66 e-Letters

published between 2019 and 2022

  • RE: Change in N-terminal pro-B-type natriuretic peptide at 1 year predicts mortality in wild-type transthyretin amyloid cardiomyopathy

    I read with great interest the report of Law et al [1]. The authors examined one-year mortality risk in 432 patients with wild-type transthyretin amyloid cardiomyopathy (wtATTR-CM) to detect useful biomarkers. The adjusted hazard ratio (HR) (95% confidence interval [CI]) of the change in N-terminal pro-B-type natriuretic peptide concentration (∆ NT-proBNP) per 500 ng/L increase for mortality was 1.04 (1.01 to 1.07). In addition, the adjusted HRs (95% CIs) of the increases in ∆ NT-proBNP of >500 ng/L, >1000 ng/L and >2000 ng/L for mortality were 1.65 (1.18-2.31), 1.92 (1.37-2.70), and 2.87 (1.93-4.27), respectively. They concluded that the change in NT-proBNP concentration during the first year was an independent predictor of mortality in patients with wtATTR-CM. I have a comment about this study.

    Ochi et al. examined two-year mortality risk in 47 patients with wtATTR-CM [2], and low serum albumin (≤3.75 g/dL), elevated high-sensitivity cardiac troponin T (hs-cTnT; >0.086 ng/mL), and low left ventricular ejection fraction (LVEF; <50%) are significantly associated with mortality in patients with wtATTR-CM. According to the total number of these 3 risk factors, patients were stratified into 4 subgroups: low risk (no risk factors), intermediate-low risk (1 risk factor), intermediate-high risk (2 risk factors), and high risk (3 risk factors). The estimated two-year survival rate of patients classified as low risk, intermediate-low risk, intermediate-high r...

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  • There are too many influencing factors to draw accurate conclusions

    We read with great interest the article titled “Premature ventricular complexes and development of heart failure in a community-based population” by Limpitikul’s team. The study by Limpitikul et al. indicates that coupling interval heterogeneity was an independent risk factor suggests that the mechanism of premature ventricular complexes(PVC) generation may influence the risk of heart failure. The prospective study of Limpitikul et al. overcomes the referral bias of previous cross-sectional studies, but there are some questions with this study. We did not see the description of the number of Holter tests in the article, so we think that maybe all the people included in the study only performed Holter once. However, the results of a single Holter monitoring may be affected by many factors. For example, unhealthy lifestyles such as mental stress, overwork, excessive smoking, alcohol, and coffee intake can all induce PVC. In view of the fact that any factor leading to premature depolarization of ventricular muscles can be the cause of PVC, we believe that the conclusion of follow-up 11 years later based on the results of a Holter is not very credible.

  • Does excision of an atrial myxoma qualify as an emergency procedure?

    To the Editor
    We read with interest the recent review by Griborio-Guzman AG et al [1] of the clinical presentation, diagnosis and management of cardiac myxomas. The authors highlighted that cardiac myxomas should be managed with prompt resection. Yet, the question of whether excision of an atrial myxoma qualifies as an emergency procedure remains unanswered.
    In an attempt to address this question, we constructed a “best evidence topic” according to a structured protocol, as described previously [2]. A comprehensive MEDLINE literature search was conducted utilizing the PubMed interface (1966-August 2021) using the keywords: [(atrial myxoma) OR (cardiac myxoma) OR (heart myxoma)] AND [(resection) OR (removal) OR (excision)] AND [(emergency) OR (urgent) OR (immediate) OR (prompt)]. References of selected articles were then reviewed to detect relevant publications that did not come up with the original search. Two hundred and fifty-six papers were found using the reported search. From these, 11 papers were identified that provided best evidence to answer the question, all of them were single-group case-series.
    In one of the earliest clinical series, Semb et al [3] emphasized that surgery should be performed as soon as the diagnosis is made, and observed that tumour fragmentation and embolization was more likely to occur when a lobulated, gelatinous and fragile myxoma was located in the central bloodstream.
    Livi et al [4] reported that sudden death could...

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  • Socioeconomic status and cardiovascular disease

    I read the report of Naylor-Wardle et al.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...

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    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.

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  • Response to: “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) by Tutarel et al.

    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...

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  • The rationale for the proposed beneficial effect of SGLT2 inhibitors in diastolic heart failure and in mitigating the risk of occurrence of atrial fibrillation

    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...

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  • Sodium-glucose co-transporter 2 inhibitors with cellular anti-ischemics: A favorable combination in diabetic patients with cardiovascular disease

    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:
    It is well known that free fatty a...

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  • Bacterial, mycobacterial, and fungal co-infection involving the pericardium or myocardium in rheumatological disordersa

    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).
    In the context of multisystem rheumatological disease the expectation is that the occurrence of pericarditis a...

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  • maximising opportunistic screening and maximising "goal" blood pressure

    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...

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