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
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.
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.
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.
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.
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
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.
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
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
We 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...
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 MoreSodium-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...
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.
...Show MoreTo 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 MoreFor 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...
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...
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...
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...
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