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Recent eLetters

Displaying 1-10 letters out of 739 published

  1. Re:T1 Mapping with CMR: an emerging clinical biomarker

    We thank Ripley and colleagues for their interest in our paper and agree that T1 mapping with CMR is an emerging imaging biomarker that is increasingly being investigated for its potential role in hypertrophic cardiomyopathy and cardiac hypertrophy in general. Convincing data have been published concerning hypertensive heart disease(Hinojar et al., 2015), hypertrophic and dilated cardiomyopathy (Puntmann et al., 2013), transthyretin amyloidosis (Fontana et al., 2014) and Anderson-Fabry disease (Pica et al., 2014). We have not found any specific published data examining the role of T1 mapping in distinguishing ventricular septal bulge in an elderly population from other etiologies of hypertrophy. We therefore decided not to include T1 mapping in our review (Canepa et al., 2016) but concur that this technique may be potentially useful in the evaluation of ventricular septal bulge.

    Canepa, M., Pozios, I., Vianello, P. F., Ameri, P., Brunelli, C., Ferrucci, L., & Abraham, T. P. (2016). Distinguishing ventricular septal bulge versus hypertrophic cardiomyopathy in the elderly. Heart, 102(14), 1087-1094. doi:10.1136/heartjnl-2015-308764

    Fontana, M., Banypersad, S. M., Treibel, T. A., Maestrini, V., Sado, D. M., White, S. K., ... Moon, J. C. (2014). Native T1 Mapping in Transthyretin Amyloidosis. JACC: Cardiovascular Imaging, 7(2), 157-165. doi:10.1016/j.jcmg.2013.10.008

    Hinojar, R., Varma, N., Child, N., Goodman, B., Jabbour, A., Yu, C.- Y., Puntmann, V. O. (2015). T1 Mapping in Discrimination of Hypertrophic Phenotypes: Hypertensive Heart Disease and Hypertrophic Cardiomyopathy: Findings From the International T1 Multicenter Cardiovascular Magnetic Resonance Study . Circulation: Cardiovascular Imaging , 8 (12 ).doi:10.1161/CIRCIMAGING.115.003285

    Pica, S., Sado, D. M., Maestrini, V., Fontana, M., White, S. K., Treibel, T., Moon, J. C. (2014). Reproducibility of native myocardial T1 mapping in the assessment of Fabry disease and its role in early detection of cardiac involvement by cardiovascular magnetic resonance. Journal of Cardiovascular Magnetic Resonance?: Official Journal of the Society for Cardiovascular Magnetic Resonance, 16(1), 99. doi:10.1186/s12968-014-0099- 4

    Puntmann, V. O., Voigt, T., Chen, Z., Mayr, M., Karim, R., Rhode, K., Nagel, E. (2013). Native T1 Mapping in Differentiation of Normal Myocardium From Diffuse Disease in Hypertrophic and Dilated Cardiomyopathy. JACC: Cardiovascular Imaging, 6(4), 475-484. doi:10.1016/j.jcmg.2012.08.019

    Conflict of Interest:

    None declared

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  2. Expediating the pathway to SVT ablation

    Honarbakhsh et al should be congratulated upon their innovative research in improving the care for patients with arrhythmias. Their paper not only demonstrates an effective community treatment strategy but importantly is cost effective during the current austerity. Potential further cost savings and enhanced patient experiences could be anticipated by encouraging General Practitioners to subsequently refer patients wishing for a curative strategy directly to Electrophysiologists for consideration of an ablation.

    Patients affected by SVTs usually experience frustrating recurrent attendances at Accident and Emergency departments prior to referral to Electrophysiologists, despite our knowledge that ablations are successful in 95% at the first procedure. Similarly, many journeys to the AED are aborted as the symptoms self terminate prior to arrival or have abated by the time of medical review. Thus frequently ECGs fail to capture their arrhythmia and clinch the diagnosis, protracting the time to effective treatment. The PARA group had a statistically significant greater chance of receiving a copy of their ECG (85% v 63%, p-value 0.035) and therefore this often illusive information would have a greater chance of being available for inclusion in the onward referral to the Cardiologist or Electrophysiologist.

    Partnerships between community and tertiary care services can expedite and improve arrhythmia care, reducing some of the burden on over stretched Emergency Departments.

    Conflict of Interest:

    None declared

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  3. Multilevel analysis of variance and hospital performance in heart failure management

    Dear Editor,

    We have read with interest the article written by Emdin et al (1) using multilevel regression analysis of variance to investigate hospital performance for heart failure management. We were pleased to note that the authors apply and refer to our previous methodological work concerning the use of the Intraclass Correlation (ICC) and Median Odds Ratio (MOR).(2) However, the authors did not consider a recent paper of ours investigating survival after heart failure hospitalization and applying a modern multilevel analytical framework.(3)

    Nevertheless, the article by Emdin et al (1) actually applies a similar way of reasoning that we presented in our previous article.(3) In this respect, we would like to take this opportunity to comment on their study.(1)

    First, much of variation in performance identified by the authors could be attributed to the ward rather than to the hospital level since the ward-level is where the genuine organisational effect could take place. In our recent study we found that the ward ICC (around 5.3%) was much larger than the hospital ICC (0.04%).(3)

    Second, while the issue of confounding, and hence the need to adjust for patient case-mix, is a cause of concern in the case of outcome indicator, it is normally not a concern when it comes to process indicators (4) and the authors should have discussed this aspect.

    Third, the authors used backward stepwise single-level regression to identify the hospital characteristics that "were significantly associated with a better performance score". We think this identification should be based on a priori theory rather than on a posteriori finding of statistical significance. Besides, the use of single level regression analysis for this task is unsuitable as it does not consider the intra- hospital correlation and provides spurious "significant" associations.(2)

    Otherwise we agree with Emdin et al(1) methodological approach and interpretation of the results. However, a reference to our previous article (3) should have been made.

    Kind Regards,

    Nermin Ghith, PHD candidate, Research Unit of Chronic Conditions, Bispebjerg Hospital, Copenhagen.

    Prof. Juan Merlo MD, PhD, Head of the Research Unit for Social Epidemiology, Dept. Clin. Sci.(Malmo), Faculty of Medicine, Lund University, Sweden

    -References

    1. Emdin CA, Conrad N, Kiran A, Salimi-Khorshidi G, Woodward M, Anderson SG, et al. Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales. Heart. 2016.

    2. Merlo J, Chaix B, Ohlsson H, Beckman A, Johnell K, Hjerpe P, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. Journal of Epidemiology and Community Health. 2006;60(4):290-7.

    3. Ghith N, Wagner P, Fr?lich A, Merlo J. Short Term Survival after Admission for Heart Failure in Sweden: Applying Multilevel Analyses of Discriminatory Accuracy to Evaluate Institutional Performance. PLoS ONE. 2016;11(2):e0148187.

    4. Rubin HR, Pronovost P, Diette GB. The advantages and disadvantages of process?based measures of health care quality. International Journal for Quality in Health Care. 2001;13(6):469-74.

    Conflict of Interest:

    None declared

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  4. T1 Mapping with CMR: an emerging clinical biomarker.

    Dear Editor,

    We read the educational review on distinguishing ventricular septal bulge (VSB) versus hypertrophic cardiomyopathy (HCM) by Canepa et al[1] with great interest. The authors recognise the increasingly established role of cardiovascular magnetic resonance (CMR) in the assessment of this difficult diagnostic dilemma. They describe the gold standard role of CMR in the quantification of myocardial mass, myocardial fibrosis with late gadolinium enhancement and the morphological and functional imaging of mitral valve abnormalities.

    T1 mapping with CMR is an emerging clinical biomarker for the quantification of myocardial disease. The technique is easily measured, highly reproducible and has recently translated into the clinical pathway[2]. With the addition of gadolinium based contrast agent the extracellular volume (ECV) can also be estimated. T1 mapping is clinically able to identify early phenotypic expression of HCM with both increased native T1 and higher ECV[3] and has been shown to distinguish between early phenotypic expression of athlete hearts vs HCM[4]. We would highly recommend T1 mapping techniques to be performed on all patients undergoing CMR which will aid the differentiation of VSB vs HCM.

    Dr David P. Ripley

    Dr Subhi E. Akleh

    Dr Alison F. Lee

    References: 1. Canepa M, Pozios I, Vianello PF, et al. Distinguishing ventricular septal bulge versus hypertrophic cardiomyopathy in the elderly. Heart 2016;102(14):1087-94. 2. Sado DM, White SK, Piechnik SK, et al. Identification and assessment of Anderson-Fabry disease by cardiovascular magnetic resonance noncontrast myocardial T1 mapping. Circ Cardiovasc Imaging 2013;6(3):392-8. 3. Puntmann VO, Voigt T, Chen Z, et al. Native T1 mapping in differentiation of normal myocardium from diffuse disease in hypertrophic and dilated cardiomyopathy. JACC Cardiovasc Imaging 2013;6(4):475-84. 4. Swoboda PP, McDiarmid AK, Erhayiem B, et al. Assessing Myocardial Extracellular Volume by T1 Mapping to Distinguish Hypertrophic Cardiomyopathy From Athlete's Heart. J Am Coll Cardiol 2016;67(18):2189- 90.

    Conflict of Interest:

    None declared

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  5. Microcirculation impairment in acute coronary syndrome: It is not always the same story

    We read with great interest the elegant work of Kasula et al. recently published on Heart [1]. The Authors showed that fractional flow reserve (FFR) may be an effective tool to discriminate the long-term functional outcome after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) [1]. This retrospective study included exclusively ACS patients for whom FFR evaluation resulted "flow limiting" (<0.80). All patients were treated with PCI and the main finding of the study was that FFR value after PCI was able to discriminate those at higher risk of adverse events. The Authors concluded that FFR reliably estimates baseline ischemia and its subsequent reduction post-PCI in patients with ACS. We totally agree with the significance of the post-PCI FFR assessment, but any comment regarding the FFR role in the determination of baseline ischemia in ACS patients should not be taken for granted. Recently, Lee et al. showed that deferring the treatment of intermediate coronary stenosis based only on the FFR value, without taking into account the features of coronary microcirculation, exposes the patient to an increase of adverse events [2]. Kasula et al. did not report the long-term outcome of patients for whom FFR result was "no flow limiting" [1]. Accordingly, the conclusion that "FFR alone may be an invaluable tool in identifying ischemia producing lesions" is methodologically incorrect. It is well established that microvascular disfunction may be the result of: i) pre-existing condition (e.g. microvascular angina), ii) chronic damage (e.g chronic kidney disease [3]), iii) acute injury (e.g. ACS) or iv) a mix of these. Therefore, the impairment in the coronary microcirculation may differ significantly across ACS patients. Some patients show a partial impairment that allows an effective adenosine action and then a proper FFR determination. Contrarily, other patients have an extensive damage and FFR assessment may result misleading. For this reason, in our opinion, it seems important to focus our attention on ACS patients with "no flow limiting" FFR assessment. In these cases, the simultaneous assessment of the coronary microcirculation (e.g. index of microcirculatory resistance) may help physicians in the decision-making process [4].

    References

    1. Kasula S, Agarwal SK, Hacioglu Y, et al. Clinical and prognostic value of poststenting fractional flow reserve in acute coronary syndromes. Heart. 2016 Aug 4 doi: 10.1136/heartjnl-2016-309422 2. Lee JM, Jung JH, Hwang D, et al. Coronary Flow Reserve and Microcirculatory Resistance in Patients With Intermediate Coronary Stenosis. J Am Coll Cardiol. 2016 15;67(10):1158-69 3. Tebaldi M, Biscaglia S, Fineschi M, et al. Fractional flow reserve evaluation and chronic kidney disease: Analysis from a multicenter Italian registry (the FREAK study). Catheter Cardiovasc Interv. 2015 Dec 31. doi: 10.1002/ccd.26364 4. Tebaldi M, Biscaglia S, Pecoraro A, et al. Fractional flow reserve implementation in daily clinical practice: A European survey. Int J Cardiol. 2016 15;207:206-7.

    Conflict of Interest:

    None declared

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  6. Re Larsson et al, Chocolate consumption adn risk fo myocardial infarction: a propspective stusy and meta-analysis

    Comment to the Heart Journal website

    re Larsson et al, Chocolate consumption and risk of myocardial infarction: a prospective study and meta-analysis. The findings of Larsson et al are fascinating and in line with earlier reports of cardio-protective effects of chocolate consumption, especially of dark chocolate. Having noticed this in the literature, a colleague and I were inspired to measure the vitamin D content of dark chocolate, since it was known that curing cocoa beans in the sun was associated with some fungal growth and that fungi synthesize vitamin D2, as evidenced in mushrooms, sometimes irradiated with UV for food fortification, and or-ur pilot study demonstrated remarkably high vitamin D2 content of the various dark chocolate samples examined. The reported benefits may, therefore, be due in part to the contained vitamin D2, since similar protection is currently being found with better vitamin D status, or supplementation. I would be interested to know, therefore, whether the cohorts reported upon happen to have measurements of serum 25(OH)D available that could be assessed for variation with chocolate consumption, and cardiovascular events, which would be of great interest, either way.

    Barbara J Boucher BSc. MD, FRCP. bboucher@doctors.org.uk

    References Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ 2011;343:d4488; Response, by Timms PM et al

    Dietary vitamin D?--a potentially underestimated contributor to vitamin D nutritional status of adults? Cashman KD, Kinsella M, McNulty BA, Walton J, Gibney MJ, Flynn A, Kiely M. Br J Nutr. 2014 Jul 28;112(2):193-202.

    The vitamin D activity of cacao shell: The effect of the fermenting and drying of cacao on the vitamin D potency of cacao shell. II. The origin of vitamin D in cacao shell. Knapp AW. Biochem J. 1935 Dec;29(12):2728-35.

    Conflict of Interest:

    None declared

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  7. Re:It is important to distinguish between HFrEF and HFpEF when interpreting these data

    We would like to thank Dr Cunnington for his interest in our study and raising some potentially interesting points . We do not have a breakdown of patients with heart failure ( HF) who had either preserved (HFpEF) or reduced ejection fraction (HFrEF) . Since beta-blockers only have a licensed indication for HFrEF on the basis of an echocardiogram , we do not believe that this is likely to be a relevant factor within our dataset . The relative prevalence of hypertension within our cohort was 13.3% verses 11.6% ,and for diabetes was 47.4% verses 41.9% respectively for HF alone verses HF with COPD . Hence the assertion made regarding a higher putative comorbidity is not supported by the data presented here . Consequently prescribing of ACEI/ARB in HF with COPD was not confounded by comorbidity due to treatment for either diabetes or hypertension . The higher use of ACEI/ARB without beta-blocker in HF with COPD compared to HF alone is more likely to reflect a reticence of physicians to prescribe add on therapy with beta-blockers in the presence of airflow obstruction due to fears of bronchoconstriction . As such we remain confident in the strength of our conclusions regarding underuse of beta-blockers in HF with COPD .

    Conflict of Interest:

    None declared

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  8. Impact of Beta-blocker on The Outcome of Takotsubo Cardiomyopathy

    The article by Isogai et al. published in Heart (1) discuss the use of beta-blockers in patients diagnosed and admitted with takotsubo cardiomyopathy (TTC).

    Although no effective guidelines have been prescribed for the treatment of TTC, it is suggested that a parable could be drawn by comparing the use of beta-blocker and angiotensin-converting-enzyme inhibitors in these patients with that of control subjects as well as those suffering from coronary artery disease. Beta-blockers were considered more likely to be prescribed to control subjects and patients diagnosed with coronary artery disease than to patients diagnosed with TTC. Interestingly, TTC and coronary artery disease patients received angiotensin-converting-enzyme inhibitors / angiotensin receptor blockers more often than control subjects. The concluding suggestion that the 5 year mortality is similar in both disease groups and higher than control subjects furthers our debate on this topic. The large International Takotsubo Registry reported a 5.6% mortality per-patient year (2) and the use of angiotensin-converting- enzyme inhibitors or angiotensin receptor- blockers was associated with improved survival rates. However, evidence establishing a marked survival benefit with beta-blocker use has yet to be documented. The pathogenesis of TTC is yet to be fully understood. A popular hypothesis suggests the involvement of a catecholamine-mediated mechanism. Although all these trials essentially compared the outcome of TTC with matched cohorts of patients with coronary artery disease, a relevant suggestion elucidates the role of an inflammatory and energetic- metabolic pathway as a possible pathophysiological mechanism (3). We retrospectively described a collective of 114 consecutive patients diagnosed with TTC between January 2003 and September 2015 at our institution. Our data showed that the use of beta-blocker was associated with improved survival rates over mean follow-up of 5 years (4). These novel findings necessitate the need for a standardized treatment regimen in TTC patients. We recommend the urgent need of randomized trials to clearly define treatment approaches and management strategies in takotsubo cardiomyopathy thus enabling the practice of evidence-based medicine within guidelines.

    References

    1. Isogai T, Matsui H, Tanaka H, et al. Early beta-blocker use and in -hospital mortality in patients with Takotsubo cardiomyopathy. Heart 2016;102(13):1029-1035. 2 . Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015;373(10):929-938. 3. Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA 2011;306(3):277-286. 4. Becher T, El-Battrawy I, Baumann S, et al. Characteristics and long- term outcome of right ventricular involvement in Takotsubo cardiomyopathy. Int J Cardiol 2016;220:371-375.

    Conflict of Interest: None declared

    Conflict of Interest:

    None declared

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  9. It is important to distinguish between HFrEF and HFpEF when interpreting these data

    In this interesting article, Lipworth and colleagues report that beta -blockers are underused in patients with heart failure (HF) and COPD, compared to those with HF alone. However, they do not quote the proportion of "HF" patients within their dataset who had HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction (LVEF) <40%) and HF with preserved ejection fraction (HFpEF; LVEF >50%). This distinction is important, as beta-blockers are only recommended in HF guidelines for patients with HFrEF (1), owing to a lack of trial data to support their efficacy in patients with HFpEF.

    Furthermore, patients with HFpEF tend to have a higher prevalence of co-morbidities compared to patients with HFrEF, including COPD, hypertension and diabetes (2). Thus, it is possible that "HF and COPD" patients in this dataset may have a higher proportion of HFpEF to HFrEF, in comparison to patients with "HF alone", and the rates of ACE/ARB prescribing may be increased in this group owing to treatment of hypertension and diabetes rather than HF. These considerations may therefore confound the strength of the authors' conclusions regarding underuse of beta-blockers in patients with HF and COPD.

    References

    1. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016; DOI: 10.1093/eurheartj/ehw128.

    2. Ather S, Chan W, Bozkurt B et al. Impact of non-cardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction. J Am Coll Cardiol 2012;59:998-1005.

    Conflict of Interest:

    None declared

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  10. Hypertrophic cardiomyopathy and the potential influence of etomidate on postoperative outcomes.

    We read with interest the paper by Dhillon and colleagues which provided a high quality propensity matched observational study of perioperative outcomes in patients with hypertrophic cardiomyopathy (HCM).1 This study showed no difference in what they defined as 'hard outcomes' such as myocardial infarction, stroke and death. They did however show an increased incidence of composite end points (10%; p= 0.03) such as post-operative congestive heart failure (CHF) (1%) and readmission rates (7%).

    One interesting point that we would like to raise is the significantly higher use of etomidate in the HCM cohort (p= 0.002). Understandably, etomidate was chosen in many cases for its rapid onset and stable haemodynamic properties. This was likely reflected in the significantly lower incidence of intra-operative tachycardia and hypotension in HCM patients. However the use of etomidate is not without controversy, with several studies have linked its use as a single dose induction agent to post operative acute adrenal insufficiency.2,3 The use of etomidate may be a significant confounding factor in this study. Previous groups have demonstrated similar types of adverse outcomes with the use of etomidate; Komatsu and colleagues found substantially increased incidence of post-operative adverse events and even mortality when compared to the current paper.2 These differences may be related to a lower rates of etomidate use by Dhillon and colleagues.

    Given that there is currently a great deal of controversy surrounding the use of etomidate it would be beneficial to see a breakdown of outcomes in the subgroup that received etomidate. If the increased incidence of adverse outcomes were related to the use of etomidate, then non-cardiac surgery performed on HCM patients in experienced centres may no longer be 'high risk'.

    References:

    1. Dhillon A, Khanna A, Randhawa M, Cywinski J, Saager L, Thamilarasan M, Lever H & Desai M (2016). Perioperative outcomes of patients with hypertrophic cardiomyopathy undergoing non-cardiac surgery. Heart. 0: 1-6.

    2. Komatsu R, You J, Mascha E, Sessler D, Kasuya Y & Turan A (2013). Anaesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery. Anaesth Analg. 117(6): 1329-37.

    3. Chan C, Mitchell A & Shorr A (2012). Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis. Crit Care Med. 40(11): 2945-2953.

    Conflict of Interest:

    None declared

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