For the sake of completeness, the cardiac manifestations of rheumatological disorders documented by Sen et al(1) also ought to include bacterial as well as mycobacterial and fungal infections which invade either the pericardium or the myocardium in patients with rheumatological disorders. The following are some examples:-
Suppurative pericarditis attributable to Staphylococcus aureus was documented by Huskisson et al in one of the patients in their series of 12 rheumatiod arthritis(RA) patients with severe , unusual and recurrent infections(2). A massive tuberculous plericardial effusion was documented in a 60 year old man with long-standing RA who was not taking any immunosuppressive medication(3).
Staphylococcal pericarditis was reported in a 52 year old woman with systemic lupus erythematosus(SLE) who was on prednisolone(4). Tuberculous pericarditis coexisted with SLE in 3 patients who were participants in a series consisting of 72 SLE patients with coexisting active tuberculosis infection(5).
Eosinophilic granulomatosis with polyangiitis was the underlying rheumatological disorder in a 60 year old woman who died after experiencing complications of congestive heart failure. Autopsy examination revealed invasive myocarditis secondary to Aspergillus fumigatus infection as well as multiple myocardial abscesses(6).
Comment
In the context of multisystem rheumatological disease the expectation is that the occurrence of pericarditis a...
For the sake of completeness, the cardiac manifestations of rheumatological disorders documented by Sen et al(1) also ought to include bacterial as well as mycobacterial and fungal infections which invade either the pericardium or the myocardium in patients with rheumatological disorders. The following are some examples:-
Suppurative pericarditis attributable to Staphylococcus aureus was documented by Huskisson et al in one of the patients in their series of 12 rheumatiod arthritis(RA) patients with severe , unusual and recurrent infections(2). A massive tuberculous plericardial effusion was documented in a 60 year old man with long-standing RA who was not taking any immunosuppressive medication(3).
Staphylococcal pericarditis was reported in a 52 year old woman with systemic lupus erythematosus(SLE) who was on prednisolone(4). Tuberculous pericarditis coexisted with SLE in 3 patients who were participants in a series consisting of 72 SLE patients with coexisting active tuberculosis infection(5).
Eosinophilic granulomatosis with polyangiitis was the underlying rheumatological disorder in a 60 year old woman who died after experiencing complications of congestive heart failure. Autopsy examination revealed invasive myocarditis secondary to Aspergillus fumigatus infection as well as multiple myocardial abscesses(6).
Comment
In the context of multisystem rheumatological disease the expectation is that the occurrence of pericarditis and/or myocarditis will be attributable to the prevailing rheumatological disorder. However, in the occasional case, those complications are attributable to bacterial, mycobacterial, or fungal co-infection. Clinicians should be vigilant for that eventuality.
References
(1)Sen G., Gordon P., Sado DM
Cardiac manifestations of rheumatological disease: a synopsis for the cardiologist
Heart Epub ahead of print
(2)Huskisson EC., Hart FD
Severe, unusual, and recurrent infections in rheumatoid arthritis
Ann Rheum Dis 1972;31:118-121
(3) Habib S., Akhter P., Razzak S et al
Presentation of tuberculosis as isolated massive pericardial effusion in a patient with rheumatiod arthritis
J Pak Med Assoc 2012;62:65-67
(4) Knodell RG., Manders SJ
Staphylococcus pericarditis in a patient with Systemic Lupus Erythematosus
CHEST 1974;65:103-105
(5)Torrez-Gonzalez P., Romero-Diaz J., Cervera-Hernandez ME et al
Tuberculosis and systemic lupus erythematosus : a case-control study in Mexico City
Clinical Rheumatology 2018;37:2095-2102
(6)Bullis SS., Krywanczyk A., Hale AJ
Aspergillosis myocarditis in the immunocompromised host
ID cases 2019;17:e00567
The management of hypertension generates huge opportunities for opportunistic screening for atrial fibrillation(AF). To maximise that opportunity documentation of regularity of the pulse and, hence, for AF, should be routine at each visit to primary care or to secondary care. Furthermore, that should be the routine during follow up visits of patients with known hypertension. The rationale is that hypertension is a recognised risk factor for incident AF(1), and for progression of paroxysmal AF to permanent AF(2). thereby mandating a recognition that patients with known hypertension should be allocated to a high risk subgroup in whom opportunistic screening for AF should be maximised. There are opportunities for AF screening even with home blood pressure measurement. Some self blood pressure measuring devices trigger an alert when there is an irregularity in the pulse. Patients should be educated to inform their doctor when such alerts occur so that the patient can be evaluated further by electrocardiography.
The treatment phase of hypertension addresses the challenge of atrial fibrillation by mitigating the risk of new onset development of that arrhythmia. Using data from SPRINT(Systolic Blood Pressure Intervention Trial) Soliman et al showed that intensive blood pressure lowering to a systolic blood pressure of < 120 mm Hg was associated with a 26% lower risk of developing new AF(hazard ratio, 0.74[95% Confidence Interval, 0.56-0.98]; P=0.37(3). What n...
The management of hypertension generates huge opportunities for opportunistic screening for atrial fibrillation(AF). To maximise that opportunity documentation of regularity of the pulse and, hence, for AF, should be routine at each visit to primary care or to secondary care. Furthermore, that should be the routine during follow up visits of patients with known hypertension. The rationale is that hypertension is a recognised risk factor for incident AF(1), and for progression of paroxysmal AF to permanent AF(2). thereby mandating a recognition that patients with known hypertension should be allocated to a high risk subgroup in whom opportunistic screening for AF should be maximised. There are opportunities for AF screening even with home blood pressure measurement. Some self blood pressure measuring devices trigger an alert when there is an irregularity in the pulse. Patients should be educated to inform their doctor when such alerts occur so that the patient can be evaluated further by electrocardiography.
The treatment phase of hypertension addresses the challenge of atrial fibrillation by mitigating the risk of new onset development of that arrhythmia. Using data from SPRINT(Systolic Blood Pressure Intervention Trial) Soliman et al showed that intensive blood pressure lowering to a systolic blood pressure of < 120 mm Hg was associated with a 26% lower risk of developing new AF(hazard ratio, 0.74[95% Confidence Interval, 0.56-0.98]; P=0.37(3). What now needs to be recognised as the next challenge is to identify which one of the antihypertensive drug classes optimally mitigates the risk of new-onset AF. In conclusion, although routine screening for atrial fibrillation has not yet become the norm, the management of hypertension generates huge opportunities for opportunistic screening for that arrhythmia, and for mitigating the risk of its occurrence.
I have no conflict of interest
References
(1)Benjamin EJ., Levy D., Vaziri SM et al
Independent risk factors for atrial fibrillation in a population-based cohort: the Framingham Heart Study
JAMA 1994;271:840-844
(2)De Vos CB., Pisters R., Noewlaat R et al
Progression fro paroxysmal to persistent atrial fibrillation. Clinical correlates and prognosis
J Am Coll Cardiol 2010;55:725-731
(3)Soliman EZ., Rahman AKMF., Zhang Z-m et al
Effect of intensive blood pressure lowering on the risk of atrial fibrillation
Hypertension 2020;75:1491-1496
In an excellent analysis published in the recent issue of the journal, “Heart” Lau et al. investigated the long-term clinic outcomes of patients with Takotsubo syndrome (TTS) in a large cohort. The results demonstrated that increasing age, male gender, diabetes mellitus, pulmonary disease and chronic kidney disease were associated with a higher risk of recurrence or death1. We wish to highlight a few points relevant to the article.
Núñez-Gil et al reported their findings whilst categorizing patients with TTS based upon proposed etiology. Individuals with idiopathic or emotional triggers were considered as having the primary disease, whereas those with likely physical causative factors were deemed to have a secondary form of the pathology. The analysis of both groups revealed a disparity in clinical outcomes; patients with underlying physical triggers displayed higher risk of both short and long-term adverse events 2. Similar findings have also been reported in other studies 3.
Prior published data has theorized that a history of diabetes mellitus may be relatively protective against developed of TTS possibly due to an ameliorated sympathetic response when compared to non-diabetics due to involvement related to diabetic neuropathy 4. Comparatively poorer outcomes in diabetic TTS patients as seen in this study may be possibly explained by the fact that these diabetic patients may have been overwhelmingly sicker to generate enough catecho...
In an excellent analysis published in the recent issue of the journal, “Heart” Lau et al. investigated the long-term clinic outcomes of patients with Takotsubo syndrome (TTS) in a large cohort. The results demonstrated that increasing age, male gender, diabetes mellitus, pulmonary disease and chronic kidney disease were associated with a higher risk of recurrence or death1. We wish to highlight a few points relevant to the article.
Núñez-Gil et al reported their findings whilst categorizing patients with TTS based upon proposed etiology. Individuals with idiopathic or emotional triggers were considered as having the primary disease, whereas those with likely physical causative factors were deemed to have a secondary form of the pathology. The analysis of both groups revealed a disparity in clinical outcomes; patients with underlying physical triggers displayed higher risk of both short and long-term adverse events 2. Similar findings have also been reported in other studies 3.
Prior published data has theorized that a history of diabetes mellitus may be relatively protective against developed of TTS possibly due to an ameliorated sympathetic response when compared to non-diabetics due to involvement related to diabetic neuropathy 4. Comparatively poorer outcomes in diabetic TTS patients as seen in this study may be possibly explained by the fact that these diabetic patients may have been overwhelmingly sicker to generate enough catecholaminic surge to have TTS 1.
The present analysis is similar to previous data and suggests that patients with underlying physical triggers may be at a disproportionate risk for unfavorable clinical outcomes 1, 4. We continue to suggest that patients with TTS be categorized and separately analyzed based upon primary or secondary disease etiology to allow for a better understanding of these two distinct entities and its related risk prognostication 4. We are also intrigued by the role of diabetes and TTS related adverse events and look forward to further research highlighting this association.
References
1. Lau C, Chiu S, Nayak R, Lin B, Lee MS. Survival and risk of recurrence of takotsubo syndrome. Heart. 2021 Jan 8:heartjnl-2020-318028. doi: 10.1136/heartjnl-2020-318028. Epub ahead of print. PMID: 33419884.
2. Núñez-Gil IJ, Almendro-Delia M, Andrés M, Sionis A, Martin A, Bastante T, Córdoba-Soriano JG, Linares JA, González Sucarrats S, Sánchez-Grande-Flecha A, Fabregat-Andrés O, Pérez B, Escudier-Villa JM, Martin-Reyes R, Pérez-Castellanos A, Rueda Sobella F, Cambeiro C, Piqueras-Flores J, Vidal-Perez R, Bodí V, García de la Villa B, Corbí-Pascua M, Biagioni C, Mejía-Rentería HD, Feltes G, Barrabés J; RETAKO investigators. Secondary forms of Takotsubo cardiomyopathy: A whole different prognosis. Eur Heart J Acute Cardiovasc Care. 2016 Aug;5(4):308-16. doi: 10.1177/2048872615589512. Epub 2015 Jun 4. PMID: 26045512.
3. Chhabra L, Sareen P, Mwansa V, Khalid N. Mortality in Takotsubo cardiomyopathy should also be accounted based on predisposing etiology. Ann Noninvasive Electrocardiol. 2019 Jul;24(4):e12664. doi: 10.1111/anec.12664. Epub 2019 Jun 2. PMID: 31155779; PMCID: PMC6931614.
4. Khalid N, Ahmad SA, Umer A, Chhabra L. Role of Microcirculatory Disturbances and Diabetic Autonomic Neuropathy in Takotsubo Cardiomyopathy. Crit Care Med. 2015 Nov;43(11):e527. doi: 10.1097/CCM.0000000000001183. PMID: 26468716.
The residual risk of stroke in subjects with nonvalvular atrial fibrillation(NVAF) is, in part, attributable to coexistence of nonvalvular atrial fibrillation(NVAF) and high-grade(stenosis(50% or more severity) involving the intracranial arterial circulation(1). In the latter study concomitant high-grade cerebrovascular stenosis was identified in 231 of 780 consecutive subjects of mean age 69.5 who had undergone angiographic studies at index stroke(1). Coexistence of extracranial carotid artery stenosis(CAS) and NVAF is also a risk factor for residual stroke(2). In the latter study Chang et al identified high-grade CAS(>50% severity) which was ipsilateral to the index ischemic cerebral infarct in 15 out of 25 patients presenting with stroke(2).
Secondary prevention of stroke in NVAF patients who have the association of either high-grade stenotic intracranial cerebrovascular disease or high-grade CAS to which the index stroke can be attributed would entail coprescription of low-dose aspirin and an oral anticoagulant drug. Edoxaban would be a suitable candidate, given the fact that the 15 mg/day dose significantly mitigates the risk of stroke ( of presumably cardioembolic origin) in NVAF subjects aged 80 or more(3). That dose is even lower than the 30 mg/day dose which is associated with significantly(p < 0.001) lower risk of gastrointestinal bleeding than warfarin(4).
Primary prevention would require strict abstinence from smoking, str...
The residual risk of stroke in subjects with nonvalvular atrial fibrillation(NVAF) is, in part, attributable to coexistence of nonvalvular atrial fibrillation(NVAF) and high-grade(stenosis(50% or more severity) involving the intracranial arterial circulation(1). In the latter study concomitant high-grade cerebrovascular stenosis was identified in 231 of 780 consecutive subjects of mean age 69.5 who had undergone angiographic studies at index stroke(1). Coexistence of extracranial carotid artery stenosis(CAS) and NVAF is also a risk factor for residual stroke(2). In the latter study Chang et al identified high-grade CAS(>50% severity) which was ipsilateral to the index ischemic cerebral infarct in 15 out of 25 patients presenting with stroke(2).
Secondary prevention of stroke in NVAF patients who have the association of either high-grade stenotic intracranial cerebrovascular disease or high-grade CAS to which the index stroke can be attributed would entail coprescription of low-dose aspirin and an oral anticoagulant drug. Edoxaban would be a suitable candidate, given the fact that the 15 mg/day dose significantly mitigates the risk of stroke ( of presumably cardioembolic origin) in NVAF subjects aged 80 or more(3). That dose is even lower than the 30 mg/day dose which is associated with significantly(p < 0.001) lower risk of gastrointestinal bleeding than warfarin(4).
Primary prevention would require strict abstinence from smoking, strict control of the lipid profile and strict control of blood pressure.
I have no funding and no conflict of interest.
References
(1) Kim YD., Cha MJ., Kim J et al
Increases in cerebral atherosclerosis according to CHADS2 scores in patients with stroke with nonvalvular atrial fibrillation
STROKE 2011;42:930-934
(2)Chang Y-J., Ryu S-J., Lin S-K
Carotid artery stenosis in ischemic stroke patients with nonvalvuar atrial fibrillation
Cerebrovascular Disease 2002;13:16020
(3)Okumura K., Akao M., Yoshida T et al
Low-dose edoxaban in very elderly patients with atrial fibrillation
N Engl J Med2020;383:1735-1745
(4)Guigliano RP., Ruff CT., Braunwald E et al
Edoxaban versus warfarin in patients with atrial fibrillation
N Engl J Med 2013;369:2093-2104
To the Editor,
We have recently read with great interest the article by Kim et al entitled ‘‘Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery’’ [1]. We appreciate the authors for their study describing the relationship of preservation of the left atrial appendage (LAA) to the risk of adverse clinical events in patients with rheumatic mitral valve disease. On the other hand, we believe that there are several major drawbacks that need to be addressed.
First of all, the LAA can be excluded from the systemic circula¬tion by obliterating its orifice with or without excising the body of the appendage [2]. During the two decades, mechanical occlusion of the LAA including the surgical approach has been adopted by clinicians as a potential approach for stroke prevention in selected patients with atrial fibrillation (AF) [2]. Surgical LAA ligation has been attempted with or without enabling devices. Although routine surgical LAA occlusion has been recommended by some, the evidence base for its actual benefit remains limited and conflicting. Surgical closure particularly using suture ligation can yield incomplete surgical left atrial appendage closure (iSLC) in more than one-third of the patients [2, 3]. Previously, Katz et al evaluated 50 patients who underwent surgical LAA closure in association with mitral valve surgery and similarly reported iSLC in 36% of their patients [3]. The readers may wonder whether routine p...
To the Editor,
We have recently read with great interest the article by Kim et al entitled ‘‘Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery’’ [1]. We appreciate the authors for their study describing the relationship of preservation of the left atrial appendage (LAA) to the risk of adverse clinical events in patients with rheumatic mitral valve disease. On the other hand, we believe that there are several major drawbacks that need to be addressed.
First of all, the LAA can be excluded from the systemic circula¬tion by obliterating its orifice with or without excising the body of the appendage [2]. During the two decades, mechanical occlusion of the LAA including the surgical approach has been adopted by clinicians as a potential approach for stroke prevention in selected patients with atrial fibrillation (AF) [2]. Surgical LAA ligation has been attempted with or without enabling devices. Although routine surgical LAA occlusion has been recommended by some, the evidence base for its actual benefit remains limited and conflicting. Surgical closure particularly using suture ligation can yield incomplete surgical left atrial appendage closure (iSLC) in more than one-third of the patients [2, 3]. Previously, Katz et al evaluated 50 patients who underwent surgical LAA closure in association with mitral valve surgery and similarly reported iSLC in 36% of their patients [3]. The readers may wonder whether routine postoperative screening can be performed in AF patients with LAA exclusion.
Second, surgical closure particularly using suture ligation can yield iSLC in more than one-third of the patients, which, in turn, may be associated with increased thromboembolic complications (TECs) [2, 4]. In another trial, Garcia-Fernandez et al [5] similarly evaluated 58 patients who underwent surgical LAA ligation and determined that lack of LAA ligation served as an independent predictor of embolic events. When identification of iSLC was taken into account, the estimated embolic risk further increased to approximately 12-fold. Previously, Aryana et al indicated that the incidence of iSLC among 72 AF patients who underwent surgical suture ligation of LAA in conjunction with mitral valve surgery was 36% [4]. Hence, these findings support the hypothesis that the presence of iSLC may be ‘worse’ than no ligation at all [2]. Although the specific reasons for this are not clearly defined, it is conceivable that due to its ‘stenotic’ neck, iSLC may be associated with a ‘low-flow’ state and increased stasis, in turn promoting a greater risk for the development of TECs. The presence of extensive trabeculation and reduced peak flow have both been proposed to influence LAA stasis and thrombus formation [2, 4]. Recently, we have reported that a small LAA neck size as a predictor of thromboembolic stroke in patients with iSLC [2]. The mechanism for this probably related to a higher degree of stasis within the LAA. This is also consistent with our observation that patients with larger LAA neck diameters exhibit a lower risk of TEC [2]. Therefore, long-term strict anticoagulation therapy and follow-up are strongly encouraged in this high-risk group of patients. In this study, the authors did not provide detailed information about the anticoagulation treatments of these patients in the post-operative period.
REFERENCES
1.Kim WK, Kim HJ, Kim JB, et al. Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery. Heart 2020; 106:1839-1846.
2.Güner A, Kalçık M, Gündüz S, et al. The relationship between incomplete surgical obliteration of the left atrial appendage and thromboembolic events after mitral valve surgery (from the ISOLATE Registry). J Thromb Thrombolysis 2020 Sep 30. doi: 10.1007/s11239-020-02291-5. Online ahead of print.
3.Katz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol 2000; 36:468–471.
4.Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm 2015; 12:1431-1437.
5.García-Fernández MA, Pérez-David E, Quiles J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol 2003; 42:1253-1258.
The observation that transient constrictive pericarditis(CP) is associated with a significantly higher erythrocyte sedimentation rate than its counterpart, persistent pericarditis, is consistent with the hypothesis that, in the former disorder, an active inflammatory process is at play, which might be responsive to corticosteroid therapy, whereas, in the latter context, irreversiible pericardial fibrosis or even pericardial calcification might have become firmly established.
This hypothesis can be tested in a disorder such as IgG4-related constrictive pericarditis, where corticosteroids are the only treatment modality available. In IgG4-related CP the disease spectrum includes, at one extreme,, effusive-constrictive pericarditis without pericardial calcification(1), and, at the other extreme, CP with pericardial calcification(2).In between, there may be gradations of acute inflammatory response..
The 79-year old man with IgG4-related effusive CP reported by Yuriditsky et al had stigmata of CP identified by simultaneous left and right-sided catheterisation. He had an initially good response to corticostroids, characterised by good diuresis over the course of 10 days. However, he had a subsequent relapse, and was eventually treated by pericardiectomy(1).
By contrast, the 29 year old woman with IgG4-related CP reported by Sekigushi et al had a consistently good response to corticosteroids. In her case, as well, there was no pericardial calcification. E...
The observation that transient constrictive pericarditis(CP) is associated with a significantly higher erythrocyte sedimentation rate than its counterpart, persistent pericarditis, is consistent with the hypothesis that, in the former disorder, an active inflammatory process is at play, which might be responsive to corticosteroid therapy, whereas, in the latter context, irreversiible pericardial fibrosis or even pericardial calcification might have become firmly established.
This hypothesis can be tested in a disorder such as IgG4-related constrictive pericarditis, where corticosteroids are the only treatment modality available. In IgG4-related CP the disease spectrum includes, at one extreme,, effusive-constrictive pericarditis without pericardial calcification(1), and, at the other extreme, CP with pericardial calcification(2).In between, there may be gradations of acute inflammatory response..
The 79-year old man with IgG4-related effusive CP reported by Yuriditsky et al had stigmata of CP identified by simultaneous left and right-sided catheterisation. He had an initially good response to corticostroids, characterised by good diuresis over the course of 10 days. However, he had a subsequent relapse, and was eventually treated by pericardiectomy(1).
By contrast, the 29 year old woman with IgG4-related CP reported by Sekigushi et al had a consistently good response to corticosteroids. In her case, as well, there was no pericardial calcification. Echocardiography showed "constrictive hemodynamics" without evidence of pericardial effusion. Computed tomography showed pericardial thickening. When repeated after 10 weeks of corticosteroid treatment echocardiography no longer showed "constrictive hemodynamics"(3). In both cases(10(3) the diagnosis of CP had, arguably, been made at trhe inflammatory stage, hence the demonstration of some degree of response to corticosteroids, albeit the response was more enduring in the patient reported by Sekiguchi et all(3).
I have no funding and no conflict of interest.
References
(1)Yuriditsky E., Dwivedi A., Narula N et al
Constrictive pericarditis caused by IgG4-related disease rquiring pericardiectomy after partial response to corticosteroids
JACC Case Report 2020;2:1558-1563
(2)Luo W-Q., Fang F., Zhen W-J et al
A case of immunoglobulin G4-related constrictive pericarditis
AnnTransl Med 2016;4(3):57
(3)Sekiguchi H., Horie R., Utz J., Ryu JH
IgG4-related systemic disease presenting with lung entrapment and constrictive pericarditis
CHEST 2012;142:781-783
For the sake of completeness, the evaluation of the deficit in knowledge and awareness and treatment of hypertension (1) should include an inquiry about two issues that are fundamental to the relationship between hypertension and stroke. For those issues to be addressed, the questionnaire should include the following items:-
(i)Did you ever have your blood pressure taken in both arms?
(ii)When you commenced antihypertensive treatment did you and your doctor agree on a "goal" blood pressure?
The rationale for those two lines of inquiry is the following:-
According to one meta analysis(10 cohorts; 13,317 patients) interarm blood pressure difference > 15 mm Hg is associated with a significant Cox stratified adjusted hazard ratio for subsequent stroke(hazard ratio, 2.42: 95% Confidence Interval, 1.27-4.60; p < 0.01) (2).
Furthermore, antihypertensive medication should be titrated against the higher of the two inter arm blood pressure measurements otherwise the patient will run the risk of suboptimal drug dosing and the risk of missed diagnosis of resistant hypertension.
A mutually agreed "goal" blood pressure should be specified from the outset otherwise there will be a risk of insidious onset of "physician inertia" which could contribute to the subsequent development of stroke.
Younger patients have the most o gain from an ambitious "goal " blood pressure which sets the target...
For the sake of completeness, the evaluation of the deficit in knowledge and awareness and treatment of hypertension (1) should include an inquiry about two issues that are fundamental to the relationship between hypertension and stroke. For those issues to be addressed, the questionnaire should include the following items:-
(i)Did you ever have your blood pressure taken in both arms?
(ii)When you commenced antihypertensive treatment did you and your doctor agree on a "goal" blood pressure?
The rationale for those two lines of inquiry is the following:-
According to one meta analysis(10 cohorts; 13,317 patients) interarm blood pressure difference > 15 mm Hg is associated with a significant Cox stratified adjusted hazard ratio for subsequent stroke(hazard ratio, 2.42: 95% Confidence Interval, 1.27-4.60; p < 0.01) (2).
Furthermore, antihypertensive medication should be titrated against the higher of the two inter arm blood pressure measurements otherwise the patient will run the risk of suboptimal drug dosing and the risk of missed diagnosis of resistant hypertension.
A mutually agreed "goal" blood pressure should be specified from the outset otherwise there will be a risk of insidious onset of "physician inertia" which could contribute to the subsequent development of stroke.
Younger patients have the most o gain from an ambitious "goal " blood pressure which sets the target at a systolic blood pressure(SBP) of < 120 mm Hg(3) because they are less likely to incur the antihypertensive drug side effects that might inhibit attainment of optimum SBP. Another benefit of intensive blood pressure lowering is that it mitigates the risk of atrial fibrillation(4), thereby also mitigating the risk of cardioembolic stroke.
I have no funding and no conflict of interest.
References
(1)O'Donnell M., Hankey GJ., Rangarajan S., Chin SL., Rao-Melacini P., Ferguson J., Xavier D et al
Variations in knowledge , awareness and treatment of hypertension and stroke risk by country income level
Heart 2019. doi:10.1136/heartjnl-2019-316515
(2)Tomiyama H., Ohkuma T., Ninomiya T., Masumoto C., Kario K., Hoshide S., Kita Y., Inoguchi T et al
Simultaneously measured interarm blood pressure difference and stroke
An Individual Participants Data Meta-Analysis
Hypertension 2018;71:1030-1038
(3)SPRINT Research Group, Wright JT., Williamson JD et al
A randomized trial of intensive versus standard blood pressure control
N Engl J Med 2015;373:2103-2116
(4)Soliman EZ., Rahman AKM F., Zhang Z-m., Rodriguez CJ., Chang TI., Bate JT et al
Effect of intensive blood pressure lowering on the risk of atrial fibrillation
Hypertension 2020;75:1491-1496
A corollary to the recommendation for anticoagulant persistence is a recognition that the time is long overdue for inclusion of evaluation of the extracranial carotid artery for evidence of high grade(ie >50 occlusion) carotid artery stenosis(CAS). The following is the rationale for the latter recommendation:-
Among patients aged > 70 high-grade CAS has a prevalence of 12% among men and 11% among women(1).
A systematic review of 9 studies(2611 patients) reporting presumed pathophysiological stroke mechanisms in patients with nonvalvular atrial fibrillation(NVAF) disclosed that 11%-24% of patients with the association of stroke and NVAF have high-grade CAS(2).
Some stroke patients with NVAF have high-grade CAS ipsilateral to the culprit cerebral infarct, implying an aetiological role for the CAS in the pathogenesis of the incident stroke(3).
During the entire history of the CHA2DS2 Vasc score we have squandared the opportunity to include ultrasonography of the extracranial carotid artery in the routine work up of newly diagnosed patients with NVAF. This was a missed opportunity to identify CAS as the potential aetiological agent in the event of the occurrence of manifestations of symptomatic CAS such as amaurosis fugax, transient ischemic attack, or non disabling stroke.. Without prior knowledge of the status of the carotid arteries those manifestations might have been missed opportunities to implement strategies such as carotid arte...
A corollary to the recommendation for anticoagulant persistence is a recognition that the time is long overdue for inclusion of evaluation of the extracranial carotid artery for evidence of high grade(ie >50 occlusion) carotid artery stenosis(CAS). The following is the rationale for the latter recommendation:-
Among patients aged > 70 high-grade CAS has a prevalence of 12% among men and 11% among women(1).
A systematic review of 9 studies(2611 patients) reporting presumed pathophysiological stroke mechanisms in patients with nonvalvular atrial fibrillation(NVAF) disclosed that 11%-24% of patients with the association of stroke and NVAF have high-grade CAS(2).
Some stroke patients with NVAF have high-grade CAS ipsilateral to the culprit cerebral infarct, implying an aetiological role for the CAS in the pathogenesis of the incident stroke(3).
During the entire history of the CHA2DS2 Vasc score we have squandared the opportunity to include ultrasonography of the extracranial carotid artery in the routine work up of newly diagnosed patients with NVAF. This was a missed opportunity to identify CAS as the potential aetiological agent in the event of the occurrence of manifestations of symptomatic CAS such as amaurosis fugax, transient ischemic attack, or non disabling stroke.. Without prior knowledge of the status of the carotid arteries those manifestations might have been missed opportunities to implement strategies such as carotid artery endarterectomy or carotid artery stenting for secondary prevention of disabling stroke.
It is unconscionable that we should allow such a state of affairs to continue indefinitely.
I have no funding and no conflict of interest.
References
(1)Kanter MC., Tegeler CH., Peasrce LA et al
Carotid stenosis in patients with atrial fibrillation. Prevalence, risk factors, and relationship to stroke in Stroke Prevention in Atrial Fibrillation Study
Arch Intern Med 1994;154:1372-1377
(2)Katsi V., Georgiopoulos G., Skafida A et al
Noncardioembolic stroke in patients with nonvalvular atrial fibrillation
Angiology 2019;70:299-304
(3)Chang Y-J., Ryu S-J., Lin S-K
Carotid artery stenosis in ischemic stroker patients with nonvalvular atrial fibrillation
Cerebrovasc Dis 2002;13:16-20
We have read with great interest the article written by Jolicoer et al. (1) about the concordant domain analysis, a new method to interpret early phase trials and we applaud their initiative which expands the horizons in the current context of progressive diffuculties to ran studies.
Randomized controlled trials (RCT) and meta-analysis constitute the highest level of evidence and the chances to succeed are high when there is a strong financial support to launch projects as Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) with 27,564 patients, which in addition to demonstrate the hypothesis of the study, it ensures the external validity and the study of subgroups.
However, recently we are witnessing a progressively more tortuous environment to launch adequately powered RCTs due to economic restrictions, lower margin to demonstrate cost-effectivity of the new treatments and more strict legal requirements and as the authors quote, only 1 in 10 investigational agents tested in phase III trials reaches the market. Some authors have already raisen concerns about the future of research and the protagonism of new methods as adaptive studies(2) or approaches to emulate RCT (3) are foreseen in the near future.
In our opinion, the combination of pilot randomized studies with new iniciatives as the described by Jolicoer may be a promising pathway when the conditions to launch large RCTs are not possible and in fa...
We have read with great interest the article written by Jolicoer et al. (1) about the concordant domain analysis, a new method to interpret early phase trials and we applaud their initiative which expands the horizons in the current context of progressive diffuculties to ran studies.
Randomized controlled trials (RCT) and meta-analysis constitute the highest level of evidence and the chances to succeed are high when there is a strong financial support to launch projects as Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) with 27,564 patients, which in addition to demonstrate the hypothesis of the study, it ensures the external validity and the study of subgroups.
However, recently we are witnessing a progressively more tortuous environment to launch adequately powered RCTs due to economic restrictions, lower margin to demonstrate cost-effectivity of the new treatments and more strict legal requirements and as the authors quote, only 1 in 10 investigational agents tested in phase III trials reaches the market. Some authors have already raisen concerns about the future of research and the protagonism of new methods as adaptive studies(2) or approaches to emulate RCT (3) are foreseen in the near future.
In our opinion, the combination of pilot randomized studies with new iniciatives as the described by Jolicoer may be a promising pathway when the conditions to launch large RCTs are not possible and in fact, we have recently seen examples of small pilot randomized trials with clinical endpoints published in journals of very high impact factor(4). In this way, our group has recently received financial support from a large company of devices to run a pilot study with 400 patients to explore a research question that requires a large and expensive trial of 2000 patients (ANGiographic Evaluation of Left main coronary INtErvention, ANGELINE, NCT04604197).
In summary, we are assisting to relevant changes in the field of research and although RCTs and meta-analysis will be and will have to be always the first goal, new initiatives as the one that Jolicoer et al. share with us deserve our attention and are very welcome.
REFERENCES
1. Jolicoeur EM, Verheye S, Henry TD et al. A novel method to interpret early phase trials shows how the narrowing of the coronary sinus concordantly improves symptoms, functional status and quality of life in refractory angina. Heart 2021;107:41-46.
2. Rapezzi C, Maggioni AP, Ferrari R. Adapting to survive. Eur Heart J 2020;41:3981-3983.
3. Franklin JM, Patorno E, Desai RJ et al. Emulating Randomized Clinical Trials with Nonrandomized Real-World Evidence Studies: First Results from the RCT DUPLICATE Initiative. Circulation 2020.
4. Yannopoulos D, Bartos J, Raveendran G et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet 2020;396:1807-1816.
In clinical practice, timing of aortic valve intervention in asymptomatic severe aortic stenosis (ASAS) has been a challenging task particularly in the absence of overt high-risk features (low ejection fraction, etc.) (1,2). The recently published article by Bing R, et al. (1), has discussed current strategies that might help risk-stratification and management of this precarious valvular phenomenon. In this context, we fully agree with the authors that serum biomarkers including natriuretic peptides, as opposed to certain imaging modalities, generally have significant limitations (1). However, serum copeptin (the surrogate marker of arginine-vasopressine (AVP) axis) might serve as a promising guide to prognostication and clinical decision-making for aortic valve intervention in patients with ASAS (2) largely due to pathophysiological implications of AVP axis in these patients:
Firstly; copeptin elevation in patients with ASAS might help ide...
In clinical practice, timing of aortic valve intervention in asymptomatic severe aortic stenosis (ASAS) has been a challenging task particularly in the absence of overt high-risk features (low ejection fraction, etc.) (1,2). The recently published article by Bing R, et al. (1), has discussed current strategies that might help risk-stratification and management of this precarious valvular phenomenon. In this context, we fully agree with the authors that serum biomarkers including natriuretic peptides, as opposed to certain imaging modalities, generally have significant limitations (1). However, serum copeptin (the surrogate marker of arginine-vasopressine (AVP) axis) might serve as a promising guide to prognostication and clinical decision-making for aortic valve intervention in patients with ASAS (2) largely due to pathophysiological implications of AVP axis in these patients:
Firstly; copeptin elevation in patients with ASAS might help identify a subgroup with a state of subtle systemic hypoperfusion (potentially associated with the failure to increase cardiac output sufficiently under stress) that might lead to unexpected coronary ischemic events and sudden cardiac death (SCD) particularly during exercise (2). Copeptin elevation due to valvular stenosis might also suggest progressive ventricular remodeling and eventual heart failure in the long term as a consequence of enhanced AVP actions on myocardium (2). However, potential confounding factors (dehydration, infections, etc.) should also be sought before associating ASAS with copeptin elevation (2).
Secondly; augmented myocardial baroreceptor reactivity (namely Bezold-Jarish reflex) is well known to be associated with syncopal attacks and, if substantial, SCD in the setting of severe aortic stenosis largely through induction of bradyarrhythmias and peripheral vasodilatation (2). Interestingly, AVP was previously demonstrated to exert a significant stimulatory impact on baroreceptor reactivity (3,4). Therefore, substantial copeptin elevation might help identify ASAS patients who might particularly be prone to excessive Bezold-Jarish reflex (and hence; to SCD risk) on follow-up. (2).
Thirdly; AVP axis has a significant correlation with adrenergic system partly attributable to the central impact of adrenergic substances on AVP release (2). Therefore, copeptin elevation denotes a state of adrenergic hyperactivation that might account for arrhythmias in patients with ASAS, particularly in those with left ventricular hypertrophy (2).
Finally; copeptin elevation in patients with ASAS might also predict rapid progression of transaortic gradient owing to profibrotic effects of augmented AVP actions on aortic valvular tissue (2).
In summary; copeptin elevation might potentially signify a higher risk for adverse events in patients with ASAS due to the hemodynamic, autonomic and fibrogenic implications of enhanced AVP actions (2). Therefore, adjunctive evaluation of serum copeptin at regular intervals might help dynamic risk-stratification, and might further optimize the timing of aortic valve intervention in these patients (2). However, this needs to be tested in large-scale clinical studies.
Conflict of Interest: None
REFERENCES:
1- Bing R, Dweck MR. Management of asymptomatic severe aortic stenosis: check or all in?
Heart Published Online First: 04 November 2020. doi: 10.1136/heartjnl-2020-317160
2- Yalta K, Palabiyik O, Gurdogan M, Gurlertop Y. Serum copeptin might improve risk stratification and management of aortic valve stenosis: a review of pathophysiological insights and practical implications. Ther Adv Cardiovasc Dis. 2019 Jan-Dec;13:1753944719826420. doi: 10.1177/1753944719826420. PMID: 30803406; PMCID: PMC6376527.
3- Roul G, Riehl-Aleil V, Germain P, Bareiss P. Neurohormonal profile before and after beta-blockade in patients with neurocardiogenic syncope. Pacing Clin Electrophysiol. 1999; 22(7): 1020-30.
4- Mosqueda-Garcia R, Furlan R, Tank J, Fernandez-Violante R. The elusive pathophysiology of neurally mediated syncope. Circulation. 2000; 102(23): 2898-906.
For the sake of completeness, the cardiac manifestations of rheumatological disorders documented by Sen et al(1) also ought to include bacterial as well as mycobacterial and fungal infections which invade either the pericardium or the myocardium in patients with rheumatological disorders. The following are some examples:-
Show MoreSuppurative pericarditis attributable to Staphylococcus aureus was documented by Huskisson et al in one of the patients in their series of 12 rheumatiod arthritis(RA) patients with severe , unusual and recurrent infections(2). A massive tuberculous plericardial effusion was documented in a 60 year old man with long-standing RA who was not taking any immunosuppressive medication(3).
Staphylococcal pericarditis was reported in a 52 year old woman with systemic lupus erythematosus(SLE) who was on prednisolone(4). Tuberculous pericarditis coexisted with SLE in 3 patients who were participants in a series consisting of 72 SLE patients with coexisting active tuberculosis infection(5).
Eosinophilic granulomatosis with polyangiitis was the underlying rheumatological disorder in a 60 year old woman who died after experiencing complications of congestive heart failure. Autopsy examination revealed invasive myocarditis secondary to Aspergillus fumigatus infection as well as multiple myocardial abscesses(6).
Comment
In the context of multisystem rheumatological disease the expectation is that the occurrence of pericarditis a...
The management of hypertension generates huge opportunities for opportunistic screening for atrial fibrillation(AF). To maximise that opportunity documentation of regularity of the pulse and, hence, for AF, should be routine at each visit to primary care or to secondary care. Furthermore, that should be the routine during follow up visits of patients with known hypertension. The rationale is that hypertension is a recognised risk factor for incident AF(1), and for progression of paroxysmal AF to permanent AF(2). thereby mandating a recognition that patients with known hypertension should be allocated to a high risk subgroup in whom opportunistic screening for AF should be maximised. There are opportunities for AF screening even with home blood pressure measurement. Some self blood pressure measuring devices trigger an alert when there is an irregularity in the pulse. Patients should be educated to inform their doctor when such alerts occur so that the patient can be evaluated further by electrocardiography.
Show MoreThe treatment phase of hypertension addresses the challenge of atrial fibrillation by mitigating the risk of new onset development of that arrhythmia. Using data from SPRINT(Systolic Blood Pressure Intervention Trial) Soliman et al showed that intensive blood pressure lowering to a systolic blood pressure of < 120 mm Hg was associated with a 26% lower risk of developing new AF(hazard ratio, 0.74[95% Confidence Interval, 0.56-0.98]; P=0.37(3). What n...
To the Editor,
In an excellent analysis published in the recent issue of the journal, “Heart” Lau et al. investigated the long-term clinic outcomes of patients with Takotsubo syndrome (TTS) in a large cohort. The results demonstrated that increasing age, male gender, diabetes mellitus, pulmonary disease and chronic kidney disease were associated with a higher risk of recurrence or death1. We wish to highlight a few points relevant to the article.
Núñez-Gil et al reported their findings whilst categorizing patients with TTS based upon proposed etiology. Individuals with idiopathic or emotional triggers were considered as having the primary disease, whereas those with likely physical causative factors were deemed to have a secondary form of the pathology. The analysis of both groups revealed a disparity in clinical outcomes; patients with underlying physical triggers displayed higher risk of both short and long-term adverse events 2. Similar findings have also been reported in other studies 3.
Prior published data has theorized that a history of diabetes mellitus may be relatively protective against developed of TTS possibly due to an ameliorated sympathetic response when compared to non-diabetics due to involvement related to diabetic neuropathy 4. Comparatively poorer outcomes in diabetic TTS patients as seen in this study may be possibly explained by the fact that these diabetic patients may have been overwhelmingly sicker to generate enough catecho...
Show MoreThe residual risk of stroke in subjects with nonvalvular atrial fibrillation(NVAF) is, in part, attributable to coexistence of nonvalvular atrial fibrillation(NVAF) and high-grade(stenosis(50% or more severity) involving the intracranial arterial circulation(1). In the latter study concomitant high-grade cerebrovascular stenosis was identified in 231 of 780 consecutive subjects of mean age 69.5 who had undergone angiographic studies at index stroke(1). Coexistence of extracranial carotid artery stenosis(CAS) and NVAF is also a risk factor for residual stroke(2). In the latter study Chang et al identified high-grade CAS(>50% severity) which was ipsilateral to the index ischemic cerebral infarct in 15 out of 25 patients presenting with stroke(2).
Show MoreSecondary prevention of stroke in NVAF patients who have the association of either high-grade stenotic intracranial cerebrovascular disease or high-grade CAS to which the index stroke can be attributed would entail coprescription of low-dose aspirin and an oral anticoagulant drug. Edoxaban would be a suitable candidate, given the fact that the 15 mg/day dose significantly mitigates the risk of stroke ( of presumably cardioembolic origin) in NVAF subjects aged 80 or more(3). That dose is even lower than the 30 mg/day dose which is associated with significantly(p < 0.001) lower risk of gastrointestinal bleeding than warfarin(4).
Primary prevention would require strict abstinence from smoking, str...
To the Editor,
Show MoreWe have recently read with great interest the article by Kim et al entitled ‘‘Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery’’ [1]. We appreciate the authors for their study describing the relationship of preservation of the left atrial appendage (LAA) to the risk of adverse clinical events in patients with rheumatic mitral valve disease. On the other hand, we believe that there are several major drawbacks that need to be addressed.
First of all, the LAA can be excluded from the systemic circula¬tion by obliterating its orifice with or without excising the body of the appendage [2]. During the two decades, mechanical occlusion of the LAA including the surgical approach has been adopted by clinicians as a potential approach for stroke prevention in selected patients with atrial fibrillation (AF) [2]. Surgical LAA ligation has been attempted with or without enabling devices. Although routine surgical LAA occlusion has been recommended by some, the evidence base for its actual benefit remains limited and conflicting. Surgical closure particularly using suture ligation can yield incomplete surgical left atrial appendage closure (iSLC) in more than one-third of the patients [2, 3]. Previously, Katz et al evaluated 50 patients who underwent surgical LAA closure in association with mitral valve surgery and similarly reported iSLC in 36% of their patients [3]. The readers may wonder whether routine p...
The observation that transient constrictive pericarditis(CP) is associated with a significantly higher erythrocyte sedimentation rate than its counterpart, persistent pericarditis, is consistent with the hypothesis that, in the former disorder, an active inflammatory process is at play, which might be responsive to corticosteroid therapy, whereas, in the latter context, irreversiible pericardial fibrosis or even pericardial calcification might have become firmly established.
Show MoreThis hypothesis can be tested in a disorder such as IgG4-related constrictive pericarditis, where corticosteroids are the only treatment modality available. In IgG4-related CP the disease spectrum includes, at one extreme,, effusive-constrictive pericarditis without pericardial calcification(1), and, at the other extreme, CP with pericardial calcification(2).In between, there may be gradations of acute inflammatory response..
The 79-year old man with IgG4-related effusive CP reported by Yuriditsky et al had stigmata of CP identified by simultaneous left and right-sided catheterisation. He had an initially good response to corticostroids, characterised by good diuresis over the course of 10 days. However, he had a subsequent relapse, and was eventually treated by pericardiectomy(1).
By contrast, the 29 year old woman with IgG4-related CP reported by Sekigushi et al had a consistently good response to corticosteroids. In her case, as well, there was no pericardial calcification. E...
For the sake of completeness, the evaluation of the deficit in knowledge and awareness and treatment of hypertension (1) should include an inquiry about two issues that are fundamental to the relationship between hypertension and stroke. For those issues to be addressed, the questionnaire should include the following items:-
Show More(i)Did you ever have your blood pressure taken in both arms?
(ii)When you commenced antihypertensive treatment did you and your doctor agree on a "goal" blood pressure?
The rationale for those two lines of inquiry is the following:-
According to one meta analysis(10 cohorts; 13,317 patients) interarm blood pressure difference > 15 mm Hg is associated with a significant Cox stratified adjusted hazard ratio for subsequent stroke(hazard ratio, 2.42: 95% Confidence Interval, 1.27-4.60; p < 0.01) (2).
Furthermore, antihypertensive medication should be titrated against the higher of the two inter arm blood pressure measurements otherwise the patient will run the risk of suboptimal drug dosing and the risk of missed diagnosis of resistant hypertension.
A mutually agreed "goal" blood pressure should be specified from the outset otherwise there will be a risk of insidious onset of "physician inertia" which could contribute to the subsequent development of stroke.
Younger patients have the most o gain from an ambitious "goal " blood pressure which sets the target...
A corollary to the recommendation for anticoagulant persistence is a recognition that the time is long overdue for inclusion of evaluation of the extracranial carotid artery for evidence of high grade(ie >50 occlusion) carotid artery stenosis(CAS). The following is the rationale for the latter recommendation:-
Show MoreAmong patients aged > 70 high-grade CAS has a prevalence of 12% among men and 11% among women(1).
A systematic review of 9 studies(2611 patients) reporting presumed pathophysiological stroke mechanisms in patients with nonvalvular atrial fibrillation(NVAF) disclosed that 11%-24% of patients with the association of stroke and NVAF have high-grade CAS(2).
Some stroke patients with NVAF have high-grade CAS ipsilateral to the culprit cerebral infarct, implying an aetiological role for the CAS in the pathogenesis of the incident stroke(3).
During the entire history of the CHA2DS2 Vasc score we have squandared the opportunity to include ultrasonography of the extracranial carotid artery in the routine work up of newly diagnosed patients with NVAF. This was a missed opportunity to identify CAS as the potential aetiological agent in the event of the occurrence of manifestations of symptomatic CAS such as amaurosis fugax, transient ischemic attack, or non disabling stroke.. Without prior knowledge of the status of the carotid arteries those manifestations might have been missed opportunities to implement strategies such as carotid arte...
We have read with great interest the article written by Jolicoer et al. (1) about the concordant domain analysis, a new method to interpret early phase trials and we applaud their initiative which expands the horizons in the current context of progressive diffuculties to ran studies.
Show MoreRandomized controlled trials (RCT) and meta-analysis constitute the highest level of evidence and the chances to succeed are high when there is a strong financial support to launch projects as Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) with 27,564 patients, which in addition to demonstrate the hypothesis of the study, it ensures the external validity and the study of subgroups.
However, recently we are witnessing a progressively more tortuous environment to launch adequately powered RCTs due to economic restrictions, lower margin to demonstrate cost-effectivity of the new treatments and more strict legal requirements and as the authors quote, only 1 in 10 investigational agents tested in phase III trials reaches the market. Some authors have already raisen concerns about the future of research and the protagonism of new methods as adaptive studies(2) or approaches to emulate RCT (3) are foreseen in the near future.
In our opinion, the combination of pilot randomized studies with new iniciatives as the described by Jolicoer may be a promising pathway when the conditions to launch large RCTs are not possible and in fa...
Kenan YALTA, MD a
Ertan YETKIN, MD b
Gokay TAYLAN, MD a
a,TrakyaUniversity, CardiologyDepartment, Edirne, TURKEY
b Derindere Hospital, Cardiology Department, Istanbul, TURKEY
Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 00905056579856
In clinical practice, timing of aortic valve intervention in asymptomatic severe aortic stenosis (ASAS) has been a challenging task particularly in the absence of overt high-risk features (low ejection fraction, etc.) (1,2). The recently published article by Bing R, et al. (1), has discussed current strategies that might help risk-stratification and management of this precarious valvular phenomenon. In this context, we fully agree with the authors that serum biomarkers including natriuretic peptides, as opposed to certain imaging modalities, generally have significant limitations (1). However, serum copeptin (the surrogate marker of arginine-vasopressine (AVP) axis) might serve as a promising guide to prognostication and clinical decision-making for aortic valve intervention in patients with ASAS (2) largely due to pathophysiological implications of AVP axis in these patients:
Show MoreFirstly; copeptin elevation in patients with ASAS might help ide...
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