the tidal volume and increasing the ventilation frequency these movements can be considerably reduced. If grasping proves more difficult, manual ventilation is applied to achieve the desired heart position. Pressure is carefully applied to the manual ventilation bag to achieve a superior position in which the leaflets can be grasped.
We believe extremely close cooperation between interventional cardiologists and cardiac anaesthetists is crucial for the successful execution of MitraClip procedures.
1.Borgia, F., Di Mario C., and Franzen O., Adenosine-induced asystole to facilitate MitraClip placement in a patient with adverse mitral valve morphology. Heart, 2011. 97(10): p. 864.
We read with great interest the study of Deftereos et al (1) about 86
patients with atrial fibrillation (AF). Half of their population had NT-
proBNP level (maximum level within 12 hours) below the cut-off value and
half had NT-proBNP level above the cut-off value. In addition, they
observed higher rates of atrial thrombus (AT) in the group with reduced NT
-proBNP concentration. As stated, this is a proof of concept study a...
We read with great interest the study of Deftereos et al (1) about 86
patients with atrial fibrillation (AF). Half of their population had NT-
proBNP level (maximum level within 12 hours) below the cut-off value and
half had NT-proBNP level above the cut-off value. In addition, they
observed higher rates of atrial thrombus (AT) in the group with reduced NT
-proBNP concentration. As stated, this is a proof of concept study and no
specific recommendations can be made regarding management of patients with
AF.
We first assume that these findings should not have direct clinical
implications. The authors performed serial measurements of NT-proBNP
within 12 hours; based on NT-proBNP concentrations, the probability of
left AT ranged from 4.7% to 30.2%. A 4.7% risk is unacceptably high to
rule out atrial thombus and recommend any change in disposition of these
patients (2).
Second, we wonder if there is not a selection bias in their cohort. This
is supported by 3 arguments: a) Their population is very young compared to
other studies involving AF patients, and more surprisingly, standard
deviation is very low (62.2?1.2 years)(2). b) They observed higher rates
of AT in the subgroup of patients with lower NT-proBNP concentrations.
This finding is somewhat unexpected and is discordant with a previous
study from Shimizu et al. (3). Shimizu et al. studied 43 patients and
reported that patients with AT and/or thromboembolic events had higher BNP
concentrations (3). c) In our population, we studied patients with AF and
no heart failure. Time from onset of AF was known, and no patients had AF
of only several hours. We observed a correlation (positive, not inversed)
between AF duration and NT-proBNP concentration (r=0.532, p=0.0002).
Patients with AF of longer duration are assumed to be at high risk of
thromboembolic events (2).
Third, they used in their study a cut-off value for NT-proBNP that has
been established in a distinct population (acute dyspnea in emergency
room).
In conclusion, the study from Deftereos et al (1) paves the way for urgent
clarification. Additional studies should specifically address the question
of how to use biomarkers in AF patients. Meanwhile physicians should
adhere to recent guidelines (2).
References
1. Deftereos S, Giannopoulos G, Kossyvakis C, et al. Estimation of atrial
fibrillation recency of onset and safety of cardioversion using NTproBNP
levels in patients with unknown time of onset. Heart 2011;97:914-7.
2. Guidelines. Camm AJ, Kirchhof P, Lip GYH, et al for The Task Force for
the Management of Atrial Fibrillation of the European Society of
Cardiology (ESC). Guidelines for the management of atrial fibrillation.
Eur Heart J 2010 ; 31 :2369-2429.
3. Shimizu H, Murakami Y, Inoue SI, et al. High Plasma Brain Natriuretic
Polypeptide Level as a Marker of Risk for Thromboembolism in Patients With
Nonvalvular Atrial Fibrillation. Stroke. 2002;33:1005-1010.
We read with great interest the article by Su?rez-Barrientos et al
(1) regarding circadian oscillations on infarct size. Although the article
is both exhaustive and clinically relevant, we felt that the authors
failed in the recognition of the potential value of melatonin in the
association between cardiovascular events and circadian variation.
We read with great interest the article by Su?rez-Barrientos et al
(1) regarding circadian oscillations on infarct size. Although the article
is both exhaustive and clinically relevant, we felt that the authors
failed in the recognition of the potential value of melatonin in the
association between cardiovascular events and circadian variation.
Synchrony between external and internal circadian rhythms and harmony
among molecular fluctuations within cells are essential for normal organ
biology. Circadian clocks exist within multiple components of the
cardiovascular system. These clocks have the potential of affecting
multiple cellular processes and, therefore, they hold the promise of
modulating various aspects of cardiovascular function over the course the
24-hr cycle (2). Many aspects of cardiovascular physiology are subject to
diurnal variations, and serious adverse cardiovascular events appear to be
conditioned by the time of day. The internal oscillator, or control
station regulating the body's circadian clock, is the suprachiasmatic
nucleus, a tiny structure located in the hypothalamus above the optic
chiasm. The circadian pacemaker within the suprachiasmatic nucleus
stimulates the pineal gland to produce circadian melatonin with high serum
levels during the night (2). The results of many publications suggest a
decrease in circulating melatonin concentration at different stages of the
coronary heart disease in humans. Furthermore, experimental and clinical
data suggest that melatonin is involved in normal cardiovascular
physiology (3).
Melatonin is known to be a powerful radical scavenger of the hydroxyl
radical and to protect against cardiac tissue damage mediated by oxidative
stress (2). A recent study from our group showed, in patients with ST-
elevation myocardial infarction undergoing primary percutaneous coronary
intervention, a relationship between melatonin concentrations and ischemia
-modified albumin, a marker of myocardial ischemia. Our data suggest that
melatonin acts as a potent antioxidant agent, reducing myocardial damage
induced by ischemia/reperfusion (4). Furthermore, melatonin rhythmicity
appears to have crucial roles in various cardiovascular functions as an
antioxidant, an anti-inflammatory agent chronobiotic and possibly as an
epigenetic regulator (2).
We recognize that melatonin is of special interest, beging an
endogenous molecule that can be used in humans, and which is also safe.
The omission in the articles, such as that of Suarez-Barrientos et al (1),
could deprive at the medical community of potentially useful information.
REFERENCES
1. Suarez-Barrientos A, Lopez-Romero P, Vivas D, et al. Circadian
variations of infarct size in acute myocardial infarction. Heart 2011
doi:10.1136/hrt.2010.212621.
2. Dominguez-Rodriguez A, Abreu-Gonzalez P, Sanchez-Sanchez JJ, Kaski JC,
Reiter RJ. Melatonin and circadian biology in human cardiovascular
disease. J Pineal Res 2010;49:14-22.
3. Reiter RJ, Tan DX. Melatonin: a novel protective agent against
oxidative injury of the ischemic/reperfused heart. Cardiovasc Res
2003;58:10-9.
4. Dominguez-Rodriguez A, Abreu-Gonzalez P, Garcia-Gonzalez MJ, Samimi-
Fard S, Reiter RJ, Kaski JC. Association of ischemia-modified albumin and
melatonin in patients with ST-elevation myocardial infarction.
Atherosclerosis 2008;199:73-78.
In a group of middle-aged, hypercholesterolic men with no prior
history of diabetes or CVD, Logue et al. (2011) recently report that
obesity is associated with fatal coronary heart disease (CHD), but not non
-fatal CHD independently of traditional CVD risk factors. The authors
hypothesize that since excessive adipose tissue is known to secrete
inflammatory mediators, that increased systemic inflammation might be
making t...
In a group of middle-aged, hypercholesterolic men with no prior
history of diabetes or CVD, Logue et al. (2011) recently report that
obesity is associated with fatal coronary heart disease (CHD), but not non
-fatal CHD independently of traditional CVD risk factors. The authors
hypothesize that since excessive adipose tissue is known to secrete
inflammatory mediators, that increased systemic inflammation might be
making these obese subjects more prone to adverse coronary events.
Although logical, there may be a potential confounder in the study as the
authors note that "There were lower proportions of current smokers and
higher proportions of ex-smokers in higher than lower BMI categories."
Current smoking to a much greater extent than past smoking is associated
with systemic inflammation and a pro-coagulative state (CJ Smith and TH
Fischer, Atherosclerosis 2001, 158: 257-267.) Although smokers form
thrombus more easily than nonsmokers, smokers survive their first heart
attack better than nonsmokers [Jaatun et al. (2004) Am J Cardiology;
Mueller et al. (1992)Circulation]. This is presumably because the smoker
presents with MI at an earlier stage of CVD. If obese subjects were
experiencing MI due to systemic inflammation, they too might be expected
to display an advantage in surviving, rather than dying from the first MI.
Sincerely,
Carr J. Smith, Ph.D.
Visiting Scholar, UNC Chapel Hill Dept. of Pathology
To the editor: I read with great interest the report by Dr. Todiere and colleagues1) discussed the right ventricular hypertrophy in patients with systemic hypertension. Although they reported that there was no difference in systolic pulmonary artery pressure between hypertensive patients with and without left ventricular hypertrophy, Lam and colleagues2) previously reported the age-associated elevation of pulmonary arter...
In light of recent clinical trials, number of guidelines about the drug treatment in the management of hypertension has amended their strategies. Among many of those, use of diuretics hopefully has been placed at the highest rank. The concept of using a diuretic, an "innocent" agent as the initial drug in the management of hypertension has changed radically e.g. went to as a "third drug" for its number of biochemical and...
To the Editor: We appreciate the work by Hermanides et al, which reported that routine prehospital treatment with high-dose tirofiban (HDT) significantly reduced the use of blinded bail-out study medication (20% vs.29%). The need for bail-out therapy was associated with a less favourable outcome (major adverse cardiac events (MACE) at 30 days 12.2% vs 5.6%). This analysis suggests that routine pretreatment is superior to...
Dear Editor,
In the excellent paper by Strauss et al,[1] the ECG utility as a screening tool for risk stratification for Chagas' disease is highlighted. ECG is widely available and inexpensive and may be properly interpreted by primary care and clinical physicians.
It should be added that trypanocide treatment in chronic chagasic adults is becoming a standard of care.[2] Although drugs for treatment of...
We read with great interest the recent article by Patterson and Foale relating to access site selection for cardiac procedures(1). The authors discuss a series of published trials comparing the use of radial and femoral access sites, and conclude that there is not sufficient evidence to justify a shift from femoral to radial access for most cardiac procedures.
The radial artery access site was introduced into c...
Letter regarding the article "If the radial artery is the new standard of care in primary percutaneous coronary intervention, why is most intervention done by the femoral approach?"
Because things take some time to change, but we're on the right lane. I must disagree however with the conclusions of this recently published point of view, where T Patterson and RA Foale comment on the performance of trans-radial pr...
We read with great interest the study of Deftereos et al (1) about 86 patients with atrial fibrillation (AF). Half of their population had NT- proBNP level (maximum level within 12 hours) below the cut-off value and half had NT-proBNP level above the cut-off value. In addition, they observed higher rates of atrial thrombus (AT) in the group with reduced NT -proBNP concentration. As stated, this is a proof of concept study a...
To the Editor:
We read with great interest the article by Su?rez-Barrientos et al (1) regarding circadian oscillations on infarct size. Although the article is both exhaustive and clinically relevant, we felt that the authors failed in the recognition of the potential value of melatonin in the association between cardiovascular events and circadian variation.
Synchrony between external and internal circ...
In a group of middle-aged, hypercholesterolic men with no prior history of diabetes or CVD, Logue et al. (2011) recently report that obesity is associated with fatal coronary heart disease (CHD), but not non -fatal CHD independently of traditional CVD risk factors. The authors hypothesize that since excessive adipose tissue is known to secrete inflammatory mediators, that increased systemic inflammation might be making t...
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