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Recent eLetters

Displaying 1-10 letters out of 727 published

  1. Fontan conversion is a dated approach to the Failing Fontan

    We read with great interest the report by van Melle et al. who conducted a retrospective multi-centre European study to assess surgical options for the failing Fontan [1]. Firstly, we would like to acknowledge the effort made to bring together the results of these infrequently performed, difficult interventions. However, we would also like to highlight concerns with the conclusions reached from this historical mixed registry data. The authors state that a late failing Fontan patient with poor ventricular function is better off with a heart transplant, while preserved ventricular function can be treated with conversion. It should be noted, however, that heart transplantation here was performed mainly in children, whilst conversion was predominantly indicated for right atrial dilatation and intractable arrhythmia in young adults with atrio-pulmonary Fontans. The atrio-pulmonary Fontan operation has not been performed for more than a decade and patient numbers with this repair are diminishing [2]. As more energy efficient circulations are developed, the substrate for arrhythmia is evolving. It is improbable that these results can therefore be generalised to make a case for future conversions. Furthermore, as the authors acknowledge, the Fontan population is aging; it is our experience that increasingly patients present in their thirties and forties with failure of the circulation due to extra-cardiac disease, most notably the liver [3,4]. Failure to identify, assess and address this in patients with preserved ventricular function may increase the risk and sometimes preclude the option of transplantation. The role of Fontan takedown, as stated, has not been elucidated for the late failing Fontan; we should question too whether there may be an alternative way to balance the circulation, avoiding the Fontan in the first place [5]. In the meantime, addressing listing criteria for late failing Fontan and exploring utility of ventricular assist devices must be the priority for the current population. Fontan conversion may have a role in highly selected cases but should not be regarded as a definitive option to timely transplantation for the growing adult patient group. Extrapolating past results in a changing surgical arena to current and future populations must be treated with caution.

    References [1] van Melle JP, Wolff D, H?rer J et al. Surgical options after Fontan failure. Heart. 2016 Apr 13. [2] d'Udekem Y, Iyengar AJ, Galati JC et al. Redefining expectations of long-term survival after the Fontan procedure: twenty-five years of follow -up from the entire population of Australia and New Zealand. Circulation. 2014;130(11 Suppl 1):S32-8. [3] Coats L, O'Connor S, Wren C et al. The single-ventricle patient population: a current and future concern a population-based study in the North of England. Heart. 2014;100(17):1348-53. [4] Greenway SC, Crossland DS, Hudson M et al. Fontan-associated liver disease: Implications for heart transplantation. J Heart Lung Transplant. 2016;35(1):26-33. [5] D'Souza TF, Samuel BP, Hillman ND, Vettukattil JJ, Haw MP. Biventricular Repair of Pulmonary Atresia After Fontan Palliation. Ann Thorac Surg. 2016;101(4):1574-6.

    Conflict of Interest:

    None declared

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  2. Loneliness and social isolation and increased risk of of coronary heart disease and stroke: clinical implications

    The recent meta-analysis published in Heart by Valtorta et al. (1) showed that loneliness and social isolation are associated with increased coronary heart disease and stroke incidence in 16 large longitudinal studies conducted in high income countries. This finding is not surprising given the extensive literature documenting such harmful consequences of social isolation, including a study my research group published in 1992 (2) showing in a large sample of CHD patients that those who were not married and did not have a confident -- and hence likely to be lonely and socially isolated -- had a 5-year mortality (50%) that was nearly three times larger than that observed (18%) in patients with a spouse and/or partner.

    The most important implication of this finding is that interventions that reduce loneliness and social isolation have the potential to prevent disease development and improve prognosis once disease is present. There is encouraging preliminary evidence that such interventions have been developed and shown to reduce social isolation in CHD patients and other groups and improve prognosis in CHD patients. Bishop et al. (3) showed in a randomized controlled trial of Singaporean male coronary artery bypass graft surgery patients that psychosocial skills training delivered in small groups produced a significant increase in satisfaction with social support and satisfaction with life, as well as decreases in depression, anger and blood pressure at rest and in response to anger recall stress. Chun et al. (4) showed in a controlled clinical trial of Chinese medical students that this same psychosocial skills training produced a significant increase in social support as well as improvements in other psychosocial risk factors. Direct support for the clinical efficacy of such training delivered in small groups comes from two randomized controlled trials in Sweden (5, 6) showing that similar interventions produced significant reductions in mortality and recurrent cardiovascular events in CHD patients.

    The evidence from the Valtorta et al. study combines with the encouraging evidence that psychosocial skills training has been shown to reduce loneliness and social isolation in both CHD and healthy groups and improve prognosis in CHD patients to make a strong case that it is now appropriate to undertake large simple trials of such interventions in CHD patient groups. If such trials document that such training produces reduced morbidity and mortality, it would then be appropriate to undertake primary prevention trials in healthy groups.

    1. Valtorta NK, Kanaan M, Gilbody S, et al. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart Published Online First 2016 (heartjnl-2015-308970).

    2. Williams, R.B., Barefoot, J.C., Califf, R.M., Haney, T.L., Saunders, W.B., Pryor, D.B., Hlatky, M.A., Siegler, I.C., Mark, D.B. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA. 1992;267:520-4.

    3. Bishop GD, Kaur D, Tan VLM, et al. Effects of a psychosocial skills training workshop on psychophysiological and psychosocial risk in patients undergoing coronary artery bypass grafting. Am Heart J 2005;150:602-609.

    4. Chun, L, Chu F, Wang H, Wang XP. Efficacy of Williams LifeSkills training for improving psychological health: a pilot comparison study of Chinese medical students. Asia Pac Psychiatry. 2014;6:161-9.

    5. Gulliksson M, Burell G, Vessby B, Lundin L, Toss H, Sverdsudd K. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Arch Intern Med. 2011;171:134-40.

    6. Orth-Gomer K, Schneiderman N, Wang HX, Walldin C, Blom M, Jernberg T. Stress reduction prolongs life in women with coronary disease: the Stockholm Women's Intervention Trial for Coronary Heart Disease (SWITCHD). Circ Cardiovasc Qual Outcomes. 2009;2:25-32.

    Sincerely,

    Redford B. Williams, M.D. Professor of Psychiatry and Behavioral Sciences, Professor of Medicine, Professor of Psychology and Neuroscience, Director, Behavioral Medicine Research Center

    Conflict of Interest:

    I am a founder and major stockholder in Williams LifeSkills,Inc., the company that developed the psychosocial skills training program used in the Bishop et al. (3) and Chun et al. (4) papers cited in my letter.

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  3. Response: A novel troponin I rule-out value below the upper reference limit for acute myocardial infarction

    To the Editor,

    Goorden et al aim to establish the optimal threshold to rule out myocardial infarction using a high-sensitivity cardiac troponin I assay. They report that a cardiac troponin I concentration <10 ng/L or a change of <20 ng/L on serial testing had a negative predictive value for the diagnosis of myocardial infarction of 99.8% and 98.7% respectively [1]. Whilst we agree there are better approaches to rule out myocardial infarction than using the 99th centile upper reference limit [2,3], we have several concerns about the generalisability and application of these thresholds in clinical practice.

    First, the authors compared diagnostic sensitivity and specificity to identify thresholds for cardiac troponin I with similar diagnostic performance to the reference standard. When used in conjunction with a separate rule in threshold, we believe the optimal threshold to rule out myocardial infarction should prioritise sensitivity alone to ensure a high negative predictive value.

    Second, the prevalence of myocardial infarction was low (8%; 114/1490) and included a significant proportion of patients with ST- segment elevation myocardial infarction (2%; 23/1490) where rule-out strategies based on cardiac biomarkers are inappropriate. Inclusion of these patients will overestimate the negative predictive value of the proposed rule out threshold. Furthermore, the negative predictive value will be lower in hospitals with a higher prevalence of myocardial infarction.

    Third, this analysis was restricted to patients where symptoms were present for at least 3 hours, limiting the clinical applicability of the derived rule out thresholds as patients presenting early are at increased risk of misdiagnosis and are precisely the population in whom rule out thresholds must be validated.

    Fourth, the analysis assumes the thresholds used for the reference standard are optimal. The recommended rule in threshold for cardiac troponin T is 14 ng/L (99th centile upper reference limit [4]) and the limit of detection (5 ng/L) has been proposed to rule out myocardial infarction. Goorden et al did not apply these thresholds in their analysis, and as such the thresholds derived for cardiac troponin I are challenging to interpret and may not be relevant to current clinical practice.

    In the absence of external validation and whilst these uncertainties remain we would caution against the use of these thresholds in clinical practice.

    References

    [1] Goorden SMI, van Engelen, RA, Wong LSM et al. A novel troponin I rule-out value below the upper reference limit for acute myocardial infarction. Heart Published Online First: 11th April 2016. doi:10.1136/heartjnl-2015-308667

    [2] Shah AS, Anand A, Sandoval Y, Lee KK, Smith SW, Adamson PD, Chapman AR et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet. 2015 Dec 19;386(10012):2481-8.

    [3] Pickering JW, Greenslade JH, Cullen L et al. Validation of presentation and 3 h high-sensitivity troponin to rule-in and rule-out acute myocardial infarction. Heart. Published online first: 8th March 2016. doi:10.1136/ heartjnl-2015-308505

    [4] Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD et al; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation. 2012 Oct 16;126(16):2020-35.

    Conflict of Interest:

    AA has received speaker fees from Abbott Laboratories. ASVS has acted as a consultant for Abbott Laboratories. NLM has acted as a consultant for Abbott Laboratories, Beckman-Coulter, Roche, and Singulex. The other authors declare no competing interests.

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  4. Regarding sex differences in cardiovascular ageing: let's not forget iron

    The interesting paper of Merz and Cheng did not mention iron as a plausible non-hormonal factor, which might in part explain the sex differences in cardiovascular aging [1].

    Mounting evidence suggests that the metabolic derangements and detrimental cardiovascular effects usually attributed to menopause represent only a mere consequence of the older age of menopausal women, rather than related to the loss of ovarian function. In fact, heart protection by premenopausal levels of female hormones, that is the oestrogen hypothesis, is not consistent with epidemiological findings that premenopausal hysterectomy essentially cancels the protection even in patients with preservation of functioning ovaries [2]. On the contrary, these data [2] suggest that an intact uterus has an important role in the protection of premenopausal women, and this is likely related to the beneficial effect of iron depletion in menstruating women (i.e. the iron hypothesis suggested since 1981 by Sullivan [3]).

    A protective effect of iron depletion may be related to the decreased availability of redox-active iron within atherosclerotic lesions. Serum ferritin concentrations, commonly used as a surrogate for iron stores, are significantly lower in premenopausal menstruating women (25-50 ng/mL) compared to men (140-150 ng/mL) of similar age, but slowly increase after menopause. Interestingly, average menstrual blood loss each year (780 mL) approximates blood loss from donating approximately two 500 mL units of whole blood [4]. It is noteworthy that phlebotomy of one unit of whole blood twice a year among predominantly white middle-aged and elderly men with peripheral arterial disease, resulted in a significant decrease in overall mortality, myocardial infarction and stroke over a several year period, compared to the control group not phlebotomized [4]. Not surprisingly, during the trial, the average serum ferritin concentration in the iron reduction group was approximately 60 ng/mL compared to 110 ng/mL in the control group [4]. On the contrary, it has become evident that supplemental iron use among elderly woman may be significantly and dose dependently associated with increased total mortality [5].

    In conclusion, higher vascular wall iron, contained in macrophages, might in part explain the sex difference in cardiovascular ageing. Moreover, donating blood twice a year by men and possibly postmenopausal women might decrease CVD morbidity and mortality. Furthermore, unnecessary iron supplements should be avoided and iron fortification of our food supply should be questioned. Finally, randomized trials of iron depletion for the primary and secondary prevention of vascular disease need to be done.

    1. Merz AA, Cheng S. Sex differences in cardiovascular ageing. Heart 2016 Feb [Epub ahead of print]. 2. Kannel WB, Levy D. Menopause, hormones, and cardiovascular vulnerability in women. Arch Intern Med 2004;164:479-81. 3. Sullivan JL. Iron and the sex difference in heart disease risk. Lancet 1981;1:1293-4. 4. Zacharski LR, Shamayeva G, Chow BK. Effect of controlled reduction of body iron stores on clinical outcomes in peripheral arterial disease. Am Heart J 2011;162:949-957.e1. 5. Mursu J, Robien K, Harnack LJ. Dietary supplements and mortality rate in older women: the Iowa Woman's Health Study. Arch Intern Med 2011;171:1625-1633.

    Conflict of Interest:

    None declared

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  5. Author Reply: Sex Differences in Cardiovascular Ageing

    We thank Dr. Goldstein for bringing to our attention the iron hypothesis as a potential non-hormonal factor contributing to sex differences in cardiovascular aging. We also find intriguing the possibility that iron depletion in menstruating women may be cardio- protective. We had previously been aware of the potential role of iron as a byproduct of heme-oxygenase activity in mediating cardiometabolic risk,[1] with a number of community studies having reported equivocal findings when examining the relation between either iron or ferritin with respect to outcomes.[2-5] It is our impression that heterogeneity in prior study results may be related to differences in participant sampling methods, the iron measures used (ferritin, total iron binding capacity, transferrin saturation, serum iron, and dietary iron intake), and presence of potential confounding variables that could influence both iron levels and a given outcome of interest (e.g. inflammation, genetic variants). Given that iron accumulation patterns have been observed to vary by age and race as well as sex,[6] we agree that further studies investigating the role of iron as a potential contributor to cardiovascular risk are warranted. In particular, interventional studies could evaluate sex-based differences and also account for variables that could influence both iron levels and a given outcome of interest (e.g. blood donation and/or phlebotomy patterns, supplemental intake of iron, dietary patterns including heme vs. non-heme iron intake, and factors that might elevate ferritin as part of the acute phase response). We look forward to learning more about the potential contribution of iron depletion to sex differences in cardiovascular disease, in particular, as additional evidence emerges from this understudied field.

    References

    1. Fredenburgh LE, Merz AA, Cheng S. Haeme oxygenase signalling pathway: implications for cardiovascular disease. Eur Heart J. 2015 Jun 21;36(24):1512-8. doi: 10.1093/eurheartj/ehv114. Epub 2015 Mar 31. Review. PubMed PMID: 25827602; PubMed Central PMCID: PMC4475572.

    2. Salonen JT, Nyyssonen K, Korpela H, Tuomilehto J, Sepp?nen R, Salonen R. High stored iron levels are associated with excess risk of myocardial infarction in eastern Finnish men. Circulation. 1992 Sep;86(3):803-11. PubMed PMID: 1516192.

    3. Baer DM, Tekawa IS, Hurley LB. Iron stores are not associated with acute myocardial infarction. Circulation. 1994 Jun;89(6):2915-8. PubMed PMID: 8205708.

    4. Mu?oz-Bravo C, Guti?rrez-Bedmar M, G?mez-Aracena J, Garc?a- Rodr?guez A, Navajas JF. Iron: protector or risk factor for cardiovascular disease? Still controversial. Nutrients. 2013 Jul 1;5(7):2384-404. doi: 10.3390/nu5072384. Review. PubMed PMID: 23857219; PubMed Central PMCID: PMC3738979.

    5. Basuli D, Stevens RG, Torti FM, Torti SV. Epidemiological associations between iron and cardiovascular disease and diabetes. Front Pharmacol. 2014 May 20;5:117. doi: 10.3389/fphar.2014.00117. eCollection 2014. Review. PubMed PMID: 24904420; PubMed Central PMCID: PMC4033158.

    6. Zacharski LR, Ornstein DL, Woloshin S, Schwartz LM. Association of age, sex, and race with body iron stores in adults: analysis of NHANES III data. Am Heart J. 2000 Jul;140(1):98-104. PubMed PMID: 10874269.

    Conflict of Interest:

    None declared

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  6. The enigma of high adiponectin levels and adverse outcomes in older people: a consequence of proinflammatory state and autoimmune activation?

    The excellently analyzed paper from the Cardiovascular Health Study on higher circulating adiponectin being associated with elevated risk of atrial fibrillation (AF) in the elderly [1), calls for focusing attention on this and analogous paradoxical manifestations accumulating in the medical literature. The investigation by Macheret and associates involved 886 incident AF events in a cohort of older -predominantly female- adults. It demonstrated a positive and linear, rather than inverse or U-shaped, association between circulating adiponectin and incident AF, independent of numerous potential confounders. Females were particularly involved, although sex-stratified analysis was not provided, African-Americans were much less susceptible than Whites, as were overweight/obese than lean people.

    Paradoxal behaviour of high adiponectin levels considered as a pro- inflammatorily converted protein had been published from the Turkish Adult Risk Factor study since 2008 repeatedly. Independently from obesity and hyperinsulinemia, serum adiponectin disclosed epidemiologic evidence of attenuation of anti-inflammatory activities (2). Serum adiponectin proved to confer no protection against hypertension and was found to diverge in women from men regarding protection against future coronary disease risk (3).

    Adiponectin is not the only plasma protein to show paradoxical outcome. HDL-cholesterol and its constituents apolipoprotein(apo) A-I, A- II, and apoE have formed relevant underlying mechanisms for hypertension, metabolic syndrome, type-2 diabetes, coronary heart disease, chronic kidney disease and osteoarthritis. Not cholesterol itself, but cholesterol -overloaded high-density lipoprotein particles were independently associated with progression of carotid atherosclerosis in a cardiovascular disease-free Chinese population. High apo A-I levels, rather than conferring protection against incident type-2 diabetes, independently predicted it among Turks. The apoB/LDL-cholesterol ratio, a measure of small dense low-density lipoprotein particles, was highly predictive of diabetes in Finnish men.

    It may thus be concluded that the enigma of high adiponectin levels and adverse outcomes in older people is most likely a consequence of proinflammatory state and autoimmune activation. Diverse factors such as sex, age, race/ethnicity, susceptibility to impaired glucose tolerance modulate this phenomenon, formed on one hand by autoimmune components composed of protective plasma proteins turned proinflammatory, on the other hand by proteins sustaining epitope damage and partially escaping immunoassay (4).

    References

    1. Macheret F, Bartz TM, Djusse L. et al. Higher circulating adiponectin levels are associated with increased risk of atrial fibrillation in older adults. Heart 2015;101:1368-1374

    2. Onat A, Hergenc G, Dursunoglu D, et al. Relatively high levels of serum adiponectin in obese women, a potential indicator of anti- inflammatory dysfunction: Relation to sex hormone-binding globulin. Int J Biol Sci 2008;4:208-14

    3. Onat A, Aydin M, Can G, et al. High adiponectin levels fail to protect against risk of hypertension and, in women, against coronary disease: involvement in autoimmunity? World J Diabet 2013;4:219-25

    4. Onat A, Can G. Enhanced proinflammatory state and autoimmune activation: a breakthrough to understanding chronic diseases. Curr Pharm Design 2014; 20:575-84

    Conflict of Interest:

    None declared

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  7. Carotid Artery Stenting Outcomes in Dataset Registries: A Cause of Concern or an Opportunity for Improvement?

    Roffi et al.1 report that contemporary outcomes following carotid stenting (CAS) in large-scale registries were comparable to carotid endarterectomy (CEA). They also concluded that, over time, complication rates following CAS had decreased.1

    We recently reviewed outcomes after >1,500,000 procedures in 21 administrative dataset registries where procedural death/stroke rates were reported for both CEA and CAS.2 One key finding was that CAS was associated with in-hospital/30-day death/stroke rates which exceeded the 3% American Heart Association (AHA) risk threshold for asymptomatic patients in 9/21 registries (43%). In symptomatic patients, death/stroke rates exceeded the 6% AHA risk threshold in 13/18 (72%) registries and exceeded 10% in 5/18 registries (28%).2 We also found no evidence of a decline (over time) in procedural risks after CAS.2

    There is no doubt that CAS experts are now reporting excellent and durable outcomes, and it is also true that CAS offers benefits (over CEA) in terms of avoiding cranial nerve injury. However, there is a discrepancy between what is being reported in randomised trials and what is happening in the 'real world', especially in symptomatic patients. Some argue that most strokes following CAS are non-disabling (i.e. not clinically important), but Thomas Brott (CREST Principal Investigator) has stated that any perioperative stroke is associated with poorer long term survival, just as with perioperative myocardial infarction.3

    In conclusion, we agree with Marco Roffi that with better patient selection, improvements in stent design/protection devices and (most importantly) centralization of CAS procedures into high-volume centres, procedural risks following CAS will become similar to CEA. But, is the movement into 'higher volume' centres really happening? Sadly, evidence suggests that in the USA, if nowhere else, many CAS practitioners perform only 1-3 procedures each year,4 making it impossible to ever overcome the learning curve.

    The future is certainly looking brighter for CAS, but key opinion leaders now need to 'step up to the plate' to ensure that patients are only treated by experienced CAS practitioners with audited outcomes within AHA risk thresholds. This will not be popular, but evidence suggests that until it does, nothing will change.

    References

    1. Roffi M, Kulcsar Z, Carrera E, et al. Carotid artery stenting. Heart 2016 Mar 4. pii: heartjnl-2015-307638. doi: 10.1136/heartjnl-2015- 307638 [Epub ahead of print]

    2. Paraskevas KI, Kalmykov EL, Naylor AR. Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review. Eur J Vasc Endovasc Surg. 2016;51:3-12.

    3. von Allmen R. Dismantling the different myths around the CREST trial. Vascular News. 2012;53(1):10. Available at: http://www.vascularnews.com/vn-newspaper- pdfs?DocumentScreen=detail&cl=371&ccs=655. Accessed on March 23, 2016.

    4. Choi JC, Johnston SC, Kim AS. Early outcomes after carotid artery stenting compared with endarterectomy for asymptomatic carotid stenosis. Stroke. 2015;46:120-125.

    Conflict of Interest:

    None declared

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  8. Complete multivessel revascularization in STEMI. Reply to the letter by Shah et al.

    To the Editor:

    We read with interest the letter by dr Shah [1] regarding our recent meta-analysis: "Complete revascularisation in ST-elevation myocardial infarction and multivessel disease: meta-analysis of randomised controlled trials" [2]. The meta-analysis was designed to compare complete multivessel PCI (MV-PCI) with non-complete MV-PCI in ST-elvation myocardial infarction (STEMI) and MV disease. Complete MV-PCI was defined as revascularisation to non-infarct-related artery lesions during index procedure, non-complete MV-PCI-encompassed culprit-only revascularization (COR) and staged approaches. First of all, we appreciate the comments by Shah and are glad that our research has become of interest to a large international readership. At the same time we believe that criticism about methodology or clinical meaningfulness of a meta- analysis should be based upon specific clinical knowledge of the topic, and, above all, careful reading of the meta-analysis design.

    Shah suggests that because the majority of staged procedures were performed within days to weeks of their index procedures, they would be considered more like complete than incomplete revascularizations over a 12 -month follow-up. This is a simply arbitrary reclassification, given the large time discrepancy between the two approaches in all included studies that were however not designed to define an optimal timing, nor it was the primary focus of our paper. As a result, Shah speculates that staged PCI should became anyhow bundled in the same group with complete revascularization. This arbitrary re-reclassification is also in contrast with the natural history of the untreated coronary lesions. These patients present a different risk profile from those allocated to staged PCI; as a reflection of this, the untreated lesions over time in the second group have led to an accrual over time of the MI rates in the IRA- only treated patients; a difference in time in this group is pivotal to demonstrate the impact of leaving a non culprit plaque untreated; same applies to staged procedures. The approach in our analysis therefore reflects true clinical practice and indeed is based on coronary- and risk profile evaluation of the patients with non culprit plaques. An arbitrary, fixed time-frame second revascularisation for all patients with non culprit lesions is not only infeasible in clinical setting but, indeed, dangerous treating in the same way patients with different coronary artery lesions; as a sensitivity analysis, a stratified meta-analysis by intervention in the control group was performed as well. Our study was not designed to compare in the same setting complete revascularization (CR) vs index hospitalization CR vs later date CR vs IRA only revascularization; neither was any study conducted to date.

    Secondly, Shah is concerned about the validity of the findings due to inconsistency driven by inclusion of the entire complete revascularization cohort from the Complete versus Culprit-Lesion Only Primary PCI Trial (CvLPRIT), while in the Supplementary Table 5 CR was performed during the index procedure for 97 patients [3]. Current meta-analysis was performed according to intention-to-treat (ITT) which is recommended as the least biased way to estimate intervention effects in randomized trials [4]: principles of ITT analyses are, first of all, to classify participants in the intervention groups to which they were randomized, regardless of the intervention they actually received, therefore inclusion of post-hoc analyses which is the case for Supplementary Table 5, is not only forbidden by design of the meta-analysis but may also lead to attrition bias with patients dropping out from the initial randomization group and consequently to results that are unequal in regard to exposure and/or outcome. In the methods section of the CvLPRIT one reads that "if randomized to complete revascularization, it was mandated that the IRA be treated first. If there were no clinical contraindications, complete revascularization was recommended at the same sitting to reduce multiple vascular punctures, avoid prolonged hospitalization, and attenuate potential patient dropout". Decision for the procedure to be staged was based on clinical reasons and left to the operator, which we cannot answer for.

    Thirdly, Shah cited part of the methods from the study by Maamoun et al. [5] and concluded this study was an observational cohort; this remark is however incorrect because what is reported also in the abstract is: "A total of 78 patients (72 males and 6 females) with ST-elevation MI presented within 12 h from the onset of symptom who had at least two angiographically-documented diseased coronary arteries (luminal diameter narrowing ?70%) and received primary PCI were included. They were randomly assigned to receive either PCI for culprit vessel only in the initial procedure (SR group) followed by another session of angioplasty to other diseased vessels (within 7 days), or (CR group) consisted of 42 patients who had received complete revascularization during the initial procedure after intracoronary administration of nitroglycerin to avoid stenting of functionally nonsignificant lesions". We have no reasons to believe it was otherwise.

    Finally, Shah advises that the trial by Ghani et al. [6] should have had as well been included in the meta-analysis. While report by Ghani et al. comprises a follow-up study, the main results derive from the article by Dambrink et al. [7]. This study was intentionally excluded as not pertinent to the design of the meta-analysis. Dambrink et al. randomized STEMI patients to invasive and conservative treatment after primary angioplasty. In the invasive- group, "ischaemia-guided additional revascularisation was performed during the in-hospital phase after primary PCI or in an out-patient setting but no later than three weeks after STEMI", therefore nowhere close to complete MV-PCI during index procedure. The last claim of other studies intentionally omitted, undermining the validity of this meta-analysis, we leave to the discretion of the Heart Editor and the Readership.

    References

    1. Rahman Shah. Letter to the Editor regarding heartjnl-2014- 307293.R2 - Complete Revascularization in ST-Elevation Myocardial Infarction and Multivessel Disease. Meta-Analysis of Randomized Controlled Trials. 17.03.2016

    2. Kowalewski M, Schulze V, Berti S, Waksman R, Kubica J, Kolodziejczak M, Buffon A, Suryapranata H, Gurbel PA, Kelm M, Pawliszak W, Anisimowicz L, Navarese EP. Complete revascularisation in ST-elevation myocardial infarction and multivessel disease: meta-analysis of randomised controlled trials. Heart 2015;101:1309-1317.

    3. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963-72.

    4. Newell DJ. Intention-to-treat analysis: implications for quantitative and qualitative research. Int J Epidemiol 1992;21:837-841.

    5. Maamoun W, Elkhaeat N, Elarasy R. Safety and feasibility of complete simultaneous revascularization during primary PCI in patients with STEMI and multivessel disease. Egyptian Heart J 2011;63:39-43.

    6. Ghani A1, Dambrink JH, van 't Hof AW, et al. Treatment of non- culprit lesions detected during primary PCI: long-term follow-up of a randomised clinical trial. Neth Heart J. 2012 Sep; 20(9): 347-353

    7. Dambrink JH, Debrauwere JP, van 't Hof AW, Ottervanger JP, Gosselink AT, Hoorntje JC, de Boer MJ, Suryapranata H. Non-culprit lesions detected during primary PCI: treat invasively or follow the guidelines? EuroIntervention 2010;5:968-975.

    Conflict of Interest:

    None declared

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  9. Complete vs Culprit-only Revascularization for Patients with ST-Segment Elevation Myocardial Infarction

    To the Editor: We read with great interest the recent meta-analysis by Kowalewski et al.[1] The authors should be congratulated for their work. However, we would like to make few comments about some issues with the meta-analysis. First, complete revascularizations (CRs) done as staged procedures (SPs) were analyzed with the incomplete revascularization group, but endpoints were measured at a median follow-up of 12 months. Because the majority of SPs were performed within days to weeks of their index procedures, clinical wisdom suggests they would behave more like CRs than incomplete revascularizations over a 12-month follow-up. Therefore, we believe that from statistical and clinical points of view, CRs performed as SPs should have been included in the complete revascularization group, as was done in other meta-analyses and randomized trials.[2] Furthermore, the authors did not consistently analyzed CRs performed as SPs with the incomplete arm. In the Complete versus Culprit-Lesion Only Primary PCI Trial (CvLPRIT), CR was performed during the index procedure for 97 patients (Supplementary Table 5 in the CvLPRIT trial),[2] but this group (for this meta-analysis)was combined with patients receiving CRs as SPs, bringing the total to 150. This inconsistency significantly impacts the validity of the meta-analysis. In addition, the title indicates the study was a meta-analysis of randomized trials, yet it included the study by Maamoun et al, an observational cohort study,[3] as evidenced by a statement in the Methods section. Maamoun et al state, "Group 1 consisted of 36 patients presented in the 1st year of the study and had undergone primary PCI for culprit vessel only in the initial procedure followed by another session of angioplasty to other diseased vessels and group 2 consisted of 42 patients presented in the 2nd year of the study and had received complete revascularization during the initial procedure." Finally, the authors did not include a trial by Ghani et al.[4] No reason for this omission was mentioned in the Methods or Discussion. Therefore, we wonder if other studies were also omitted, undermining the validity of this meta-analysis. References: 1. Kowalewski M, Schulze V, Berti S, et al. Complete revascularisation in ST-elevation myocardial infarction and multivessel disease: meta-analysis of randomised controlled trials. Heart. 2015;101(16):1309-17. 2. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963-72. 3. Maamoun W, Elkhaeat N, Elarasy R. Safety and feasibility of complete simultaneous revascularization during primary PCI in patients with STEMI and multivessel disease. Egyptian Heart J 2011;63:39-43. 4. Ghani A1, Dambrink JH, van 't Hof AW, et al. Treatment of non-culprit lesions detected during primary PCI: long-term follow-up of a randomised clinical trial. Neth Heart J. 2012 Sep; 20(9): 347-353.

    Conflict of Interest:

    None declared

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  10. Assessing effect of remote ischaemic preconditioning on clinical outcomes in patients undergoing cardiac bypass surgery

    Assessing effect of remote ischaemic preconditioning on clinical outcomes in patients undergoing cardiac bypass surgery

    To the Editor : In a recent article of Candilio et al.1 assessing the effect of remote ischaemic preconditioning (RIPC) on postoperative outcomes in patients undergoing cardiac surgery, they showed that RIPC reduced the amount of perioperative myocardial injury by 26% and the incidence of acute kidney injury by 48%.The authors discuss the limitations of their work.In our view, the following important issues in this study seemed not to be well addressed.

    Perioperative dexmedetomidine infusion was not included in data analysis.Actually,perioperative dexmedetomidine infusion is common among patients undergoing cardiac surgery. Dexmedetomidine, a highly selective?2 adrenoreceptor agonist, has advantages for reducing renal injury. Perioperative dexmedetomidine infusion effectively reduces the incidence and severity of acute kidney injury in cardiac surgery.2 Preoperative Contrast angiography was not included in data analysis.

    Preoperative Contrast angiography is not rare among patients undergoing coronary artery bypass grafting surgery.The contrast-induced nephropathy is independently associated with increased postoperative risks of adverse renal events 3.

    Aminoglycoside, a commonly administered antibiotic in the operating room, independently associated with increased risks of postoperative acute renal injury(AKI) through intracellular processes such as mitochondrial dysfunction and reduction of protein synthesis.4

    We are concerned that if there is any disbalance in these factors would have confounded the interpretation of the results.

    1.Candilio L, Malik A, Ariti C, et al. Effect of remote ischaemic preconditioning on clinical outcomes in patients undergoing cardiac bypass surgery:a randomised controlled clinical trial. Heart 2015;101:185-92

    2.Jin Sun Cho, Jae-Kwang Shim, Sara Soh , et al.Perioperative dexmedetomidine reduces the incidence and severity of acute kidney injury following valvular heart surgery. Kidney Int 2015; advance online publication, 7 October 2015;doi:10.1038/ki.2015.306

    3.Persson PB, Hansell P, Liss P. Pathophysiology of contrast medium- induced nephropathy. Kidney Int 2005; 68:14-22.

    4. Sharfuddin AA, Weisbord SD, Palevsky PM, Molitoris BA. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA,Skorecki K, Yu ASL, Brenner BM, eds. Brenner and Rector's The Kidney. Philadelphia, USA: Elsevier, 2012; 1044-99

    Feng Xue, 1Hai chen Chu,1Wei Zhang2

    1.Department of Anesthesiology, the Affiliated Hospital of Qingdao University ,Qingdao ,China

    2.Department of nephrology ,the Affiliated Hospital of Qingdao University , Qingdao ,China

    Correspondence:

    Wei Zhang, Department of Nephrology, The Affilitated Hospital of Qingdao University,Qingdao266003, China. E-mail:xfwwww@163.com

    Contributors: Feng Xue read the manuscript of Candilio et al.; analysed their methods and data; suggested comment points and drafted this manuscript; responsible for this manuscript; and approved the final manuscript. Hai chen Chu read the paper of Candilio et al.;analysed their data; revised the comment points and this manuscript; and approved the final manuscript.Wei Zhang read the manuscript of Candilio et al.; analysed their methods and data; revised the comment points and this manuscript; and approved the final manuscript.

    Conflict of Interest:

    None declared

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