I read the report of Naylor-Wardle et al.1 The authors reviewed the effect of socioeconomic status (SES) on all-cause and cardiovascular disease in the COVID-19 era. Combination of CVD morbidity and COVID-19 infection relate to severity of disease and poor prognosis. A lower SES and ethnic minority both contribute to the increased mortality and CVD incidence, which is accelerated by COVID-19 infection, especially in the vulnerable elderly populations. They also made an emphasis that lifestyle factors such as tobacco, alcohol, high-fat and salt content food might be more exposed in populations with lower SES, and I want to present some information about this review.
First, Machado et al. conducted a long-term retrospective cohort study to evaluate the association between midlife wealth mobility and risk of CVD events in adults of 50 years or older.2 Higher initial wealth was significantly associated with lower cardiovascular risk. In addition, participants who experienced upward and downward wealth mobility significantly presented lower and higher hazards of a subsequent non-fatal CVD event or CVD death, respectively. This means that the inverse relationship between SES and CVD are also observed in a changing state of SES midlife populations. In the era of COVID-19 pandemic, SES in people might be changed in response to social status. Taken together, health risk assessment should be conducted prospectively by considering...
I read the report of Naylor-Wardle et al.1 The authors reviewed the effect of socioeconomic status (SES) on all-cause and cardiovascular disease in the COVID-19 era. Combination of CVD morbidity and COVID-19 infection relate to severity of disease and poor prognosis. A lower SES and ethnic minority both contribute to the increased mortality and CVD incidence, which is accelerated by COVID-19 infection, especially in the vulnerable elderly populations. They also made an emphasis that lifestyle factors such as tobacco, alcohol, high-fat and salt content food might be more exposed in populations with lower SES, and I want to present some information about this review.
First, Machado et al. conducted a long-term retrospective cohort study to evaluate the association between midlife wealth mobility and risk of CVD events in adults of 50 years or older.2 Higher initial wealth was significantly associated with lower cardiovascular risk. In addition, participants who experienced upward and downward wealth mobility significantly presented lower and higher hazards of a subsequent non-fatal CVD event or CVD death, respectively. This means that the inverse relationship between SES and CVD are also observed in a changing state of SES midlife populations. In the era of COVID-19 pandemic, SES in people might be changed in response to social status. Taken together, health risk assessment should be conducted prospectively by considering the change in SES.
Second, Makaroun et al. reported that low wealth was significantly associated with death and disability in the United States and England,3 and the significant relationship existed from middle into later life in adults. Although ethnic difference should be evaluated comprehensively, there was no generation gap on the inverse association between SES and mortality/disability. Combinations of unhealthy lifestyle factors might be strongly associated with CVD events and mortality, and SES would affect the association. Namely, SES would have interactions with lifestyle factors and also moderate the association between lifestyle factor combinations and adverse health outcomes. In any case, a meta-analysis of prospective studies is needed to evaluate the inter-relationship among SES, lifestyle factors and CVD events.4
Finally, De Bacquer et al. precisely evaluated the relationship between SES and cardiovascular risk factors.5 The adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of low SES for smoking in men, physical activity in men and women, obesity in men and women were 1.63 (1.37 to 1.95), 1.51 (1.28 to 1.78), 1.77 (1.32 to 2.37), 1.28 (1.11 to 1.49) and 1.65 (1.30 to 2.10), respectively. In addition, the adjusted OR (95% CI) of low SES for raised blood pressure in men and women were 1.24 (1.07 to 1.43) and 1.31 (1.03 to 1.67), respectively. Furthermore, there was also a significant relationship between SES and markers of well-being. These data present that preclinical stage of CVD is closely related to low SES and social determinants for CVD may be relatively large. In the era of COVID-19, there are increasing needs for considering socioeconomic factors for CVD evens.
REFERENCES
Naylor-Wardle J, Rowland B, Kunadian V. Socioeconomic status and cardiovascular health in the COVID-19 pandemic. Heart 2021;107:358-65.
Machado S, Sumarsono A, Vaduganathan M. Midlife wealth mobility and long-term cardiovascular health. JAMA Cardiol 2021 Jun 30:e212056. doi: 10.1001/jamacardio.2021.2056. [Epub ahead of print]
Makaroun LK, Brown RT, Diaz-Ramirez LG, et al. Wealth-associated disparities in death and disability in the United States and England. JAMA Intern Med 2017;177:1745-53.
Foster H, Polz P, Mair F, et al. Understanding the influence of socioeconomic status on the association between combinations of lifestyle factors and adverse health outcomes: a systematic review protocol. BMJ Open 2021;11:e042212.
De Bacquer D, van de Luitgaarden IAT, De Smedt D, et al. Socioeconomic characteristics of patients with coronary heart disease in relation to their cardiovascular risk profile. Heart 2021;107:799-806.
Dear Editor,
we thank you for your recent Editorial (1) that gives a balanced and useful view of the use of anti-interleukin1 agents for the treatment of recurrent pericarditis (2). As it is common, the authors conclude that “however, larger RCT data are required for further validation of the efficacy and safety of these novel medications in the treatment of recurrent pericarditis.” Here there is a technical issue, that sometimes may be not well appreciated. One of the first step in planning a RCT is to calculate the sample size. The point is that RCT that will randomize subjects to anti-IL 1 agents vs placebo will never be large, and will always include a small number of subjects, as compared to sample sizes common in other fields of cardiology, simply given the large treatment effect; for this reason is not ethical to randomize higher number of subjects. The calculated sample sizes are relatively small only due to the expected extremely high efficacy: e.g. the per protocol calculated sample sizes were 20 subjects in the AIRTRIP trial (3) and 56 in the RHAPSOSY trial (4). In practice we will never have “large” RCT on this topic, because these agents are expected to be so effective that the calculated sample sizes will be always small.
1. Anthony C, Collier P. Anti-interleukin-1 for recurrent pericarditis; maybe a fix (but prior studies do not really mix). Heart. 2021 May 10:heartjnl-2021-319282. doi: 10.1136/heartjnl-2021-319282. Online ahead of print.
Dear Editor,
we thank you for your recent Editorial (1) that gives a balanced and useful view of the use of anti-interleukin1 agents for the treatment of recurrent pericarditis (2). As it is common, the authors conclude that “however, larger RCT data are required for further validation of the efficacy and safety of these novel medications in the treatment of recurrent pericarditis.” Here there is a technical issue, that sometimes may be not well appreciated. One of the first step in planning a RCT is to calculate the sample size. The point is that RCT that will randomize subjects to anti-IL 1 agents vs placebo will never be large, and will always include a small number of subjects, as compared to sample sizes common in other fields of cardiology, simply given the large treatment effect; for this reason is not ethical to randomize higher number of subjects. The calculated sample sizes are relatively small only due to the expected extremely high efficacy: e.g. the per protocol calculated sample sizes were 20 subjects in the AIRTRIP trial (3) and 56 in the RHAPSOSY trial (4). In practice we will never have “large” RCT on this topic, because these agents are expected to be so effective that the calculated sample sizes will be always small.
1. Anthony C, Collier P. Anti-interleukin-1 for recurrent pericarditis; maybe a fix (but prior studies do not really mix). Heart. 2021 May 10:heartjnl-2021-319282. doi: 10.1136/heartjnl-2021-319282. Online ahead of print.
2. Imazio M, Andreis A, Piroli F, et al. Anti-interleukin1 agents for the treatment of recurrent pericarditis: a systematic review and meta-analysis.Heart 2021. doi:10.1136/heartjnl-2020-318869. [Epub ahead of print: 18 Mar 2021].
3. Brucato A, Imazio M, Gattorno M, et al. Effect of Anakinra on recurrent pericarditis among patients with colchicine resistance and corticosteroid dependence: the AIRTRIP randomized clinical trial. JAMA 2016;316:1906–12.
4. Klein AL, Imazio M, Cremer P, et al. Phase 3 trial of interleukin-1 trap rilonacept in recurrent pericarditis. N Engl J Med 2021;384:31–41.
We read with great interest the recent results from ESC-EORP
Registry of Pregnancy and Cardiac disease (ROPAC), concerning pregnancy.
outcomes in women with systemic right ventricle (sRV) and transposition of the
great arteries (TGA) by Tutarel et al. (1) In Tutarel et al. analysis HF was the
most frequent maternal complication (9.1%). These results are concordant
with our previous observations of 24 pregnancies of women with TGA after
atrial switch operation and matched non-pregnant controls with TGA after atrial
redirection. 2 In our series 2 women deteriorated from the functional NYHA
class I to II after the first pregnancy and one woman in her fourth pregnancy
deteriorated from class I to III. Tutarel’s results reinforce our conclusion that,
from a cardiologist’s point of view, pregnancy after the Mustard/Senning
operation was relatively well-tolerated and safe.
In ROPAC study the information on tricuspid regurgitation (TR) was collected, but was
not mandatory. Therefore Tutarel et al. concluded that dedicated studies focusing on
sRV function and TR are warranted. Our dataset provided relevant information
on sRV and TR. At baseline, all women had preserved or only mildly reduced
sRV function estimated by echocardiography before pregnancy and absent or
mild TR. There were no differences between non-pregnant matched controls
and pregnant women in sRV function, deg...
We read with great interest the recent results from ESC-EORP
Registry of Pregnancy and Cardiac disease (ROPAC), concerning pregnancy.
outcomes in women with systemic right ventricle (sRV) and transposition of the
great arteries (TGA) by Tutarel et al. (1) In Tutarel et al. analysis HF was the
most frequent maternal complication (9.1%). These results are concordant
with our previous observations of 24 pregnancies of women with TGA after
atrial switch operation and matched non-pregnant controls with TGA after atrial
redirection. 2 In our series 2 women deteriorated from the functional NYHA
class I to II after the first pregnancy and one woman in her fourth pregnancy
deteriorated from class I to III. Tutarel’s results reinforce our conclusion that,
from a cardiologist’s point of view, pregnancy after the Mustard/Senning
operation was relatively well-tolerated and safe.
In ROPAC study the information on tricuspid regurgitation (TR) was collected, but was
not mandatory. Therefore Tutarel et al. concluded that dedicated studies focusing on
sRV function and TR are warranted. Our dataset provided relevant information
on sRV and TR. At baseline, all women had preserved or only mildly reduced
sRV function estimated by echocardiography before pregnancy and absent or
mild TR. There were no differences between non-pregnant matched controls
and pregnant women in sRV function, degree of TR, at the last follow-up visit
(mean follow-up period 80 ± 57 months for pregnant group versus 84 ± 49
months for nulliparous controls (P=NS). Significant deterioration of tricuspid
regurgitation (from mild to moderate) was observed in one pregnant woman
(after fourth pregnancy) and in one nulliparous woman. Increase in TR severity
was not accompanied by a significant reduction of sRV systolic function evaluated by
echocardiography.
References
1. Tutarel O, Baris L, Budts W, et al
Pregnancy outcomes in women with a systemic right ventricle and transposition of the great arteries results from the ESC-EORP Registry of Pregnancy and Cardiac disease (ROPAC)
Heart Published Online First: 28 April 2021. doi: 10.1136/heartjnl-2020-318685
2. Lipczynska M, Szymanski P, Trojnarska O, et al. Pregnancy in women with complete transposition of the great arteries following the atrial switch procedure. A study from three of the largest Adult Congenital Heart Disease centers in Poland, The Journal of Maternal-Fetal & Neonatal Medicine, DOI:10.1080/14767058.2016.1177821
The observation that SGLT-2 inhibitors might favourably modify the natural history of heart failure with preserved ejection fraction(HFpEF) and might also mitigate the risk of onset of atrial fibrillation(AF)(1) might have, as its rationale, the fact that both disorders are characterised by the presence of myocardial fibrosis, the latter a probable consequence of an obesity-related proinflammatory cascade which is potentially amenable to mitigation by SGLT-2 inhibitor therapy.
Adipose tissue is a source of proinflammatory cytokines such as tumor necrosis factor-alpha(TNF-alpha), Interleukin 1(IL-1), and Interleukin 6(IL-6), all three of which are secreted in increased amounts in response to obesity(2). Accordingly the presence of myocardial fibrosis either in the atria or in the ventricles might be the end result of a proinflammatory cascade originating in adipose tissue. Atrial fibrosis has been documented in obese subjects(body mass index > 30 kg/metre squared) who do not have AF(3) and and also in subjects who have established AF(4). In the former category there are, arguably, some individuals who will subsequently develop AF.
The relevance of SGLT-2 inhibitors to the association of myocardial fibrosis and either HFpEF or AF has emerged from the study which showed an anti-inflammatory effect of SGLT2 inhibitor therapy in the normoglycemic rabbit model of atherosclerosis. In that study the inflammatory content of atherosclerotic plaqu...
The observation that SGLT-2 inhibitors might favourably modify the natural history of heart failure with preserved ejection fraction(HFpEF) and might also mitigate the risk of onset of atrial fibrillation(AF)(1) might have, as its rationale, the fact that both disorders are characterised by the presence of myocardial fibrosis, the latter a probable consequence of an obesity-related proinflammatory cascade which is potentially amenable to mitigation by SGLT-2 inhibitor therapy.
Adipose tissue is a source of proinflammatory cytokines such as tumor necrosis factor-alpha(TNF-alpha), Interleukin 1(IL-1), and Interleukin 6(IL-6), all three of which are secreted in increased amounts in response to obesity(2). Accordingly the presence of myocardial fibrosis either in the atria or in the ventricles might be the end result of a proinflammatory cascade originating in adipose tissue. Atrial fibrosis has been documented in obese subjects(body mass index > 30 kg/metre squared) who do not have AF(3) and and also in subjects who have established AF(4). In the former category there are, arguably, some individuals who will subsequently develop AF.
The relevance of SGLT-2 inhibitors to the association of myocardial fibrosis and either HFpEF or AF has emerged from the study which showed an anti-inflammatory effect of SGLT2 inhibitor therapy in the normoglycemic rabbit model of atherosclerosis. In that study the inflammatory content of atherosclerotic plaques was assessed by immunostaining for TNF-alpha, IL-1 Beta , and IL-6. The content of all three cytokines was significantly decreased in the subgroup of rabbits pretreated with SGLT-2 inhibitors(5), implying a role for SGLT-2 inhibitors in the amelioration of the proinflammatory cascade that culminates in the formation of atherosclerotic plaques. The corollary might, arguably, be amelioration, by SGLT-2 inhibitors, of the proinflammatory cascade that culminates in the occurrence of myocardial fibrosis in HFpEF and AF.
I have no funding and no conflict of interest
References
(1) Gulsin GS., GrahampBrown MPM., Squire IB et al
Benefits of sodium glucose cotransporter 2 inhibitors across the spectrum of cardiovascular diseases
Heart 2021
Article in Press
(2)Lee H., Lee IS., Choue R
Obesity, inflammation an diet
Pediatric Gastroenterology, Hepatology & Nutrition 2013;16:143-152
(3)Siebermair J., Suksaranjit P., McGann CJ et al
Atrial fibrosis in non-atrial fibrillation individuals and prediction of atrial fibrillation by use of late gadolinium enhancement magnetic resonance imaging
J Cardiovasc Electrophysiol 2019;30:550-556
(4) Gai P., Marrouche NF
Magnetic resonance imaging of atrial fibrosis : redefining atrial fibrillation to ma syndrome
Eur Heart J 2017;38:14-19
(5) Lee S-G., Lee S-J., Lee J-J et al
Anti-inflammatory effect for atherosclerosis progression by sodium-glucose cotransporter 2 (SGLT-2) inhibitor in a normoglycemic rabbit model
Korean Circulatory Journal 2020;50:443-457
Sodium-glucose co-transporter 2 (SGLT2) inhibitor therapy is a specific mode of anti-diabetic strategy that significantly improves cardiovascular outcomes (1). The recently published article by Joshi SS, et al (1) has focused on beneficial effects of SGLT2 inhibitors in the setting of heart failure (HF). We fully agree that complex cellular mechanisms, beyond diuresis (1), seem to underlie pleitrophic actions of these agents. More specifically, it also seems likely that SGLT2 inhibitors might potentiate favorable effects of certain metabolic agents including cellular anti-ischemics (and vice versa) in diabetic patients with cardiovascular disease. Accordingly, combination of SGLT2 inhibitors with cellular anti-ischemic regimens might have important implications in these patients:
It is well known that free fatty a...
Sodium-glucose co-transporter 2 (SGLT2) inhibitor therapy is a specific mode of anti-diabetic strategy that significantly improves cardiovascular outcomes (1). The recently published article by Joshi SS, et al (1) has focused on beneficial effects of SGLT2 inhibitors in the setting of heart failure (HF). We fully agree that complex cellular mechanisms, beyond diuresis (1), seem to underlie pleitrophic actions of these agents. More specifically, it also seems likely that SGLT2 inhibitors might potentiate favorable effects of certain metabolic agents including cellular anti-ischemics (and vice versa) in diabetic patients with cardiovascular disease. Accordingly, combination of SGLT2 inhibitors with cellular anti-ischemic regimens might have important implications in these patients:
It is well known that free fatty acids (FFAs) serve as the major energy source in myocardium under physiological conditions (1). However, a significant shift to oxidation of more energy-efficient substrates (including glucose and ketone bodies) usually takes place in the setting of myocardial ischemia and/or failure (2). Moreover, this shift is expected to be even more pronounced under certain medications including cellular anti-ischemics (trimetazidine, etc.) that exert their actions largely through inhibition of FFA oxidation (3). In a recent meta-analysis comprising diabetic patients, trimetazidine was demonstrated to exert favorable effects including improvement in left ventricular systolic functions, myocardial ischemic episodes and serum glucose parameters (fasting glucose and HbA1C), etc. largely attributable to its metabolic, anti-oxidant and anti-hyperglycemic effects in these patients (3). However, impaired myocardial uptake of glucose in diabetic patients (1-3) potentially hinders maximum therapeutic benefits of cellular anti-ischemics during periods of heightened metabolic demand. This signifies the need for alternative energy-efficient substrates (including ketone bodies) in diabetic patients receiving cellular anti-ischemics.
In this context, SGLT2 inhibitors provide sufficient amounts of circulating ketone bodies (1) that seem to maximize actions of cellular anti-ischemics on myocardial energetics in diabetic patients. Moreover, hyperketonemia associated with SGLT2 inhibitors (1) might also prevent excessive uptake of FFAs (a reactive phenomenon predisposing to diabetic cardiomyopathy due to lipotoxicity (2)) potentially associated with the use of cellular anti-ischemics in diabetic patients. On the other hand, cellular anti-ischemics might possibly heighten favorable impact of SGLT2 inhibitors mostly through their metabolic actions (increased insulin sensitivity due to translocation of GLUT4 ,etc. (3)) and anti-oxidant features (that might reverse myocardial remodeling (3)). Accordingly, combined use of certain metabolic agents including SGLT2 inhibitors, dichloroacetate, perhexiline, trimetazidine, etc. , was previously suggested as a potential strategy to combat failing myocardium (yet; with no recommendation of a particular combination) (4). In this regard, combination of SGLT2 inhibitors and trimetazidine seems to be a promising option (due to the mutually complementary actions of these agents).
In summary, concomitant use of cellular anti-ischemics and SGLT2 inhibitors might result in a synergistic therapeutic benefit in diabetic patients with cardiovascular disease (HF and coronary syndromes). However, this needs to be tested in clinical trials.
Conflict of Interest: None
References:
1- Joshi SS, Singh T, Newby DE, Singh J. Sodium-glucose co-transporter 2 inhibitor therapy: mechanisms of action in heart failure. Heart. 2021 Feb 26:heartjnl-2020-318060. doi: 10.1136/heartjnl-2020-318060. Epub ahead of print. PMID: 33637556
2- García-Ropero Á, Vargas-Delgado AP, Santos-Gallego CG, Badimon JJ. Inhibition of Sodium Glucose Cotransporters Improves Cardiac Performance. Int J Mol Sci. 2019; 20(13): 3289. doi: 10.3390/ijms20133289. PMID: 31277431; PMCID: PMC6651487.
3- Lin Y, Wang ZL, Yan M, Zhu FY, Duan Y, Sun ZQ. Effect of Trimetazidine on Diabetic Patients with Coronary Heart Diseases: A Meta-Analysis of Randomized, Controlled Trials. Chin Med Sci J. 2020; 35(3): 226-238.
4- Hamilton DJ. Metabolic Recovery of the Failing Heart: Emerging Therapeutic Options. Methodist Debakey Cardiovasc J. 2017; 13(1): 25-28. doi: 10.14797/mdcj-13-1-25. PMID: 28413579; PMCID: PMC5385791.
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.
I read the report of Naylor-Wardle et al.1 The authors reviewed the effect of socioeconomic status (SES) on all-cause and cardiovascular disease in the COVID-19 era. Combination of CVD morbidity and COVID-19 infection relate to severity of disease and poor prognosis. A lower SES and ethnic minority both contribute to the increased mortality and CVD incidence, which is accelerated by COVID-19 infection, especially in the vulnerable elderly populations. They also made an emphasis that lifestyle factors such as tobacco, alcohol, high-fat and salt content food might be more exposed in populations with lower SES, and I want to present some information about this review.
First, Machado et al. conducted a long-term retrospective cohort study to evaluate the association between midlife wealth mobility and risk of CVD events in adults of 50 years or older.2 Higher initial wealth was significantly associated with lower cardiovascular risk. In addition, participants who experienced upward and downward wealth mobility significantly presented lower and higher hazards of a subsequent non-fatal CVD event or CVD death, respectively. This means that the inverse relationship between SES and CVD are also observed in a changing state of SES midlife populations. In the era of COVID-19 pandemic, SES in people might be changed in response to social status. Taken together, health risk assessment should be conducted prospectively by considering...
Show MoreDear Editor,
we thank you for your recent Editorial (1) that gives a balanced and useful view of the use of anti-interleukin1 agents for the treatment of recurrent pericarditis (2). As it is common, the authors conclude that “however, larger RCT data are required for further validation of the efficacy and safety of these novel medications in the treatment of recurrent pericarditis.” Here there is a technical issue, that sometimes may be not well appreciated. One of the first step in planning a RCT is to calculate the sample size. The point is that RCT that will randomize subjects to anti-IL 1 agents vs placebo will never be large, and will always include a small number of subjects, as compared to sample sizes common in other fields of cardiology, simply given the large treatment effect; for this reason is not ethical to randomize higher number of subjects. The calculated sample sizes are relatively small only due to the expected extremely high efficacy: e.g. the per protocol calculated sample sizes were 20 subjects in the AIRTRIP trial (3) and 56 in the RHAPSOSY trial (4). In practice we will never have “large” RCT on this topic, because these agents are expected to be so effective that the calculated sample sizes will be always small.
1. Anthony C, Collier P. Anti-interleukin-1 for recurrent pericarditis; maybe a fix (but prior studies do not really mix). Heart. 2021 May 10:heartjnl-2021-319282. doi: 10.1136/heartjnl-2021-319282. Online ahead of print.
...Show MoreWe read with great interest the recent results from ESC-EORP
Show MoreRegistry of Pregnancy and Cardiac disease (ROPAC), concerning pregnancy.
outcomes in women with systemic right ventricle (sRV) and transposition of the
great arteries (TGA) by Tutarel et al. (1) In Tutarel et al. analysis HF was the
most frequent maternal complication (9.1%). These results are concordant
with our previous observations of 24 pregnancies of women with TGA after
atrial switch operation and matched non-pregnant controls with TGA after atrial
redirection. 2 In our series 2 women deteriorated from the functional NYHA
class I to II after the first pregnancy and one woman in her fourth pregnancy
deteriorated from class I to III. Tutarel’s results reinforce our conclusion that,
from a cardiologist’s point of view, pregnancy after the Mustard/Senning
operation was relatively well-tolerated and safe.
In ROPAC study the information on tricuspid regurgitation (TR) was collected, but was
not mandatory. Therefore Tutarel et al. concluded that dedicated studies focusing on
sRV function and TR are warranted. Our dataset provided relevant information
on sRV and TR. At baseline, all women had preserved or only mildly reduced
sRV function estimated by echocardiography before pregnancy and absent or
mild TR. There were no differences between non-pregnant matched controls
and pregnant women in sRV function, deg...
The observation that SGLT-2 inhibitors might favourably modify the natural history of heart failure with preserved ejection fraction(HFpEF) and might also mitigate the risk of onset of atrial fibrillation(AF)(1) might have, as its rationale, the fact that both disorders are characterised by the presence of myocardial fibrosis, the latter a probable consequence of an obesity-related proinflammatory cascade which is potentially amenable to mitigation by SGLT-2 inhibitor therapy.
Show MoreAdipose tissue is a source of proinflammatory cytokines such as tumor necrosis factor-alpha(TNF-alpha), Interleukin 1(IL-1), and Interleukin 6(IL-6), all three of which are secreted in increased amounts in response to obesity(2). Accordingly the presence of myocardial fibrosis either in the atria or in the ventricles might be the end result of a proinflammatory cascade originating in adipose tissue. Atrial fibrosis has been documented in obese subjects(body mass index > 30 kg/metre squared) who do not have AF(3) and and also in subjects who have established AF(4). In the former category there are, arguably, some individuals who will subsequently develop AF.
The relevance of SGLT-2 inhibitors to the association of myocardial fibrosis and either HFpEF or AF has emerged from the study which showed an anti-inflammatory effect of SGLT2 inhibitor therapy in the normoglycemic rabbit model of atherosclerosis. In that study the inflammatory content of atherosclerotic plaqu...
Sodium-glucose co-transporter 2 inhibitors with cellular anti-ischemics: A favorable combination in diabetic patients with cardiovascular disease
Kenan YALTA, MD a
Ugur OZKAN, MD a
Tulin YALTA, MD b
a,TrakyaUniversity, CardiologyDepartment, Edirne, TURKEY
b,TrakyaUniversity, Pathology Department, Edirne, TURKEY
Corresponding Author: Kenan YALTA Trakya University, CardiologyDepartment, Edirne, TURKEY
Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 00905056579856
Sodium-glucose co-transporter 2 (SGLT2) inhibitor therapy is a specific mode of anti-diabetic strategy that significantly improves cardiovascular outcomes (1). The recently published article by Joshi SS, et al (1) has focused on beneficial effects of SGLT2 inhibitors in the setting of heart failure (HF). We fully agree that complex cellular mechanisms, beyond diuresis (1), seem to underlie pleitrophic actions of these agents. More specifically, it also seems likely that SGLT2 inhibitors might potentiate favorable effects of certain metabolic agents including cellular anti-ischemics (and vice versa) in diabetic patients with cardiovascular disease. Accordingly, combination of SGLT2 inhibitors with cellular anti-ischemic regimens might have important implications in these patients:
Show MoreIt is well known that free fatty 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:-
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...
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