837 e-Letters

  • Stress echocardiography a low cost alternative to CTFFR

    The authors (Nazir et al) of the review of CT fractional flow reserve published in Heart are to be congratulated on very well balanced and well written review of this relatively new technology (1).

    We would like to raise a couple of points regarding imaging stress tests functioning as a gatekeeper to invasive coronary angiography after a stenosis is identified on CTCA. A recent survey of UK cardiologists identified imaging stress tests as the most common approach to assess the functional significance of a moderate stenosis (50-70%) on CTCA, with only 2% electing to use CT-FFR (2). The current increase in the use of CT-FFR is because it is nationally funded. Importantly, stress echocardiography is a very low cost test with a national tariff of £177, which compares favourably with the new reduced tariff for CT-FFR of £530. With time, this may be re-balance in favour of CT-FFR if the tariff drops further, particularly given the attraction of a single patient episode and with an anticipated growth of cardiac CT in line with NICE recommendations.

    It is important to remind readers that the PLATFORM (3) trial compared CTCA plus CT-FFR versus the standard of care in patients with stable chest pain. The patients were divided into an invasive sub-study (n=380) and a non-invasive sub-study (n=204) and the end point of the study was reduction of invasive coronary angiography that showed no obstructive CAD. In the non-invasive sub-study there was no difference in the r...

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  • Specification of criteria for diagnosis of prosthetic valve endocarditis is fundamental

    A review of comparative incidence of infective endocarditis in bioprosthetic vs mechanical valves (1) can only be complete if there is a clear statement of the criteria for the diagnosis of infective endocarditis. An important characteristic of prosthetic valve endocarditis is that "the diagnosis[of endocarditis] is more difficult in the presence of a prosthetic valve when compared with a native valve" due to the fact that "the Duke criteria have been shown to be less helpful in prosthetic valve endocarditis because of lower sensitivity in this setting"(2). Furthermore,
    the diagnostic accuracy of some imaging modalities is suboptimal in prosthetic valve endocarditis(3). According to the latter review , among patients with suspected prosthetic valve endocarditis sensitivity of transthoracic echocardiography can be as low as 17%-36%. For transoesophageal echocardiography(TOE) that parameter increases to 82-96%, the latter statistic comparable to the sensitivity associated with 18 Fluorodeoxyglucose positron emission tomography/CT(PET/CT). Also in the context of prosthetic valve endocarditis, TOE and PET/CT also have comparable specificities in the range 80-96%(3). The major limitation of TOE is that it is invasive and also operator dependent. By contrast PET/CT not only increases the sensitivity of the modified Duke criteria from 70% to 97%(without affecting specificity) but that modality also identifies metastatic septic embol...

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  • Low thromboembolic risk does not necessarily rule out risk of complications of undiagnosed coexisting high-grade carotid artery stenosis

    Regardless of the conclusions of the authors regrading thromboembolic risk(1), atrial fibrillation patients with CHA2DS2 Vasc score of zero or 1 cannot be pronounced to be at truly low risk of stroke unless coexisting high-grade carotid artery stenosis(CAS) has been ruled out. According to one study, among patients with nonvalvular atrial fibrillation(NVAF) who are older than 70 years, the frequency of high grade carotid stenosis(stenosis of 50% or more) is 12% in men and 11% in women(2). High-grade CAS, in turn, is an important risk factor for stroke. Potentially modifiable risk factors for CAS-related stroke include smoking, hypertension, diabetes mellitus, and hyperlipidaemia(3). According to an observational study of subjects with asymptomatic high-grade CAS, progression of the severity of CAS can be mitigated by optimally controlling those risk factors(4). Accordingly, the management of NVAF subjects with CHA2DS2 Vasc score of zero or 1 should include screening for CAS, and optimal control of hypertension, diabetes, and low density lipoprotein levels, over and above cessation of smoking, in the event of a diagnosis of coexisting high-grade CAS. There is also a diagnostic advantage from awareness of the coexistence of high-grade CAS in a patients with zero or 1 CHA2DS2 Vasc score. If such a patient experiences an ischaemic stroke characterised by a cerebral infarct ipsilateral to the high-grade CAS the appropriate management would be prompt prescription o...

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  • Time for action in the broadest sense

    Given the fact that high-sensitivity cardiac troponin is a parameter prevalent, not only in acute myocardial infarction(AMI)(1), but also in close mimics of AMI such as pulmonary embolism(PE)(2) and dissecting aortic aneurysm(DAA)(3), respectively, it is now time for action to be taken to include point-of-care transthoracic echocardiography(TTE) in the algorithm for triaging patients who present with the association of chest pain and an electrocardiogram simulating ST segment elevation myocardial infarction(STEMI). PE subgroups with STEMI-like presentation and DAA subgroups with STEMI-like presentation are each likely to have subsets of subjects with TTE stigmata unique to PE(4) and to DAA(5), respectively, which enable them to be differentiated from subjects with AMI, thereby mitigating the risk of inappropriate percutaneous coronary intervention. When patients with suspected AMI are triaged towards the observation zone that should also be an opportunity to elicit stigmata that might favour a diagnosis of either PE or DAA. For PE those stigmata can be elicited by invoking the Wells clinical decision rule(6), and also by specifically looking for clinical stigmata of deep vein thrombosis(7), and even triggering a Doppler scan of the lower limbs(7), and where appropriate, the upper limbs as well.
    For DAA the "red flags" to look for include interarm blood pressure difference(8), the murmur of aortic regurgitation(9), and mediastinal widening(10)(11), the...

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    Kenan YALTA, MD a
    Ertan YETKIN, MD b
    Gokay TAYLAN, MD a
    Tulin YALTA, MD c

    a Trakya University, Cardiology Department, Edirne, TURKEY
    b Istinye University, Liv Hospital, Cardiology Department, Istanbul, TURKEY
    c Trakya University, Pathology Department, Edirne, TURKEY

    Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
    Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 00905056579856

    Acute myocardial injury has been suggested as an important prognostic factor in Covid-19 patients (1-3). In their recently published article (1), Wei JF, et al. have demonstrated a significant association of acute myocardial injury (defined as elevation of high sensitive troponin-T (hs-TnT) levels) with older age, pre-existing cardiovascular disease, disease severity (and hence; general frailty) and adverse prognosis in Covid-19 patients . The authors have principally attributed this injury to certain factors including systemic inflammation, hypoxemia and direct myocardial invasion by the viral agent (1). However, as described below, an acute autoimmune reaction triggered by the virus might also be considered as an alternative mechanism of myocardial injury par...

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  • Other treatable causes of recurrent pericarditis

    Among the underlying causes of recurrent pericarditis which require specific treatment strategies (1) mention must also be made of recurrent pericarditis attributable to coeliac disease(2)(3), and recurrent pericarditis attributable either to Type 2 autoimmune endocrinopathy(4) or to hypoadrenalism(5).
    Faizallah et al reported 3 patients aged 40, 40, and 56, respectively, with recurrent pericarditis attributable to coeliac disease. The first patient presented with a temperature of 38.5 degrees Celsius, pericardial friction rub, and macrocytic anaemia attributable to folate deficiency. Pericardiocentesis yielded blood stained fluid that tested negative on bacteriological and M tuberculosis culture. Viral studies were negative and there were no malignant cells in the pericardial fluid. He responded well to reducing doses of corticosteroid therapy. However, it was only after a relapse of pericarditis that he had a duodenal biopsy, the latter an evaluation which revealed histological stigmata of coeliac disease. He was subsequently managed with a gluten-free diet(GFD), concurrently with an attempt to taper off the corticosteroid treatment. In spite of two subsequent relapses, corticosteroid treatment was eventually permanently terminated without any further relapse of pericarditis. The second patient was on GFD as well as a small dose of prednisolone at the time of publication of the report. The third patient, characterised by two episodes of pericarditi...

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  • Red flags as an adjunct to clinical decision rules in aortic dissection

    The clinical presentation which simulates ST-segment elevation myocardial infarction(STEMI)(1) is one of the most deceptive manifestations of dissecting aortic aneurysm(DAA), deserving detailed analysis notwithstanding its infrequent(2)(3)(4) occurrence. In Zhu et al DAA was prevalent in only 0.5% of 1576 subjects with suspected STEMI(2). Conversely, Kosuge et al documented a 4%(9 patients) prevalence of ST segment elevation among 233 subjects with confirmed DAA(3). In Hirata et al ST segment elevation was prevalent in 8.2% of 159 subjects with type A aortic dissection(4). When ST segment elevation occurs as a manifestation of DAA, there is a high prevalence of involvement of the inferior leads, exemplified by 6 of the 9 patients in Kosuge et al(3)., and seven of the 13 cases in Hirata et al(4)., arguably because type A aortic dissection is more likely to compromise the ostium of the right coronary artery than the ostium of the left coronary artery(5). In view of the life-threatening nature of DAA clinicians should not rely only on clinical decision rules to raise the index of suspicion. The rationale for a more open-minded approach is that clinical decision rules such as the AAD risk score tend to emphasise typical symptoms, such as the "tearing" character of the back pain(1), almost to the total exclusion of less typical symptoms such as nonspecific back pain, the latter typically radiating from a retrosternal chest pain. For example, a literat...

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  • Release of troponin after exercise stress test in hypertrophic cardiomyopathy

    Release of troponin after exercise stress test in hypertrophic cardiomyopathy

    Pawel Petkow Dimitrow1, Renata Rajtar-Salwa2, Tomasz Tokarek2
    1 2nd Department of Cardiology, Jagiellonian University Medical College, Kraków, Poland
    2 Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
    Correspondence to: Paweł Petkow Dimitrow, 2nd Department of Cardiology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland, e-mail: dimitrow@mp.pl, tel. 0048 12 400 22 50

    Recently Cramer et al. demonstrated very important observation on troponin level increase after exercise in patients with hypertrophic cardiomyopathy (HCM) [1]. Several concerns regarding to methodology of their study should be explained. Authors decided to perform only one measurement of troponin level at 6 hours after end of exercise. In our opinion, sampling after 6, 12, 18 and 24 hours after exercise provide more adequate profile of troponin level and allow to monitor possible post-exercise ischemia. Furthermore, data on prevalence of silent myocardial ischemia (only troponin increase) should be provided. In our study [2] painless ischemia detected by troponin measurement after normal daily physical activity was present in 25% of HCM patients. In another study [3], among HCM patients monitored by HOLTER ECG during normal daily physical activity, maximum heart rate was higher in th...

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    Kenan YALTA, MD a
    Tulin YALTA, MD b
    Muhammet GURDOGAN, MD a

    aTrakya University, Cardiology Department, Edirne, TURKEY
    b Trakya University, Pathology Department, Edirne, TURKEY
    Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
    Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 0090505657985

    In the setting of takotsubo cardiomyopathy (TTC), coronary microvascular dysfunction has been mostly considered as a causative factor (1,2). In their recently published article (1), Montone RA et al have demonstrated, for the first time, the prognostic value of coronary slow flow (CSF) phenomenon in TTC patients. Of note, as we previously discussed, on a theoretical basis, the particular prognostic value of CSF phenomenon in these patients (3), we feel now pleased to notice that this theory has been fully confirmed by a well-designed study (1). Nevertheless, we would like to make a few comments on this issue:
    Firstly; temporal emergence of CSF phenomenon might possibly matter in TTC as well. Accordingly; an acutely evolving CSF pattern (due to severe adrenergic discharge (1)) as compared with a sole pre-existing one (emerging long before the index TTC as part of generalized...

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  • Problems with the clinical director role

    I read with interest the super article by Chris Steadman regarding being a clinical director in the NHS. I would add to this article that a particular problem has now become grossly apparent with taking on such a role which is the amount of pension tax that many will find they have to pay in taking such a role on. Previously, leadership and management roles have often attracted a rise in pensionable salary, which was a clear incentive to take them - as per the article, they clearly result in alot of work to the individual and so should be rewarded for this. However with the pension taper which started in 2016 and a low annual allowance, this creates a major problem, with many stories of doctors taking on such roles and receiving a large tax bill as result. How big a bill this may or may not be will depend on the personal circumstances of the individual and the amount of extra pensionable salary the individual trust is offering. For example, under current rules, a £10,000 increase in pensionable pay would result in me doing such a job at a big financial loss in my first year of doing it! Unless the UK government change the pension tax rules, it has created major disincentive for doctors to take on such roles.