We read with great interest the article by Politi et al. (1) on
revascularisation of patients presenting with ST-elevation myocardial
infarction (STEMI) in the context of multivessel coronary disease, and its
accompanying Editorial. Whilst the data are interesting and hypothesis-
generating, they fall short of demanding any change in current practice
owing to a potential flaw in the study design and in the findings as
pre...
We read with great interest the article by Politi et al. (1) on
revascularisation of patients presenting with ST-elevation myocardial
infarction (STEMI) in the context of multivessel coronary disease, and its
accompanying Editorial. Whilst the data are interesting and hypothesis-
generating, they fall short of demanding any change in current practice
owing to a potential flaw in the study design and in the findings as
presented that makes it difficult to fully agree with the authors'
conclusions.
Firstly, no explanation is given for the MACE detriment seen in the
culprit-only revascularisation (COR) group; we would agree with previous
comments regarding the reasons for repeat rehospitalisation and repeat
revascularisation, that both require further clarification to understand
their importance. However, it is the high inhospital mortality rate in the
COR group compared with the staged revascularisation (SR) group that is
most perplexing: both groups would have been expected to have a similar
inhospital course given the same initial PCI strategy, with the SR group
perhaps being expected to perform better than COR at medium- or long-term
follow-up. This, along with the imbalance in patient numbers between
groups, perhaps suggests that the results are presented by treatment
received rather than by intention-to-treat (ie. patient randomised to SR
dies in hospital after initial PCI and is counted in COR group), thereby
introducing a bias that may render the results uninterpretable.
Secondly, and perhaps more importantly, the study by Qarawani et al.
(2) used to inform the power calculation to determine the sample size for
this study is not only a nonrandomised study with a huge imbalance in the
numbers within its 2 arms, but crucially is also an outlier in terms of
the difference in MACE rates between COR and CR during primary
angioplasty: inhospital MACE rates were 52% and 16.7% respectively,
compared with far more modest differences of 0 vs. 3.8% observed in the
study by Di Mario et al. (3) and 6.3 vs. 7.4% in the study by Ijsselmuiden
et al. (4). In this latter study, a randomised comparison with a similar
number of patients in the COR and CR arms as that of Politi et al. (1),
MACE rates at 1 year were still not significantly different between the
two arms (32.4 vs. 26.9%) in stark contrast to the findings described
here. Granted, these studies were performed when primary angioplasty
techniques were not as advanced as today in terms of device and
pharmacological developments, but even so it is difficult to justify the
retrospective application of a power calculation from a study that is more
contemporary (Qarawani et al. (2) published their findings in 2008, the
year after patient recruitment for the study of Politi et al (1) had
finished) simply to provide the statistical power to generate a
significant p value.
For the moment, we believe that in primary angioplasty for STEMI in
the absence of cardiogenic shock, there is not enough evidence to support
a change from the strategy of culprit-only revascularisation with a staged
approach to non-culprit lesions. Clearly we agree with the authors that
further research, likely in the form of a large multicentre randomised
trial, is needed to determine the optimal therapy for these patients.
References
1. A randomised trial of target-vessel versus multi-vessel
revascularisation in ST-elevation myocardial infarction: major adverse
cardiac events during long-term follow-up. Politi L, Sgura F, Rossi R et
al. Heart 2010; 96: 662-667.
2. Culprit only versus complete coronary revascularization during
primary PCI. Qarawani D, Nahir M, Abboud M et al. Int J Cardiol 2008; 123:
288-292.
3. Single vs. multivessel treatment during primary angioplasty:
results of the multicentre randomised HEpacoat for culprit or multivessel
stenting for Acute Myocardial Infarction (HELP-AMI) study. Di Mario C,
Mara S, Flavio A et al. Int J Cardiovasc Intervent 2004; 6: 128-133.
4. Complete versus culprit vessel percutaneous coronary intervention
in multivessel disease: A randomized comparison. Ijsselmuiden AJJ,
Ezechiels JP, Westendorp ICD et al. Am Heart J 2004; 148: 467-474.
The publication of not one but two reviews of catheter ablation for
atrial fibrillation (AF) in this week's edition of Heart is very
welcome.(1,2) The English and Welsh guidance from the National Institute
for Clinical and Public Health Excellence (NICE) was published in 2006,(3)
but a great deal of new comparative effectiveness evidence has been
published recently. However there is a significant gap...
The publication of not one but two reviews of catheter ablation for
atrial fibrillation (AF) in this week's edition of Heart is very
welcome.(1,2) The English and Welsh guidance from the National Institute
for Clinical and Public Health Excellence (NICE) was published in 2006,(3)
but a great deal of new comparative effectiveness evidence has been
published recently. However there is a significant gap in both reviews:
they fail to mention the costs of alternative treatments, or even the
risks of hospital readmission for recurrent AF.
A cost-effectiveness analysis published in 2003(4) showed that
initiating treatment with pharmacologic cardioversion (CV) cost less per
successful CV than initiating treatment with electrivcal CV in all
patients (US$1,240 versus US$1,917 p=0.002). Little information was
available about longer term costs at that time, and so the results might
look quite different now.
References
(1)Hunter RJ, Schilling RJ. Long-term outcome after catheter ablation
for atrial fibrillation: safety, efficacy and impact on prognosis. Heart
2010;96:1259-1263.
(2)Kirchhof P, Eckardt L. Atrial fibrillation: Ablation of atrial
fibrillation: for whom and how? Heart 2010;96:1325-1330.
(3) National Collaborating Centre for Chronic Conditions. Atrial
fibrillation: national clinical guideline for management in primary and
secondary care. NICE 2006. Available from:
http://guidance.nice.org.uk/CG36/Guidance/pdf/English
4) de Paola AA, Figueiredo E, Sesso R et al. Effectiveness and costs
of chemical versus electrical cardioversion of atrial fibrillation.
International Journal of Cardiology. 2003;88:157-3.
Ullah and Stewart present a case of pacemaker-mediated tachycardia
(PMT) and described it as a "malfunction of dual chamber pacing". However,
I would contend that the pacemaker is functioning appropriately, ie: it is
sensing atrial activity in the atrium and pacing (capturing) the
ventricle. The problem in PMT is the retrograde atrial activation beyond
the PVARP as described and appropriate programming of the PVARP based o...
Ullah and Stewart present a case of pacemaker-mediated tachycardia
(PMT) and described it as a "malfunction of dual chamber pacing". However,
I would contend that the pacemaker is functioning appropriately, ie: it is
sensing atrial activity in the atrium and pacing (capturing) the
ventricle. The problem in PMT is the retrograde atrial activation beyond
the PVARP as described and appropriate programming of the PVARP based on
the VA conduction time (and/or the use of PVARP extension post-PVC) will
minimise this problem. It should also be noted that the PVARP is a
refractory period and not a "blanking period" as erroneously described in
the report. The differentiation of blanking and refractory periods is
fundamental to the understanding of pacemaker programming, function and
diagnostics.
Sir,
As a "jobbing cardiologist", I am grateful for the NICE guidance on the
investigation of stable chest pain. I am grateful for the emphasis on
clinical assessment, and I am grateful for the shift away from exercise
testing. I am astonished, however, that the guideline does not say one
word about the utility of a therapeutic trial in cases of uncertainty, and
nor does the editorial by Fox & McLean. Every cardiol...
Sir,
As a "jobbing cardiologist", I am grateful for the NICE guidance on the
investigation of stable chest pain. I am grateful for the emphasis on
clinical assessment, and I am grateful for the shift away from exercise
testing. I am astonished, however, that the guideline does not say one
word about the utility of a therapeutic trial in cases of uncertainty, and
nor does the editorial by Fox & McLean. Every cardiologist knows that
chest pain which responds to nitrate is much more likely to be cardiac and
if it doesn't it is much less likely to be cardiac. Every cardiologist
knows that chest pain which responds to a beta-blocker is much more likely
to be cardiac and if it doesn't it is much less likely to be cardiac.
However many non-invasive and/or invasive investigations we perform there
will always be cases of clinical uncertainty that can't be protocolised
out of existence and will require some clinical common sense. Something
that appears to be distinctly lacking from the NICE guidance.
Fox & Mclean suggest that application of the NICE guideline would
lead to a 20% increase in invasive angiography and a 42% increase in non-
invasive imaging from the rapid-access chest pain clinic. These are
absolute rather than relative increases. This is a bizarre way of
expressing the data, if not a disingenous one. The relative increase in
invasive angiography is 83% and the relative increase in non-invasive
imaging is 717% ! These are very different headline figures and give a
much truer idea of the mountain we have to climb !
The recent editorial of Fox and Mclean concludes ââ¬à The NICE guidance on chest pain provides a series of important advances over the current status of investigation and triage of chest pain and should be welcomed by the profession 1. One of the key recommendations of the recently published National Institute for Health and Clinical excellence (NICE) guidelines for the early management of unstable...
The recent editorial of Fox and Mclean concludes â₁“The NICE guidance on chest pain provides a series of important advances over the current status of investigation and triage of chest pain and should be welcomed by the profession 1. One of the key recommendations of the recently published National Institute for Health and Clinical excellence (NICE) guidelines for the early management of unstable angina and non-ST-segment-elevation myocardial infarction is the formal assessment of individual risk of future adverse cardiovascular events using the Global Registry of Acute Coronary Events (GRACE) risk stratification score 2. GRACE is a simple risk model that is able to predict the level of risk for individual patients for both in hospital and 6-month risk of mortality and mortality or MI and is based upon outcome data derived from a large, multinational, prospective observational study of patients with an ACS (N=43 810).
Under the current guidelines, using the GRACE risk score, patients found to be at lowest risk, defined as 6-month mortality, 1.5%, would not require clopidogrel and would be managed conservatively. Similarly, patients found to be at low risk, defined as 6-month mortality of 1.5-3%, are to be treated with clopidogrel but also managed conservatively with the value of non-invasive testing questioned. In the absence of recurrent ischaemia, coronary angiography and revascularization are recommended only if predicted 6 month mortality exceeds 3%.
The NICE algorithm is based on analysis of the benefits of clopidogrel and an invasive versus conservative strategy in relation to mortality risk. However, the algorithm does not take into account risk of MI which in young patients may be considerable despite a very low risk of mortality. We propose that this is a major flaw in the guidelines for the following reasons. The trial evidence for the value of clopidogrel in ACS comes predominantly from the CURE trial, in which the main component of cardiovascular risk reduction was the significant reduction in MI with a relative risk reduction of 23% 3. Similarly, in a recent meta-analysis of 5 RCTs involving 7818 patients the main component of benefit for an invasive compared to a conservative strategy was the significant reduction in MI rather than mortality, with a relative risk reduction of 27% 4. The NICE algorithm therefore does not recommend treatments shown to significantly reduce risk of MI, to young patients at high risk of MI. For example, using the GRACE risk calculator, a 40 to 50 year old male without co-morbidities admitted with cardiac chest pain, a normal ECG and raised troponin with a heart rate of 70-89, a systolic blood pressure of at least 120mmHg, normal renal function (creatinine 71-105 ï�ÂÂmol/l) and no evidence of heart failure, the predicted 6 month mortality risk is 1% (lowest risk). The NICE algorithm for this patient does not recommend either clopidogrel (despite a very low bleeding risk) or invasive approach or mandate non-invasive testing despite a 6-month risk of nonfatal MI of 12%. If that patient also has ECG changes his predicted 6-month mortality risk is 2% (low risk) and so he would receive clopidogrel but be managed conservatively despite a predicted 6-month risk of nonfatal MI of 19%. Furthermore, as hypertension is protective in terms of mortality, if this patient was 39 years old with an admission BP of at least 160 mmHg and was admitted with a cardiac arrest in addition to ECG changes and a raised Troponin his predicted 6 month mortality is 3% (low risk) and so he would still be managed conservatively despite a predicted 6-month risk of nonfatal MI of 31 %.
Young patients therefore, with a low predicted mortality but a substantial risk of MI are not well served by the NICE guidelines that do not recommend clopidogrel in some or an invasive approach in most of these patients despite good evidence that these interventions would substantially reduce the risk of MI. Furthermore the NICE guidelines are directly opposed to the European Society of Cardiology 5 and American College of Cardiology / American Heart Association guidelines 6 in these patients which recommend an invasive strategy in patients with either elevated cardiac biomarkers or new ECG changes. Our proposal therefore, is not that the GRACE risk score is not useful in predicting risk but that it's predicted risk of both mortality and nonfatal MI should be used to make treatment decisions. Although written as a guideline for treatment, many units may choose to adopt the NICE algorithm as their hospital ACS protocol perhaps without direct physician or cardiologist involvement in individual patients. This makes it especially important that all patient groups are well served by this guidance.
References
1. Fox KAA, McLean S. Nice guidance on the investigation of chest pain. Heart 2010; 96: 903-906 (Editorials)
2. Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction; Clinical guidelines CG94: March 2010; 1-360. http://www.nice.org.uk/guidance/CG94.
3. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494-502.
4. Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2010;3:CD004815.
5. Bassand JP, Hamm CW, Ardissino D et al. Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology. Guidelines for the diagnosis and treatment of non-ST-elevation acute coronary syndromes, Eur Heart J 2007; 28: 1598-1660.
6. Anderson JL, Adams CD, Antman EM et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007; 50(7):e1-157.
Author Contributions
Dr Mamas Mamas and Dr Doug Fraser contributed equally to the article and text.
Conflicts of Interest
All authors declare that the answer to the questions on your competing interest form are all No and therefore have nothing to declare
The avoidance of redundant publication is the core of the editorial
task; therefore editors have established clear policies posted in their
instructions for authors. The term Redundant publication has always been
used for research reported by the same author and sent to two or more
different journals. We report here a different situation that also results
in unplanned redundant publication....
The avoidance of redundant publication is the core of the editorial
task; therefore editors have established clear policies posted in their
instructions for authors. The term Redundant publication has always been
used for research reported by the same author and sent to two or more
different journals. We report here a different situation that also results
in unplanned redundant publication.
We bring to your attention the following facts relating to the meta-
analysis published in Heart in 2009 by Zhang et al[1]. We have found out
that 4 very similar meta-analyses on the same subject were published last
year in different journals within a 6 month period, by different
investigators working at different institutions. The enclosed table
contains the relevant details of the 4 publications. Several comments are
pertinent on this issue. Neither the editors nor the authors could have
been aware of the redundancy because they were written simultaneously and
accepted on the same week of July (this information is not available for
the EuroIntervention article). Likewise, the same worrying considerations
apply to this surprising situation in that there has been a waste of
reviewers' and readers' time and published pages. It is worth noting that
both a general cardiology journal such as Heart[1] and sub speciality
ones, such as Journal of Invasive Cardiology,[2] Circulation
Cardiovascular Intervention[3] and EuroIntervention[4] have found the
article appealing. In 3 cases the publications were original articles,
while the last one was an expert review; remarkably, only one journal has
impact factor. This unfortunate coincidence could be further deleterious
for all these journals, as they will be competing for citations on the
very same topic. Although this letter focuses on the editorial aspects of
this coincidence, it is also interesting to consider that, even though the
main conclusions of the 4 articles are identical, the results of the meta-
analyses are slightly different due probably to the methods used. We have
also analyzed a possible trigger for this sudden interest in this topic,
but could not find any reasonable explanation.
References:
1.- Zhang F, Dong L, Ge J. Simple versus complex stenting strategy for
coronary artery bifurcation lesions in the drug-eluting stent era: a meta-
analysis of randomised trials. Heart. 2009;95:1676-81. Epub 2009 Jul 29.
2.- Hakeem A, Khan FM, Bhatti S, et al. Provisional vs complex stenting
strategy for coronary bifurcation lesions: Meta-analysis of randomized
trials. J Invasive Cardiol 2009;21:589-95
3.- Katritsis DG, Siontis GCM, Ioannidis JPA. Double versus single
stenting for coronary bifurcation lesions. A Meta-analysis. Cir Cardiovasc
Intervent. 2009;2:409-15
4.- Brar SJ, Gray WA, Dangas G, et al. Bifurcation stenting with drug-
eluting stents: a systematic review and meta-analysis of randomised
trials. Eurointervention 2009;5:475-84
note: the following information is formatted as a table and not
supported by your submission system. The information is paramount for the
understanding of this letter and too long to include in the text.
Brar
Article: Expert review
Journal: EuroIntervention
Submission date: N/A
Acceptance date: N/A
Publication date: Sep 2009
Method: Search several databases
no. studies: 6
no. patients: 1.641
Endpoint: Death, MI, TVR, stent thrombosis 1yr
OR death: 1,12 (0,42-3,02)
OR MI: 0,57 (0,37-0,87)
OR TVR: 0,91 (0,61-1,35)
OR Stent thrombosis: 0,56 (0,23-1,35)
Hakeem
Article: Original
Journal: J Invasive Cardiol
Submission date: 28.5.2009
Acceptance date: 20.7.2009
Publication date: 11.11.2009
Method: Search several databases
no. studies: 6
no. patients: 1.641
Endpoint: Clinical and angiographic **
OR death: 0,93 (0,37-2,33)
OR MI: 1,71 (1,02-2,88)
OR TVR: 1,1 (0,73-1,64)
OR Stent thrombosis: 1,6 (0,65-3,91)
Kastritis
Article: Original
Journal: Cir Cardiovas Intervent
Submission date: 24.3.2009
Acceptance date: 22.7.2009
Publication date: 3.11.2009
Method: Search several databases
no. studies: 6
no. patients: 1.642
Endpoint: Death, MI, TVR, stent thrombosis
OR death: 0,81
OR MI: 1,78
OR TVR: 1,09
OR Stent thrombosis: 1,85
Zhang
Article: Original
Journal: Heart
Submission date: N/A
Acceptance date: 21.7.2009
Publication date: 29.7.2009 (on-line)
Method: Search several databases
no. studies: 5*
no. patients: 1.553
Endpoint: Death, MI, TVR, stent thrombosis
OR death: 0,68 (0,21-2,25)
OR MI: 0,54 (0,37-0,78)
OR TVR: 0,93 (0,62-1,41)
OR Stent thrombosis: 0,50 (0,19-1,32)
N/A: not available
* excluded Sirius Bifurcation Study because the results of the paper
were not reported as 'intention to treat', but rather by treatment
received
To the Editor: I read with interest, the article by Christian J M
Vrints (1) on spontaneous coronary artery dissection (SCAD). The images
from current imaging modalities are impressive. The author has given an
useful and practical approach to managing patients with SCAD.
The author has recommended medical therapy for asymptomatic patients
with SCAD, followed by computed tomogram on follow up. Myocardial
perfu...
To the Editor: I read with interest, the article by Christian J M
Vrints (1) on spontaneous coronary artery dissection (SCAD). The images
from current imaging modalities are impressive. The author has given an
useful and practical approach to managing patients with SCAD.
The author has recommended medical therapy for asymptomatic patients
with SCAD, followed by computed tomogram on follow up. Myocardial
perfusion imaging (MPI) with Single Photon Emissin Computed Tomography
(SPECT) or Positron Emission Tomography (PET) is an useful tool for risk
stratifying asymptomatic patients with SCAD. MPI provides valuable data
regarding myocardial viability as well as extend of myocardium at
jeopardy. Revascularization is warranted even in asymptomatic patients if
there is evidence of inducible ischemia or if there is viable myocardium
in patients with left ventricular systolic dysfunction. On the contrary,
conservative treatment is sufficient if MPI reveals absence of inducible
ischemia or infarcted myocardium.
We had reported a case of asymptomatic SCAD in a 25-years-old male,
who had sustained a silent anterior wall myocardial infarction (2). Though
the patient refused MPI, he remains asymptomatic at 4 years of follow up,
on medical therapy.
References:
1) Christian J M Vrints Acute coronary syndromes: Spontaneous
coronary artery dissection Heart 2010;96:801-808
doi:10.1136/hrt.2008.162073
2) Shankarappa RK, Panneerselvam A, Dwarakaprasad R, Karur S,
Krishnanaik GB, Nanjappa MC Spontaneous asymptomatic coronary artery
dissection in a young man. J Cardiol 2009; 54 (3),499-502
Our ischaemic cardiopathy study group have read with interest the
article written by Lawesson
et al (1). First of all, the occurrence of ST-elevation myocardial
infarction in young women is
rare and the tobacco nocive role is well established in the medical
literature. However, we
would like to emphasize that smoking in women is growing nowadays.
According to World
Health Organization, there are 1,2 billion smokers around...
Our ischaemic cardiopathy study group have read with interest the
article written by Lawesson
et al (1). First of all, the occurrence of ST-elevation myocardial
infarction in young women is
rare and the tobacco nocive role is well established in the medical
literature. However, we
would like to emphasize that smoking in women is growing nowadays.
According to World
Health Organization, there are 1,2 billion smokers around the world, in
which 200 million are
women (2). Even with this, in the article, the women are not having
infarctions more often.
Regarding this, we would like to know the position of the authors on the
following questions
judged relevant by our group: first, what is the prevalence of early
coronary diseases in the
first grade relatives of these women? And second, knowing that the use of
drugs or vasoactive
substances and having AIDS are related to the occurrence of myocardial
infarction in youngs,
we ask if these factors were present in the studied female population.
REFERENCES
1.Lawesson SS, Stenestrand U, Lagerqvist B et al. Gender perspective on
risk factors,
coronary lesions and long-term outcome in young patients with ST-elevation
myocardial
infarction. Heart 2010;96:453-459
2.Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med
1999;107:254e61. 3.World Health Organization (WHO). Tobbaco Free
Iniciative.
http://www.who.int/tobacco/en
We have read with interest the article written by Bramlage et al (1)
and we want to congratulate the authors and manifest our agreement with
the findings of lower mortality in patients receiving optimal medical
therapy (OMT) with statins, aspirin, clopidogrel, b-blockers, rennin
angiotensin system blockers/ angiotensin-receptor blockers.
However, we think appropriate to mention that patients who received OMT
probably nee...
We have read with interest the article written by Bramlage et al (1)
and we want to congratulate the authors and manifest our agreement with
the findings of lower mortality in patients receiving optimal medical
therapy (OMT) with statins, aspirin, clopidogrel, b-blockers, rennin
angiotensin system blockers/ angiotensin-receptor blockers.
However, we think appropriate to mention that patients who received OMT
probably needed to have medical conditions that could support this type
of approach, such as blood pressure levels that tolerate hypotensive
drugs, having adequate ventricular function to receive negative inotropic
agents or the coagulation system working properly to receive anticoagulant
/ antiplatelet drugs, among other conditions that allow the use of these
and other classes of medications (2). Hence, patients that can receive the
OMT are already better, and thus will have better outcomes.
Regarding the use of statin, which is a medication commonly used (3), we
would like to know the position of the authors on the following question:
what are the reasons in this study for its limited use, especially in
suboptimal group?
References
1. Bramlage P, Messer C, Bitterlich N, Pohlmann C, Cuneo A, Stammwitz E,
et al. The effect of optimal medical therapy on 1-year mortality after
acute myocardial infarction. Heart. 2010 Apr;96(8):604-9.
2. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS,
et al. ACC/AHA guideline update for the management of patients with
unstable angina and non-ST-segment elevation myocardial infarction--2002:
summary article: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee on the
Management of Patients With Unstable Angina). Circulation. 2002 Oct
1;106(14):1893-900.
3. Wiviott SD, Cannon CP, Morrow DA, Ray KK, Pfeffer MA, Braunwald E. Can
low-density lipoprotein be too low? The safety and efficacy of achieving
very low low-density lipoprotein with intensive statin therapy: a PROVE IT
-TIMI 22 substudy. J Am Coll Cardiol. 2005 Oct 18;46(8):1411-6.
We read with interest the work "A randomised trial of target-vessel
versus multi-vessel revascularisation in ST-elevation myocardial
infarction: major adverse cardiac events during long-term follow-up"by
Luigi Politi. According to the conclusion of the article, culprit vessel-
only angioplasty was associated with the highest rate of long-term MACE
compared with multivessel treatment including simultaneous
revascularizati...
We read with interest the work "A randomised trial of target-vessel
versus multi-vessel revascularisation in ST-elevation myocardial
infarction: major adverse cardiac events during long-term follow-up"by
Luigi Politi. According to the conclusion of the article, culprit vessel-
only angioplasty was associated with the highest rate of long-term MACE
compared with multivessel treatment including simultaneous
revascularization and staged revascularization[1].
This is the first prospective study in which the culprit-only
revascularisation was separated as a isolated group(excluded the staged
revascularization) while previous studies divided patients into two
groups[2][3]. Is this classification reasonable?
According to the ACC/AHA recommendation[4], the culprit vessel should
be treated in the primary procedure, and staged PCI can be performed in an
elective procedure for the STEMI patients with multivessel disease. But in
this study, staged PCI had not been considered in the COR group for 2.5
years.So the higher incidence of re-PCI and re-hospitalization was
inevitable. The investigators aslo admitted that the incidence of repeat
revascularisation and re-hospitalisation was significantly higher only in
the COR group, whereas there was no significant difference in other
outcomes among the three groups. Under the circumstances, the higher rate
of long-term MACE in COR group is a really convinced conclusion?
references
[1] Luigi Politi, Fabio Sgura, Rosario Rossi, et al.A randomised trial of
target-vessel versus multi-vessel revascularisation in ST-elevation
myocardial infarction: major adverse cardiac events during long-term
follow-up.heart 2010;96:662-667.
[2] Di Mario C, Mara S, Flavio A, et al. Single vs multivessel treatment
during primary angioplasty: results of the multicentre randomised HEpacoat
for cuLPrit or multivessel stenting for Acute Myocardial Infarction ((HELP
AMI) Study. Int J Cardiovasc Intervent 2004;6:128-133.
[3] Khattab AA, Abdel-Wahab M, Rother C, et al. Multi-vessel stenting
during primary percutaneous coronary intervention for acute myocardial
infarction: A single-
center experience.Clin Res Cardiol 2008;97:32-38.
[4] Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the
ACC/AHA 2004 guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. J
Am Coll Cardiol 2008;51:210-47.
We read with great interest the article by Politi et al. (1) on revascularisation of patients presenting with ST-elevation myocardial infarction (STEMI) in the context of multivessel coronary disease, and its accompanying Editorial. Whilst the data are interesting and hypothesis- generating, they fall short of demanding any change in current practice owing to a potential flaw in the study design and in the findings as pre...
Dear Editor
The publication of not one but two reviews of catheter ablation for atrial fibrillation (AF) in this week's edition of Heart is very welcome.(1,2) The English and Welsh guidance from the National Institute for Clinical and Public Health Excellence (NICE) was published in 2006,(3) but a great deal of new comparative effectiveness evidence has been published recently. However there is a significant gap...
Ullah and Stewart present a case of pacemaker-mediated tachycardia (PMT) and described it as a "malfunction of dual chamber pacing". However, I would contend that the pacemaker is functioning appropriately, ie: it is sensing atrial activity in the atrium and pacing (capturing) the ventricle. The problem in PMT is the retrograde atrial activation beyond the PVARP as described and appropriate programming of the PVARP based o...
Sir, As a "jobbing cardiologist", I am grateful for the NICE guidance on the investigation of stable chest pain. I am grateful for the emphasis on clinical assessment, and I am grateful for the shift away from exercise testing. I am astonished, however, that the guideline does not say one word about the utility of a therapeutic trial in cases of uncertainty, and nor does the editorial by Fox & McLean. Every cardiol...
The recent editorial of Fox and Mclean concludes ââ¬à The NICE guidance on chest pain provides a series of important advances over the current status of investigation and triage of chest pain and should be welcomed by the profession 1. One of the key recommendations of the recently published National Institute for Health and Clinical excellence (NICE) guidelines for the early management of unstable...
Dear editor,
The avoidance of redundant publication is the core of the editorial task; therefore editors have established clear policies posted in their instructions for authors. The term Redundant publication has always been used for research reported by the same author and sent to two or more different journals. We report here a different situation that also results in unplanned redundant publication....
To the Editor: I read with interest, the article by Christian J M Vrints (1) on spontaneous coronary artery dissection (SCAD). The images from current imaging modalities are impressive. The author has given an useful and practical approach to managing patients with SCAD.
The author has recommended medical therapy for asymptomatic patients with SCAD, followed by computed tomogram on follow up. Myocardial perfu...
Our ischaemic cardiopathy study group have read with interest the article written by Lawesson et al (1). First of all, the occurrence of ST-elevation myocardial infarction in young women is rare and the tobacco nocive role is well established in the medical literature. However, we would like to emphasize that smoking in women is growing nowadays. According to World Health Organization, there are 1,2 billion smokers around...
We have read with interest the article written by Bramlage et al (1) and we want to congratulate the authors and manifest our agreement with the findings of lower mortality in patients receiving optimal medical therapy (OMT) with statins, aspirin, clopidogrel, b-blockers, rennin angiotensin system blockers/ angiotensin-receptor blockers. However, we think appropriate to mention that patients who received OMT probably nee...
We read with interest the work "A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up"by Luigi Politi. According to the conclusion of the article, culprit vessel- only angioplasty was associated with the highest rate of long-term MACE compared with multivessel treatment including simultaneous revascularizati...
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