To the Editor:
We read with great interest the recent meta-analysis by Kowalewski et al.[1] The authors should be congratulated for their work. However, we would like to make few comments about some issues with the meta-analysis.
First, complete revascularizations (CRs) done as staged procedures (SPs) were analyzed with the incomplete revascularization group, but endpoints were measured at a median follow-up of 12 months. Becaus...
To the Editor:
We read with great interest the recent meta-analysis by Kowalewski et al.[1] The authors should be congratulated for their work. However, we would like to make few comments about some issues with the meta-analysis.
First, complete revascularizations (CRs) done as staged procedures (SPs) were analyzed with the incomplete revascularization group, but endpoints were measured at a median follow-up of 12 months. Because the majority of SPs were performed within days to weeks of their index procedures, clinical wisdom suggests they would behave more like CRs than incomplete revascularizations over a 12-month follow-up. Therefore, we believe that from statistical and clinical points of view, CRs performed as SPs should have been included in the complete revascularization group, as was done in other meta-analyses and randomized trials.[2] Furthermore, the authors did not consistently analyzed CRs performed as SPs with the incomplete arm. In the Complete versus Culprit-Lesion Only Primary PCI Trial (CvLPRIT), CR was performed during the index procedure for 97 patients (Supplementary Table 5 in the CvLPRIT trial),[2] but this group (for this meta-analysis)was combined with patients receiving CRs as SPs, bringing the total to 150. This inconsistency significantly impacts the validity of the meta-analysis.
In addition, the title indicates the study was a meta-analysis of randomized trials, yet it included the study by Maamoun et al, an observational cohort study,[3] as evidenced by a statement in the Methods section. Maamoun et al state, "Group 1 consisted of 36 patients presented in the 1st year of the study and had undergone primary PCI for culprit vessel only in the initial procedure followed by another session of angioplasty to other diseased vessels and group 2 consisted of 42 patients presented in the 2nd year of the study and had received complete revascularization during the initial procedure."
Finally, the authors did not include a trial by Ghani et al.[4] No reason for this omission was mentioned in the Methods or Discussion. Therefore, we wonder if other studies were also omitted, undermining the validity of this meta-analysis.
References:
1. Kowalewski M, Schulze V, Berti S, et al. Complete revascularisation in ST-elevation myocardial infarction and multivessel disease: meta-analysis of randomised controlled trials. Heart. 2015;101(16):1309-17.
2. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963-72.
3. Maamoun W, Elkhaeat N, Elarasy R. Safety and feasibility of complete simultaneous revascularization during primary PCI in patients with STEMI and multivessel disease. Egyptian Heart J 2011;63:39-43.
4. Ghani A1, Dambrink JH, van 't Hof AW, et al. Treatment of non-culprit lesions detected during primary PCI: long-term follow-up of a randomised clinical trial. Neth Heart J. 2012 Sep; 20(9): 347-353.
Atrial fibrillation (AF) constitutes a major risk factor for stroke and death.1 ,2 The potential of biomarkers to improve the prognostication concerning stroke and other cardiovascular events in patients with AF is gaining strength of evidence and clinical promise. In particular the biomarkers of cardiovascular stress and dysfunction such as cardiac troponin (cTn), a marker of myocardial cell damage; N-terminal B-type natriuretic peptide (NT-proBNP), a marker of cardiac dysfunction; and growth-differentiation factor-15 (GDF-15), a marker of inflammation and oxidative stress, have been shown to be strong independent predictors.3–8 Although inflammatory activation has been linked to the occurrence of AF and to a prothrombotic state, the association with subsequent cardiovascular events during treatment with oral anticoagulation has not been fully established.9–14 Prior studies evaluating the relation between inflammation and cardiovascular events in patients with AF have often been exploratory and did not take into account the protective effect of oral anticoagulation. In addition the associations with outcomes have not been fully adjusted for other risk indicators, in particular other cardiovascular biomarkers, which recently have show
Atrial fibrillation (AF) constitutes a major risk factor for stroke and death.1 ,2 The potential of biomarkers to improve the prognostication concerning stroke and other cardiovascular events in patients with AF is gaining strength of evidence and clinical promise. In particular the biomarkers of cardiovascular stress and dysfunction such as cardiac troponin (cTn), a marker of myocardial cell damage; N-terminal B-type natriuretic peptide (NT-proBNP), a marker of cardiac dysfunction; and growth-differentiation factor-15 (GDF-15), a marker of inflammation and oxidative stress, have been shown to be strong independent predictors.3–8 Although inflammatory activation has been linked to the occurrence of AF and to a prothrombotic state, the association with subsequent cardiovascular events during treatment with oral anticoagulation has not been fully established.9–14 Prior studies evaluating the relation between inflammation and cardiovascular events in patients with AF have often been exploratory and did not take into account the protective effect of oral anticoagulation. In addition the associations with outcomes have not been fully adjusted for other risk indicators, in particular other cardiovascular biomarkers, which recently have showed to be independent and powerful markers of adverse outcomes in patients with AF.4 In this predefined biomarker study within the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial we asse...
Atrial fibrillation (AF) constitutes a major risk factor for stroke and death.1 ,2 The potential of biomarkers to improve the prognostication concerning stroke and other cardiovascular events in patients with AF is gaining strength of evidence and clinical promise. In particular the biomarkers of cardiovascular stress and dysfunction such as cardiac troponin (cTn), a marker of myocardial cell damage; N-terminal B-type natriuretic peptide (NT-proBNP), a marker of cardiac dysfunction; and growth-differentiation factor-15 (GDF-15), a marker of inflammation and oxidative stress, have been shown to be strong independent predictors.3–8 Although inflammatory activation has been linked to the occurrence of AF and to a prothrombotic state, the association with subsequent cardiovascular events during treatment with oral anticoagulation has not been fully established.9–14 Prior studies evaluating the relation between inflammation and cardiovascular events in patients with AF have often been exploratory and did not take into account the protective effect of oral anticoagulation. In addition the associations with outcomes have not been fully adjusted for other risk indicators, in particular other cardiovascular biomarkers, which recently have showed to be independent and powerful markers of adverse outcomes in patients with AF.4 In this predefined biomarker study within the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial we assessed the associations between levels of the inflammatory biomarkers interleukin 6 (IL-6) and C reactive protein (CRP) at baseline and clinical outcomes including adjustments for established clinical risk factors and other previously shown to be prognostically significant cardiovascular biomarkers in approximately 15 000 patients with AF treated with either warfarin or apixaban oral anticoagulation.15 ,16 Further, the prognostic information gained by the inflammatory biomarkers in relation to the currently used CHA2DS2VASc (risk model to assess risk of stroke) and HAS-BLED (risk model to asses risk of major bleeding) scores was evaluated, as well as potential interactions with the effects of apixaban as compared with warfarin on all outcomes.Atrial fibrillation (AF) constitutes a major risk factor for stroke and death.1 ,2 The potential of biomarkers to improve the prognostication concerning stroke and other cardiovascular events in patients with AF is gaining strength of evidence and clinical promise. In particular the biomarkers of cardiovascular stress and dysfunction such as cardiac troponin (cTn), a marker of myocardial cell damage; N-terminal B-type natriuretic peptide (NT-proBNP), a marker of cardiac dysfunction; and growth-differentiation factor-15 (GDF-15), a marker of inflammation and oxidative stress, have been shown to be strong independent predictors.3–8 Although inflammatory activation has been linked to the occurrence of AF and to a prothrombotic state, the association with subsequent cardiovascular events during treatment with oral anticoagulation has not been fully established.9–14 Prior studies evaluating the relation between inflammation and cardiovascular events in patients with AF have often been exploratory and did not take into account the protective effect of oral anticoagulation. In addition the associations with outcomes have not been fully adjusted for other risk indicators, in particular other cardiovascular biomarkers, which recently have showed to be independent and powerful markers of adverse outcomes in patients with AF.4 In this predefined biomarker study within the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial we assessed the associations between levels of the inflammatory biomarkers interleukin 6 (IL-6) and C reactive protein (CRP) at baseline and clinical outcomes including adjustments for established clinical risk factors and other previously shown to be prognostically significant cardiovascular biomarkers in approximately 15 000 patients with AF treated with either warfarin or apixaban oral anticoagulation.15 ,16 Further, the prognostic information gained by the inflammatory biomarkers in relation to the currently used CHA2DS2VASc (risk model to assess risk of stroke) and HAS-BLED (risk model to asses risk of major bleeding) scores was evaluated, as well as potential interactions with the effects of apixaban as compared with warfarin on all outcomes.
Assessing effect of remote ischaemic preconditioning on clinical
outcomes in patients undergoing cardiac bypass surgery
To the Editor : In a recent article of Candilio et al.1 assessing the
effect of remote ischaemic preconditioning (RIPC) on postoperative
outcomes in patients undergoing cardiac surgery, they showed that RIPC
reduced the amount of perioperative myocardial injury by 26% and the
incidence of acute...
Assessing effect of remote ischaemic preconditioning on clinical
outcomes in patients undergoing cardiac bypass surgery
To the Editor : In a recent article of Candilio et al.1 assessing the
effect of remote ischaemic preconditioning (RIPC) on postoperative
outcomes in patients undergoing cardiac surgery, they showed that RIPC
reduced the amount of perioperative myocardial injury by 26% and the
incidence of acute kidney injury by 48%.The authors discuss the
limitations of their work.In our view, the following important issues in
this study seemed not to be well addressed.
Perioperative dexmedetomidine infusion was not included in data
analysis.Actually,perioperative dexmedetomidine infusion is common among
patients undergoing cardiac surgery.
Dexmedetomidine, a highly selective?2 adrenoreceptor agonist, has
advantages for reducing renal injury. Perioperative dexmedetomidine
infusion effectively reduces the incidence and severity of acute kidney
injury in cardiac surgery.2
Preoperative Contrast angiography was not included in data analysis.
Preoperative Contrast angiography is not rare among patients
undergoing coronary artery bypass grafting surgery.The contrast-induced
nephropathy is independently associated with increased postoperative risks
of adverse renal events 3.
Aminoglycoside, a commonly administered antibiotic in the operating
room, independently associated with increased risks of postoperative acute
renal injury(AKI) through intracellular processes such as mitochondrial
dysfunction and reduction of protein synthesis.4
We are concerned that if there is any disbalance in these factors
would have confounded the interpretation of the results.
1.Candilio L, Malik A, Ariti C, et al. Effect of remote ischaemic
preconditioning on clinical outcomes in patients undergoing cardiac bypass
surgery:a randomised controlled clinical trial. Heart 2015;101:185-92
2.Jin Sun Cho, Jae-Kwang Shim, Sara Soh , et al.Perioperative
dexmedetomidine reduces the incidence and severity of acute kidney injury
following valvular heart surgery. Kidney Int 2015; advance online
publication, 7 October 2015;doi:10.1038/ki.2015.306
3.Persson PB, Hansell P, Liss P. Pathophysiology of contrast medium-
induced nephropathy. Kidney Int 2005; 68:14-22.
1.Department of Anesthesiology, the Affiliated Hospital of Qingdao
University ,Qingdao ,China
2.Department of nephrology ,the Affiliated Hospital of Qingdao
University , Qingdao ,China
Correspondence:
Wei Zhang, Department of Nephrology, The Affilitated Hospital of
Qingdao University,Qingdao266003, China.
E-mail:xfwwww@163.com
Contributors: Feng Xue read the manuscript of Candilio et al.;
analysed their methods and data; suggested comment points and drafted this
manuscript; responsible for this manuscript; and approved the final
manuscript. Hai chen Chu read the paper of Candilio et al.;analysed their
data; revised the comment points and this manuscript; and approved the
final manuscript.Wei Zhang read the manuscript of Candilio et al.;
analysed their methods and data; revised the comment points and this
manuscript; and approved the final manuscript.
Tanu Pramanik Senior Lecturer (Psychology)
Effect of sleep deprivation on cardiac patients is an well documented clinical entity which the authors of the current article established with experimental data and therefore deserve sincere applause(1).
WHO guideline:
The World Health Organization guidelines say that for a good sleep, sound level should not exceed 30 dB(A) for continuous background noise, and 45 dB(A) for individual no...
Tanu Pramanik Senior Lecturer (Psychology)
Effect of sleep deprivation on cardiac patients is an well documented clinical entity which the authors of the current article established with experimental data and therefore deserve sincere applause(1).
WHO guideline:
The World Health Organization guidelines say that for a good sleep, sound level should not exceed 30 dB(A) for continuous background noise, and 45 dB(A) for individual noise events.(2)
Clinical Psychologists point of view:
Many clinical psychologists and sleep medicine experts consider that normal sleep should be regarded as one of the basic human rights, because chronic sleep disturbance due to any kind of noise pollution is a well-documented cause of several psychosomatic disorders(3).
Cardiologists point of view:
Major part of effective treatment result depends on restful sleep for the patients suffering from cardiac arrhythmia , myocardial infarction and related cardiac ailments.These autonomic responses to noise during sleep can be obtained for much lower peak noise intensities as during wake states. These effects, mainly involving increased heart rate and vaso-constriction, have been found to habituate over successive noise-exposed nights as opposed to long exposure times. This could indicate an effect on cardiovascular response over the long term exposure (4). During sleep, heart rate is related to changes in the parasympathetic-sympathetic balance with an increase in sympathetic tone associated with activation and with electroencephalogram (EEG) arousal. Catecholamine levels and sympathetic activity decrease during sleep.This association has been observed not only with sleep deprivation but also with regard to sleep disruption.(5) Brief awakenings from sleep for only a few seconds are associated with temporary elevation in blood pressure and heart rate that results from an autonomic reflex.(6) Currently, we proposed a well organized case control study to explore effect of sleep fragmentation on cardiac arrhythmia patients due to noise generated from cell phone and cardiac monitors in intensive coronary units.We are concerned that otherwise negligible noise pollution may cause delayed recovery of vulnerable cardiac patients.
References:
1. e0265 Analysis of 24 h sleep deprivation on arrhythmia and heart rate variability:Wei-Ren Chen, and Xiang-Min Shi:Heart 2010 96:A83; doi:10.1136/hrt.2010.208967.265
2. Berglund B, Lindvall T, Schwela DH. Guidelines for Community Noise. World Health Organization 1999. Available from: http://www.who.int/docstore/peh/noise/guidelines2.html . [Accessed on 2010 March 28].
3. Tanu Pramanik.Re: wind turbine noise: Response to:-
Editorials:Wind turbine noise.BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e1527 (Published 08 March 2012) Cite this as: BMJ 2012;344:e1527.
4. Muzet A, Ehrhart J, Eschenlauer R, Lienhard JP. Habituation and age differences of cardiovascular responses to noise during sleep. In Sleep 1980;212-5.
5. Sforza E, Chapotot F, Lavoie S, Roche F, Pigeau R, Buguet A. Heart rate activation during spontaneous arousals from sleep: Effect of sleep deprivation. Clin Neurophysiol 2004;115:2442-51.
6. Bonnet MH, Arand DL. Clinical effects of sleep fragmentation versus sleep deprivation. Sleep Med Rev 2003;7:297-310.
We would like to thank Professor Madias for his comments and interest
in our study.[1] We appreciate the editors of Heart for giving us the
opportunity to reply.
The Diagnosis Procedure Combination database in Japan contains hospital
administrative claims data and discharge abstracts representing
approximately 50% of all inpatient admissions to acute-care hospitals in
Japan.[2] As per the request by Professor Madias, we...
We would like to thank Professor Madias for his comments and interest
in our study.[1] We appreciate the editors of Heart for giving us the
opportunity to reply.
The Diagnosis Procedure Combination database in Japan contains hospital
administrative claims data and discharge abstracts representing
approximately 50% of all inpatient admissions to acute-care hospitals in
Japan.[2] As per the request by Professor Madias, we additionally
extracted data on diabetes mellitus (DM) and hypertension (HTN) in our
2672 study patients with Takotsubo cardiomyopathy (TC), using the
International Classification of Diseases, 10th Revision codes (DM, E10-
14.x; HTN, I10.x). Of the 2672 patients, 367 (13.7%) had a diagnosis of DM
and 1201 (44.9%) had a diagnosis of HTN as a comorbidity at admission. We
also performed a 1:4 propensity score-matching analysis including DM and
HTN as covariates, and obtained results consistent with those in our main
analysis [1] (30-day in-hospital mortality, early beta-blocker group 2.4%
[10/413] vs. control group 2.5% [42/1652]; P=1.000).
The proportions of DM and HTN in our study patients with TC were
comparable to those recently reported by Professor Madias.[3] However, it
remains uncertain whether the prevalence of DM was lower in patients with
TC compared with general population in Japan because the contemporary data
on the prevalence of DM in the general population were not available in
our dataset.
References
1. Isogai T, Matsui H, Tanaka H, et al. Early beta-blocker use and in-
hospital mortality in patients with Takotsubo cardiomyopathy. Heart 2016
Feb 15. pii: heartjnl-2015-308712. doi:10.1136/heartjnl-2015-308712. [Epub
ahead of print].
2. Isogai T, Yasunaga H, Matsui H, et al. Out-of-hospital versus in-
hospital Takotsubo cardiomyopathy: Analysis of 3719 patients in the
Diagnosis Procedure Combination database in Japan. Int J Cardiol
2014;176:413-7.
3. Madias JE. Low prevalence of diabetes mellitus in patients with
Takotsubo syndrome: A plausible 'protective' effect with pathophysiologic
connotations. Eur Heart J Acute Cardiovasc Care 2016;5:164-70.
To the Editor:
The report by Isogai al,1 published online ahead of print on February 15,
2016 in the Journal, about the 2672 patients (81.5% women) who had
suffered Takotsubo syndrome (TTS) between 2010 and 2014, deriving from the
"Diagnosis Procedure Combination nationwide inpatient database in Japan"
is an invaluable resource, since it comprises all patients with this
pathology admitted to acute-care hospitals in the en...
To the Editor:
The report by Isogai al,1 published online ahead of print on February 15,
2016 in the Journal, about the 2672 patients (81.5% women) who had
suffered Takotsubo syndrome (TTS) between 2010 and 2014, deriving from the
"Diagnosis Procedure Combination nationwide inpatient database in Japan"
is an invaluable resource, since it comprises all patients with this
pathology admitted to acute-care hospitals in the entire nation, where TTS
was originally described. The authors, employing score-matching and
instrumental variable analyses, analyzed 2110 patients from 615 hospitals
(422 who received ?-blocker therapy on hospitalization day 1 or 2, and
1688 patients who did not receive ?-blockers), and found that there was no
difference between these 2 subgroups in regards to 30-day mortality.
It has been reported recently that a history of diabetes mellitus
(DM) has a low prevalence in patients admitted with TTS.2 The hypothesized
pathophysiological connotation of this observation is that DM may have a
"protective" effect for the expression of TTS under stress, via a
mediating (ameliorating) effect of the underlying diabetic neuropathy (and
presumably autonomic nervous system [ANS] neuropathy), which provides a
"bridling" CNS effect on "the catecholamine-mediated mechanism, which has
been implicated in the pathogenesis of TTS.1 The authors, in their
article's Table 1, provided details of the prevalence of chronic
(malignancy, chronic pulmonary disease, chronic liver disease, chronic
renal failure, peptic ulcer disease, thyrotoxicosis, rheumatic disease,
psychiatric disease), and acute diseases for the unmatched, and the "1:4
propensity score-matched" groups of the entire cohort,1 but curiously
have not included information about hypertension (HTN) or DM in their
patients with TTS. Since the authors have access to data in the "Diagnosis
Procedure Combination nationwide inpatient database in Japan", it will be
of interest to provide the readers of the Journal with information on the
prevalence of HTN and DM in their 2672 patients with TTS.
Conflicts of Interest
None.
References
1.Isogai T, Matsui H, Tanaka H, Fushimi K, Yasunaga H. Early ?-
blocker use and in-hospital mortality in patients with Takotsubo
cardiomyopathy. Heart. 2016 Feb 15. pii: heartjnl-2015-308712. doi:
10.1136/heartjnl-2015-308712. [Epub ahead of print].
2. Madias JE. Low prevalence of diabetes mellitus in patients with
Takotsubo syndrome: a plausible 'protective' effect with pathophysiologic
connotations Eur Heart J Acute Cardiovasc Care (2015) [Epub ahead of
print; 11 Feb, pii: 2048872615570761].
Authors mentioned, that meta-analysis include both published and unpublished data from randomised controlled trials (this remove bias of selective clinical trial reporting), and results were regardless of background statin or combination laropiprant therapy ( to maintain clarity, and or to remove confusion with regards to results). 34% higher risk of developing diabetes was reported with Niacin therapy and new-onset diabetes i...
Authors mentioned, that meta-analysis include both published and unpublished data from randomised controlled trials (this remove bias of selective clinical trial reporting), and results were regardless of background statin or combination laropiprant therapy ( to maintain clarity, and or to remove confusion with regards to results). 34% higher risk of developing diabetes was reported with Niacin therapy and new-onset diabetes is a major concern (1), however diabetogenic effect of statins is difficult to ignore in patients. Niacin (nicotinic acid) reduces cardiovascular events in patients with dyslipidemia also a cause of vasodilation, and Laropiprant is a selective antagonist of the prostaglandin D2 receptor subtype 1 (DP1), was effective in suppressing both subjective and objective manifestations of niacin-induced vasodilation [2], combintion still in use in the USA and elsewhere but Merck withdraws Tredaptive in Europe & globally (1).
I read the article with great interest.
With Regards, Dr.Rajiv Kumar Professor, Pharmacology Department. Goverment Medical College & Hospital,Chandigarh- 160030, India.
References:
1.Christina Goldie, Allen J Taylor, Peter Nguyen, Cody McCoy, Xue-Qiao Zhao, David Preiss. Niacin therapy and the risk of new-onset diabetes: a meta-analysis of randomised controlled trials . Heart Published Online First: 14 September 2015 doi:10.1136/heartjnl-2015-308055.
2.Lai E, De Lepeleire I, Crumley TM et al. "Suppression of niacin-induced vasodilation with an antagonist to prostaglandin D2 receptor subtype 1". Clin. Pharmacol. Ther. 2007; 81(6): 849-57.
Having scanned many a patient with pacemakers in the presence of new
algorithms which allow significant AV delays (essentially P-R)
prolongation, I have noticed that due to the timings, long P-R can cause
truncation of diastolic filling time (E:A fusion). This will significantly
impact the preload of the LV, reduce stroke volume and may even impact on
coronary filling. I am unsure why this would increase the risk of AF bu...
Having scanned many a patient with pacemakers in the presence of new
algorithms which allow significant AV delays (essentially P-R)
prolongation, I have noticed that due to the timings, long P-R can cause
truncation of diastolic filling time (E:A fusion). This will significantly
impact the preload of the LV, reduce stroke volume and may even impact on
coronary filling. I am unsure why this would increase the risk of AF but
the overall performance of the heart as a pump will be reduced due to the
truncated diastolic filling.
Interestingly, even today I have seen a patient who has had
algorithms which allow long AV delays to prevent ventricular pacing who
has come back feeling breathless and fatigued. With optimal AV delays I
expect this will disappear but it does highlight the physiological impact
of a long P-R and potential implication in symptomatic, but otherwise
apparently healthy patients.
Atrial fibrillation (AF) constitutes a major risk factor for stroke and death.1 ,2 The potential of biomarkers to improve the prognostication concerning stroke and other cardiovascular events in patients with AF is gaining strength of evidence and clinical promise. In particular the biomarkers of cardiovascular stress and dysfunction such as cardiac troponin (cTn), a marker of myocardial cell damage; N-terminal B-type natriuretic peptide (NT-proBNP), a marker of cardiac dysfunction; and growth-differentiation factor-15 (GDF-15), a marker of inflammation and oxidative stress, have been shown to be strong independent predictors.3–8 Although inflammatory activation has been linked to the occurrence of AF and to a prothrombotic state, the association with subsequent cardiovascular events during treatment with oral anticoagulation has not been fully established.9–14 Prior studies evaluating the relation between inflammation and cardiovascular events in patients with AF have often been exploratory and did not take into account the protective effect of oral anticoagulation. In addition the associations with outcomes have not been fully adjusted for other risk indicators, in particular other cardiovascular biomarkers, which recently have show
Atrial fibrillation (AF) constitutes a major risk factor for stroke and death.1 ,2 The potential of biomarkers to improve the prognostication concerning stroke and other cardiovascular events in patients with AF is gaining strength of evidence and clinical promise. In particular the biomarkers of cardiovascular stress and dysfunction such as cardiac troponin (cTn), a marker of myocardial cell damage; N-terminal B-type natriuretic peptide (NT-proBNP), a marker of cardiac dysfunction; and growth-differentiation factor-15 (GDF-15), a marker of inflammation and oxidative stress, have been shown to be strong independent predictors.3–8 Although inflammatory activation has been linked to the occurrence of AF and to a prothrombotic state, the association with subsequent cardiovascular events during treatment with oral anticoagulation has not been fully established.9–14 Prior studies evaluating the relation between inflammation and cardiovascular events in patients with AF have often been exploratory and did not take into account the protective effect of oral anticoagulation. In addition the associations with outcomes have not been fully adjusted for other risk indicators, in particular other cardiovascular biomarkers, which recently have showed to be independent and powerful markers of adverse outcomes in patients with AF.4 In this predefined biomarker study within the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial we asse...
Show Morebeta testing beta testing
Assessing effect of remote ischaemic preconditioning on clinical outcomes in patients undergoing cardiac bypass surgery
To the Editor : In a recent article of Candilio et al.1 assessing the effect of remote ischaemic preconditioning (RIPC) on postoperative outcomes in patients undergoing cardiac surgery, they showed that RIPC reduced the amount of perioperative myocardial injury by 26% and the incidence of acute...
We would like to thank Professor Madias for his comments and interest in our study.[1] We appreciate the editors of Heart for giving us the opportunity to reply. The Diagnosis Procedure Combination database in Japan contains hospital administrative claims data and discharge abstracts representing approximately 50% of all inpatient admissions to acute-care hospitals in Japan.[2] As per the request by Professor Madias, we...
To the Editor: The report by Isogai al,1 published online ahead of print on February 15, 2016 in the Journal, about the 2672 patients (81.5% women) who had suffered Takotsubo syndrome (TTS) between 2010 and 2014, deriving from the "Diagnosis Procedure Combination nationwide inpatient database in Japan" is an invaluable resource, since it comprises all patients with this pathology admitted to acute-care hospitals in the en...
Having scanned many a patient with pacemakers in the presence of new algorithms which allow significant AV delays (essentially P-R) prolongation, I have noticed that due to the timings, long P-R can cause truncation of diastolic filling time (E:A fusion). This will significantly impact the preload of the LV, reduce stroke volume and may even impact on coronary filling. I am unsure why this would increase the risk of AF bu...
Pages