eLetters

71 e-Letters

published between 2019 and 2022

  • The potential for using dose-related beta-blockade in Takotsubo syndrome

    In the investigation recently published in “Heart”, the authors discuss the efficacy of beta blockade in treating individuals with the Takotsubo cardiomyopathy. [1] Another recent publication shows this to be a controversial topic. [2] These discussions emphasize the significance of the dose-related sensitivity of one component of three-dimensional aggregation of the ventricular cardiomyocytes, a feature which, thus far, has received little attention. Intraoperative cardio-dynamic measurements [3] have shown that the cardiomyocytes within the three-dimensional mesh that are aggregated in intruding, as opposed to tangential, fashion are statistically more sensitive to both positive and negative inotropes when given at low doses. The cardiomyocytes aggregated in transmural fashion exert a dilatory effect, in contrast to the tangential aggregates, which act exclusively to drive ventricular ejection. The different functions of the two populations indicates that the ventricular cone, as a whole, functions as an antagonistic system. [4]
    When the ventricular walls are hypertrophied in response to increased resistance to flow, ventricular wall thickening stretches and tilts the cardiomyocytes aggregated in transmural fashion, thus increasing the dilating forces. At the same time, of course, the transmural cardiomyocytes themselves undergo hypertrophy. This triggers a vicious circle, with both populations of cardiomyocytes undergoing hypertrophy. In this situation, however,...

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  • Re: Longitudinal changes of thoracic aortic diameters in the general population aged 55 years or older

    Thijssen et al. reported factors affecting the diameters of the thoracic aorta in participants (1). By using non-enhanced cardiac CT, the diameters of the ascending (AA) and descending aorta (DA) were measured. The median absolute change in diameters during follow-up with mean scan interval of 14.1 years, was 1 mm for both the AA and DA. Absolute changes per decade in AA and AD diameters were significantly larger in males than in females. Significant determinants of changes in AA diameter were age, body mass index (BMI) and diastolic blood pressure (DBP) in female, and BMI in males. In addition, significant determinants of changes in DA diameter were age, BMI, DBP, and current smoking in female, and age and BMI in males. I have a comment about the study.

    There are some sex differences in significant determinants for the change of AA and AD diameters, and BMI is a common risk factor. Ferrara et al. reported that there were no effects of gender, BMI, AA diameter, aortic stiffness index, smoking habits, diabetes mellitus, and Marfan syndrome on AA tissue in patients with AA aneurysms. In contrast, aging and hypertension made the AA tissue weaker (2). The significant determinants for dilation of AA and DA diameters may not directly relate to the risk of thoracic aneurysm, and BMI management is important to prevent thoracic aorta dilations in general population.

    Reference
    1. Thijssen CGE, Mutluer FO, van der Toorn JE, et al. Longitudinal changes of thoracic...

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  • Physician

    I take great concern in regards to the conclusions that this and multiple other previous cardiology articles have laid claim to in regards to calcium supplementation. Many providers read these articles and tell patients to stop taking calcium, this then results in osteoporosis and fractures which also has a high mortality rate. There must be significant caution in making the conclusions that this article makes. The amount of calcium the patients were taking was quite varied between 500-2,000 mg a day, patients with bone disease need 1200 mg a day in order to maintain normal bone turnover and rebuilding by the osteoblast. There needs to be data from this study showing the poor outcome patient’s calcium supplement amounts. To insinuate that all calcium supplements are bad is not only a disservice but a detriment to our patients. Patients now have access to articles more than ever and will read this and now won’t take their calcium supplements, this means that anyone treating osteoporosis will now have to explain this and other articles. Patients are more likely to believe bad data than good data. The truth is that calcium is needed for good bone health and there is a safe amount that is not a risk to cardiac health. This article amongst others does not bring in that side of the story.

  • Correspondence on “Physical activity and exercise recommendations for patients with valvular heart disease” by Chatrath et al

    To the Editor We read with interest the review article “Physical activity and exercise recommendations for patients with valvular heart disease” by Doctors Nikhil Chatrath and Michael Papadakis, which was published in a recent edition of Heart.1 The focused clinical review is particularly useful for physicians and other health care workers dealing with patients with valvular heart disease (VHD). However, we would like to share some additional thoughts based upon our own experiences from Heart Valve Clinics and our previous publications derived from the EXTAS (exercise testing in aortic stenosis) cohort study.2 Indeed, some notions in their work, were previously explored by us in the EXTAS study and deserve mention. We showed that exercise testing (modified Bruce protocol) was safe, tolerable and revealed symptoms not confirmed on the history in approximately 40% of patients with asymptomatic severe and 24% moderate AS.2 Serial exercise testing added incremental prognostic information to baseline testing. Furthermore, in another follow-up study we showed that an early rapid rise in heart rate (defined as achieving at least 85% of target heart rate or ≥50% increase from baseline within the first 6 min) was associated with revealed symptoms later in the test and an increased risk of death in moderate AS in the following 2 years.3 We speculated that rapid risk in heart rate was probably a compensation for a fall in stroke volume to maintain cardiac output in early exercise whi...

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  • A potential influence of omega-3 supplementation on metabolic syndrome and/or Helicobacter pylori-related risk of cardio-cerebrovascular disorders

    To the Editor,

    In an initial review and meta-analysis, Rizos et al1 stated that omega-3 supplementation at low and higher dosages showed no or weak associations with cardiovascular disease (CVD) outcomes. Then, we reported more recent reviews that displayed a protective activity of omega-3 supplementation against CVD outcomes.2 Moreover, we reported that both metabolic syndrome (MetS) and Helicobacter pylori infection (Hp-I) increase the risk of cardio-cerebrovascular events, the endpoint of MetS,2 and omega-3 acids are beneficial against these disorders.2 Next, a corresponding piece commenting on our own paper by Rizos et al,3 reported that some recent data showed, for instance, low and/or high dosage of omega-3 supplementation was not associated with CVD outcomes.3 However, multiple trials continue to use low dosage of omega-3, which demonstrated substantial CVD benefits and other recent data showed that higher dosage of omega-3 (4 g/day) also induced a remarkable reduction in CVD events.4 The current contradictory findings can be attributed to several contributors including diverse types of omega-3 fatty acids (only eicosapentaenoic acid (EPA) or combination of EPA plus docosahexaenoic acid), their dosage (higher vs. lower dose), diverse comparators (corn or mineral oil), the severity degree of the CVD risk and/or the usage of statins.5 Therefore, according to Jo et al.’s claim,5 further large-scale prospective studies are warranted to elucidate this “hype”.5...

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  • 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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  • LARGER RANDOMIZED CONTROLLED TRIALS (RCT)

    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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