We have read the article by dr. Ghannam with interest. We appreciate their summary of the available data on anticoagulant treatment in special patient populations. However, with the rapidly increasing evidence in this field, some recent relevant studies were not mentioned.
For instance, in patients undergoing cardioversion, the authors suggest treatment with VKA or rivaroxaban, based on the statement that this is the only available NOAC studied prospectively in this setting. Last year, the data of the ENSURE-AF with edoxaban were presented, which provide similar evidence for the use of edoxaban in this setting (1). Furthermore, the recently published EMANATE-AF study adds solid evidence for the use of apixaban in this setting (2).
Similarly, in patients undergoing catheter ablation, the RE-CIRCUIT study published earlier this year provides very reassuring prospective data on the uninterrupted use of dabigatran in patients undergoing catheter ablation (3), yet this is not mentioned in the article. At the ESC in 2017, the data of the RE-DUAL PCI study provide insight in different strategies on how to combine dabigatran with single or dual antiplatelet therapy in patients undergoing percutaneous coronary interventions (4). Similar data for rivaroxaban were described in the PIONEER study (5), and the results of the ongoing AUGUSTUS study with apixaban are expected within the next years.
In summary, the very large number of patients studied...
We have read the article by dr. Ghannam with interest. We appreciate their summary of the available data on anticoagulant treatment in special patient populations. However, with the rapidly increasing evidence in this field, some recent relevant studies were not mentioned.
For instance, in patients undergoing cardioversion, the authors suggest treatment with VKA or rivaroxaban, based on the statement that this is the only available NOAC studied prospectively in this setting. Last year, the data of the ENSURE-AF with edoxaban were presented, which provide similar evidence for the use of edoxaban in this setting (1). Furthermore, the recently published EMANATE-AF study adds solid evidence for the use of apixaban in this setting (2).
Similarly, in patients undergoing catheter ablation, the RE-CIRCUIT study published earlier this year provides very reassuring prospective data on the uninterrupted use of dabigatran in patients undergoing catheter ablation (3), yet this is not mentioned in the article. At the ESC in 2017, the data of the RE-DUAL PCI study provide insight in different strategies on how to combine dabigatran with single or dual antiplatelet therapy in patients undergoing percutaneous coronary interventions (4). Similar data for rivaroxaban were described in the PIONEER study (5), and the results of the ongoing AUGUSTUS study with apixaban are expected within the next years.
In summary, the very large number of patients studied in phase III studies, the increasing number of data from phase IV studies, and the ongoing prospective studies in specific patient situations continue to provide new data on anticoagulation therapy in situations where this was never available before. This increasing knowledge is likely to further advance the field, and algorithms as presented in this article should reflect which choices are based on clear contra-indications, and which suggestions are based on current absence of specific data, where recommendations may change based on the availability of new data.
Sincerely,
(1) Lancet. 2016 Oct 22;388(10055):1995-2003. doi: 10.1016/S0140-6736(16)31474-X. Epub 2016 Aug 30.
(2) Ezekowitz MD, et al. Late Breaking Clinical Trials 2. Presented at: European Society of Cardiology Congress; August 26-30, 2017; Barcelona, Spain
(3) Calkins H, Willems S, Gerstenfeld EP, Verma A, Schilling R, Hohnloser SH, Okumura K, Serota H, Nordaby M, Guiver K, Biss B, Brouwer MA, Grimaldi M; RE-CIRCUIT Investigators. N Engl J Med. 2017 Apr 27;376(17):1627-1636. doi: 10.1056/NEJMoa1701005. Epub 2017 Mar 19.
(4) Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, Maeng M, Merkely B, Zeymer U, Gropper S, Nordaby M, Kleine E, Harper R, Manassie J, Januzzi JL, Ten Berg JM, Steg PG, Hohnloser SH; RE-DUAL PCI Steering Committee and Investigators.
(5) Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, Birmingham M, Ianus J, Burton P, van Eickels M, Korjian S, Daaboul Y, Lip GY, Cohen M, Husted S, Peterson ED, Fox KA. N Engl J Med. 2016 Dec 22;375(25):2423-2434. doi: 10.1056/NEJMoa1611594. Epub 2016 Nov 14.
In a recent edition of Heart, Potier et al reported the results of a large, observational analysis of the REACH registry[1]. The authors sought to retrospectively compare clinical outcomes in angiotensin receptor blocker (ARB), and angiotensin converting enzyme inhibitor (ACEi) treated patients, using propensity score matching to reduce confounding by indication. They conclude that treatment with ARB was more effective than with ACEi, across a wide spectrum of cardiovascular diseases and with regard to a number of different clinical outcomes. However, we believe that their methodology falls short of the standards expected from a well-conducted pharmacoepidemiological analysis[2].
Although the REACH Registry is a well-powered cohort of patients at risk of adverse cardiovascular outcomes, several characteristics make it disadvantageous in the context of comparative drug efficacy analysis. Firstly, exposure to ACEi or ARB was established at baseline; all participants were prevalent users of these agents. Much evidence exists to suggest that bias is introduced by such an approach; the characteristics of prevalent users may be affected by the drug itself[3]. A new-user design would have eliminated such concerns.
The indication for ACE inhibition and angiotensin receptor blockade differed greatly in this cohort of patients, recruited in 2003 and 2004. During this time, the evidence base for the use of ARBs was limited; most patients wo...
In a recent edition of Heart, Potier et al reported the results of a large, observational analysis of the REACH registry[1]. The authors sought to retrospectively compare clinical outcomes in angiotensin receptor blocker (ARB), and angiotensin converting enzyme inhibitor (ACEi) treated patients, using propensity score matching to reduce confounding by indication. They conclude that treatment with ARB was more effective than with ACEi, across a wide spectrum of cardiovascular diseases and with regard to a number of different clinical outcomes. However, we believe that their methodology falls short of the standards expected from a well-conducted pharmacoepidemiological analysis[2].
Although the REACH Registry is a well-powered cohort of patients at risk of adverse cardiovascular outcomes, several characteristics make it disadvantageous in the context of comparative drug efficacy analysis. Firstly, exposure to ACEi or ARB was established at baseline; all participants were prevalent users of these agents. Much evidence exists to suggest that bias is introduced by such an approach; the characteristics of prevalent users may be affected by the drug itself[3]. A new-user design would have eliminated such concerns.
The indication for ACE inhibition and angiotensin receptor blockade differed greatly in this cohort of patients, recruited in 2003 and 2004. During this time, the evidence base for the use of ARBs was limited; most patients would have received an ARB for the treatment of hypertension and heart failure (but not in the post-infarction or high cardiovascular risk settings). The authors match only on propensity score, without restricting or forcing matching by indication. Participants receiving ACEi use had a greater burden of cardiovascular morbidities, such as ischaemic heart disease and heart failure, than those receiving ARBs, who tended to have more hypertension (Supplementary Table 1). Although the burden of these comorbidities was marginally balanced in the propensity-matched ACEi and ARB groups, it is plausible that many patients receiving an ACEi in the early post-infarction setting (at high risk of adverse outcomes) were matched with patients receiving an ARB for hypertension (at relatively lower risk), with similar propensity. Clearly, significant confounding by indication persists.
Given that the conclusions of this analysis are contrary to data from head-to-head randomised controlled trials, and multiple meta-analyses[4], we advise significant caution when interpreting these findings. The analytic methodology is deeply flawed; the conclusions of this study most probably reflect residual confounding by indication.
Yours sincerely,
Jonathan A Batty
Alistair S Hall
1. Potier L, Roussel R, Elbez Y, Marre M, Zeymer U, Reid CM, et al. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high vascular risk. Heart. 2017.
2. Glynn RJ. Use of Propensity Scores To Design Observational Comparative Effectiveness Studies. Journal of the National Cancer Institute. 2017;109(8).
3. Ray WA. Evaluating medication effects outside of clinical trials: new-user designs. American journal of epidemiology. 2003;158(9):915-20.
4. Li EC, Heran BS, Wright JM. Angiotensin converting enzyme (ACE) inhibitors versus angiotensin receptor blockers for primary hypertension. The Cochrane database of systematic reviews. 2014(8):Cd009096.
We thank Dr. Launey Y et al for their constructive comments regarding our recent report.[1] We also greatly appreciate their shared interests in traumatic intra-cranial hemorrhage (ICH) and the subsequent incidence of atrial fibrillation (AF).
Dr Launey and colleagues concerned about the acute effects of inflammation on the onset of AF.[2] In our study, the mean follow-up period was 4.36 (standard deviation, SD=3.41) and 5.35 (SD=3.19) years in traumatic ICH group and control group, respectively. Interestingly, the mean follow-up period of the onset of AF was 2.94 years (SD=2.64) in traumatic ICH group, which is significantly less than 3.57 (SD=2.67) years in control group (Table 1) (p<0.001). Although acute inflammation plays a role on the onset of AF,[3, 4] our study along with previous evidence indicate the chronic persistent inflammation, which occurs after traumatic brain injury (TBI), contributes the development of AF.[1, 5] This partly explains the results of AF occurrence on TBI patients in our study.
We agree that sepsis may contribute to the development of AF. In this study, after adjustment for age, sex, and comorbidities including sepsis and ventilator associated pneumonia, the adjusted HR (aHR) for developing AF was 1.24-fold higher (95% CI = 1.18-1.31) for patients with traumatic ICH compared with the control cohorts in multivariable cox regression models (Table 2). These results further support the association betwee...
We thank Dr. Launey Y et al for their constructive comments regarding our recent report.[1] We also greatly appreciate their shared interests in traumatic intra-cranial hemorrhage (ICH) and the subsequent incidence of atrial fibrillation (AF).
Dr Launey and colleagues concerned about the acute effects of inflammation on the onset of AF.[2] In our study, the mean follow-up period was 4.36 (standard deviation, SD=3.41) and 5.35 (SD=3.19) years in traumatic ICH group and control group, respectively. Interestingly, the mean follow-up period of the onset of AF was 2.94 years (SD=2.64) in traumatic ICH group, which is significantly less than 3.57 (SD=2.67) years in control group (Table 1) (p<0.001). Although acute inflammation plays a role on the onset of AF,[3, 4] our study along with previous evidence indicate the chronic persistent inflammation, which occurs after traumatic brain injury (TBI), contributes the development of AF.[1, 5] This partly explains the results of AF occurrence on TBI patients in our study.
We agree that sepsis may contribute to the development of AF. In this study, after adjustment for age, sex, and comorbidities including sepsis and ventilator associated pneumonia, the adjusted HR (aHR) for developing AF was 1.24-fold higher (95% CI = 1.18-1.31) for patients with traumatic ICH compared with the control cohorts in multivariable cox regression models (Table 2). These results further support the association between TBI and AF.
We acknowledge that our study had several limitations including no available data on the severity of TBI and AF occurrence, and the medication use in both traumatic ICH and control groups in the National Health Insurance Research Database. However, with the growing evidence suggesting the mechanisms linking inflammation, TBI, and AF, our studies provide critical clinical evidence supporting the important role of TBI on the development of AF.
References
1 Lin WS, Lin TC, Hung Y, et al. Traumatic intracranial haemorrhage is in association with an increased risk of subsequent atrial fibrillation. Heart 2017;103:1286-91.
2 Launey Y, Seguin, P. Is traumatic intracranial hemorrhage a specific risk factor of atrial fibrillation. Heart 2017;103.
3 Meierhenrich R, Steinhilber E, Eggermann C, et al. Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. Crit Care 2010;14:R108.
4 Chaikittisilpa N, Krishnamoorthy V, Lele AV, et al. Characterizing the relationship between systemic inflammatory response syndrome and early cardiac dysfunction in traumatic brain injury. J Neurosci Res 2017.
5 Mitrofanova LB, Orshanskaya V, Ho SY, et al. Histological evidence of inflammatory reaction associated with fibrosis in the atrial and ventricular walls in a case-control study of patients with history of atrial fibrillation. Europace 2016;18:iv156-iv62.
The study of Olmos et al., on prediction of in-hospital mortality in patients with active infective endocarditis undergoing cardiac surgery, is of great interest.1
Indeed, this topic is fascinating because it is complicated to make a choice in so dramatic and not so rare situation.
To help with this decision-making, the authors proposed a model for predicting hospital mortality: a classic multivariate logistic regression model.
However, the editorial published with this article evokes in the title a new method: machine learning.2 Machine learning, which is a field of artificial intelligence, has already been used for predicting hospital mortality after elective cardiac surgery.3 This study aimed at comparing a machine learning model, a classic logistic regression model and EuroSCORE II on a cohort including 6,520 patients. The comparison of these models was based on ROC curves and decision curve analysis (DCA).4 Whatever the method of comparison, machine learning model was more accurate than other models.
Our experience in this area probably allows us to make some comments on this editorial. Considering, the increase of studies comparing machine learning with logistic regression, it is now known that supervised machine learning algorithms improve the prediction of post-operative mortality. However, the size of the cohort used in the present study makes it difficult to apply machine learning algorithms. Indeed, this cohort comprised 671 patients who...
The study of Olmos et al., on prediction of in-hospital mortality in patients with active infective endocarditis undergoing cardiac surgery, is of great interest.1
Indeed, this topic is fascinating because it is complicated to make a choice in so dramatic and not so rare situation.
To help with this decision-making, the authors proposed a model for predicting hospital mortality: a classic multivariate logistic regression model.
However, the editorial published with this article evokes in the title a new method: machine learning.2 Machine learning, which is a field of artificial intelligence, has already been used for predicting hospital mortality after elective cardiac surgery.3 This study aimed at comparing a machine learning model, a classic logistic regression model and EuroSCORE II on a cohort including 6,520 patients. The comparison of these models was based on ROC curves and decision curve analysis (DCA).4 Whatever the method of comparison, machine learning model was more accurate than other models.
Our experience in this area probably allows us to make some comments on this editorial. Considering, the increase of studies comparing machine learning with logistic regression, it is now known that supervised machine learning algorithms improve the prediction of post-operative mortality. However, the size of the cohort used in the present study makes it difficult to apply machine learning algorithms. Indeed, this cohort comprised 671 patients who had cardiac surgery, with a cohort of derivation containing only 424 patients (300 discharged alive and 124 died after surgery). This cohort was probably too small for efficient use of machine learning algorithms. However, it would have been interesting to fit a machine learning model in this field. Moreover, the fact that this database is spread over 18 years compromises the validity of this model in 2017.
In conclusion, this article and the accompanying editorial very well illustrate the current problem of artificial intelligence in medicine: how to find reliable data in sufficient quantities?
References
1 Olmos C, Vilacosta I, Habib G, et al. Risk score for cardiac surgery in active left-sided infective endocarditis. Heart 2017; 10.1136/heartjnl-2016-311093.
2 Donal E, Flecher E, Tattevin P. Machine learning to support decision-making for cardiac surgery during the acute phase of infective endocarditis. Heart Published Online First: 8 May 2017. doi:10.1136/heartjnl-2017-311512
3 Allyn J, Allou N, Augustin P, et al. A Comparison of a Machine Learning Model with EuroSCORE II in Predicting Mortality after Elective Cardiac Surgery: A Decision Curve Analysis. PloS One 2017;12:e0169772. doi:10.1371/journal.pone.0169772
4 Fitzgerald M, Saville BR, Lewis RJ. Decision curve analysis. JAMA 2015;313:409–10. doi:10.1001/jama.2015.37
We read with great interest this paper which demonstrated erectile dysfunction (ED), not only as a preclinical predictor of cardiovascular disease (CVD), treatment for ED. But also has a role in a reduced mortality and heart failure hospitalization1.However, a multi-country and region population-based survey indicated that the majority of Asian men have never sought treatment for ED because of cultural factors or sexual conservatism2.
Unfortunately, this situation is more serious in China. A multi-center investigation of 3327 subjects showed that although the proportion of severe cases (IIEF＜8) among the Chinese elderly is the highest in all age groups, most elderly men are reluctant to visit the hospital just for the loss of erectile function (EF). They consider the loss of libido and EF with increasing age to be a natural process of aging3. Moreover, even the old men who seek help for ED were more concerned about the side effects of Western medicine (e.g., PDE5i); only a few of them (19%) used Western medicine as the first choice4. Furthermore, Chinese physicians seldom ask patients about their sexual health during routine consultations, their neglect of the health education about ED also aggravated this vicious circle2, 4.
Hence, there is a substantial need for promoting Andersson et al 's 1 findings on health education of elderly ED patients in China. The improved awareness and cultural factors would lead more Chinese elderly to visit the hospi...
We read with great interest this paper which demonstrated erectile dysfunction (ED), not only as a preclinical predictor of cardiovascular disease (CVD), treatment for ED. But also has a role in a reduced mortality and heart failure hospitalization1.However, a multi-country and region population-based survey indicated that the majority of Asian men have never sought treatment for ED because of cultural factors or sexual conservatism2.
Unfortunately, this situation is more serious in China. A multi-center investigation of 3327 subjects showed that although the proportion of severe cases (IIEF＜8) among the Chinese elderly is the highest in all age groups, most elderly men are reluctant to visit the hospital just for the loss of erectile function (EF). They consider the loss of libido and EF with increasing age to be a natural process of aging3. Moreover, even the old men who seek help for ED were more concerned about the side effects of Western medicine (e.g., PDE5i); only a few of them (19%) used Western medicine as the first choice4. Furthermore, Chinese physicians seldom ask patients about their sexual health during routine consultations, their neglect of the health education about ED also aggravated this vicious circle2, 4.
Hence, there is a substantial need for promoting Andersson et al 's 1 findings on health education of elderly ED patients in China. The improved awareness and cultural factors would lead more Chinese elderly to visit the hospital for the loss of erectile function, and take PDE5i or other Western medicine as the preferred treatment. Then they could not only improve the quality of life, but also reduce the risk of CVD.
References:
1. Andersson DP, Trolle LY, Grotta A, Bellocco R, Lehtihet M, Holzmann MJ. Association between treatment for erectile dysfunction and death or cardiovascular outcomes after myocardial infarction. Heart. 2017-08-01 2017;103(16):1264-1270.
2. Tan HM, Low WY, Ng CJ, et al. Prevalence and correlates of erectile dysfunction (ED) and treatment seeking for ED in Asian Men: the Asian Men's Attitudes to Life Events and Sexuality (MALES) study. J Sex Med. 2007-11-01 2007;4(6):1582-1592.
3. Li D, Jiang X, Zhang X, et al. Multicenter pathophysiologic investigation of erectile dysfunction in clinic outpatients in China. Urology. 2012-03-01 2012;79(3):601-606.
4. Zhang K, Yu W, He ZJ, Jin J. Help-seeking behavior for erectile dysfunction: a clinic-based survey in China. Asian J Androl. 2014-01-01 2014;16(1):131-135.
Correspondence to Dr Dongjie Li. Department of Geriatrics, Xiangya International Medical Center, Xiangya Hospital, Central South University, Changsha 410008，China. Jerry1375@126.com.
We read the study of Wei-Shiang Lin et al.[1] with a great interest. In their large-scale cohort retrospective study, they found that traumatic intracranial hemorrhage was associated with an increased risk of atrial fibrillation (AF) and hypothesized that inflammation and/or secondary cardiac insult due to the traumatic brain injury (TBI) may cause AF. Nevertheless, several points should be discussed. First, acute inflammation is well-known to be related to AF in trauma patients. The risk of new-onset AF is reasonably expected to occur at the acute phase following the trauma. This point has already been previously demonstrated to occur during the days following cardiac surgery or septic shock onset.[2] In the same way, cardiac insult occurs at the very early phase of TBI and the consecutive cardiac systolic dysfunction was reported to be reversible within the first week after the trauma. [3] In this perspective, how to explain that the risk of AF persists one year after the trauma? It would be very helpful if the authors could provide data on the delay between the day of trauma and the day of new-onset AF. Furthermore, inflammation and cardiac dysfunction are related to the TBI severity and it would be valuable to know whether the more severe TBI patients are more prone to develop AF than mild or moderate TBI. Finally, in their statistical model, the authors have taken into account comorbidities which are also known to favor AF. But others factors, such as sepsis and relat...
We read the study of Wei-Shiang Lin et al.[1] with a great interest. In their large-scale cohort retrospective study, they found that traumatic intracranial hemorrhage was associated with an increased risk of atrial fibrillation (AF) and hypothesized that inflammation and/or secondary cardiac insult due to the traumatic brain injury (TBI) may cause AF. Nevertheless, several points should be discussed. First, acute inflammation is well-known to be related to AF in trauma patients. The risk of new-onset AF is reasonably expected to occur at the acute phase following the trauma. This point has already been previously demonstrated to occur during the days following cardiac surgery or septic shock onset.[2] In the same way, cardiac insult occurs at the very early phase of TBI and the consecutive cardiac systolic dysfunction was reported to be reversible within the first week after the trauma. [3] In this perspective, how to explain that the risk of AF persists one year after the trauma? It would be very helpful if the authors could provide data on the delay between the day of trauma and the day of new-onset AF. Furthermore, inflammation and cardiac dysfunction are related to the TBI severity and it would be valuable to know whether the more severe TBI patients are more prone to develop AF than mild or moderate TBI. Finally, in their statistical model, the authors have taken into account comorbidities which are also known to favor AF. But others factors, such as sepsis and related medications are of major concerns in increasing inflammation and the risk of new-onset AF.[4] Especially, TBI patients are particularly at risk to develop sepsis in the course of disease, mainly ventilator-associated pneumonia amongst the more severe TBI patients. We think these factors should be mentioned and included in the Cox regression model.
1 Lin W-S, Lin T-C, Hung Y, et al. Traumatic intracranial haemorrhage is in association with an increased risk of subsequent atrial fibrillation. Heart Br Card Soc Published Online First: 7 April 2017. doi:10.1136/heartjnl-2016-310451
2 Meierhenrich R, Steinhilber E, Eggermann C, et al. Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. Crit Care Lond Engl 2010;14:R108. doi:10.1186/cc9057
3 Chaikittisilpa N, Krishnamoorthy V, Lele AV, et al. Characterizing the relationship between systemic inflammatory response syndrome and early cardiac dysfunction in traumatic brain injury. J Neurosci Res Published Online First: 2 June 2017. doi:10.1002/jnr.24100
4 Launey Y, Lasocki S, Asehnoune K, et al. Impact of Low-Dose Hydrocortisone on the Incidence of Atrial Fibrillation in Patients With Septic Shock. J Intensive Care Med 2017;:885066617696847. doi:10.1177/0885066617696847
We congratulate McDowell et al. on their educational and interesting case report.1 However, we would like to comment on their use of the term ‘near-drowning’. This, and other confusing and older terms which caused inconsistencies in the literature, have been abandoned by organisations such as the International Liaison Committee on Resuscitation (ILCOR) and the World Health Organisation (WHO) who recommend a more structured and clearer way of reporting drowning incidents.2,3 For several years now, drowning has been defined as ‘a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident’. 2,3 We would thus recommend that the authors and readers of your journal follow ILCOR and WHO recommendations, and simply use the term ‘drowning’ irrespective of the patient outcome. While this may seem pedantic, we do believe that it will assist with standardisation in drowning research and literature.
References
1. McDowell K, Carrick D, Weir R. Heart Published Online First: 18 may 2017. doi:10.1136/heartjnl-2016-311043.
2. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe...
We congratulate McDowell et al. on their educational and interesting case report.1 However, we would like to comment on their use of the term ‘near-drowning’. This, and other confusing and older terms which caused inconsistencies in the literature, have been abandoned by organisations such as the International Liaison Committee on Resuscitation (ILCOR) and the World Health Organisation (WHO) who recommend a more structured and clearer way of reporting drowning incidents.2,3 For several years now, drowning has been defined as ‘a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident’. 2,3 We would thus recommend that the authors and readers of your journal follow ILCOR and WHO recommendations, and simply use the term ‘drowning’ irrespective of the patient outcome. While this may seem pedantic, we do believe that it will assist with standardisation in drowning research and literature.
References
1. McDowell K, Carrick D, Weir R. Heart Published Online First: 18 may 2017. doi:10.1136/heartjnl-2016-311043.
2. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe PE, Quan L, Szpilman D, Wigginton JG, Modell JH, American Heart Association. Recommended guidelines for uniform reporting of data from drowning: the "Utstein style". Circulation 2003;108:2565-74.
3. van Beeck E, Branche C, Szpilman D, Modell J, Bierens J. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ 2005;83:853-6.
Sawhney et al. reported that nurse-led, physician-directed moderate sedation during cardiac electrophysiology procedures is safe (1). All of the patients undergoing cardiac electrophysiological (EP) procedures and cardiac implantable electronic device (CIED) implantation during the last 12 years were moderately sedated. Since this study is a retrospective study, we could not comprehend why all patients were sedated despite the fact that routine sedation during all cardiac EP procedures and all CIED implantation is not recommended.
Moreover, as mentioned in the article, sedation is a continuum and it is not always possible to predict how individual patients will respond. Therefore, a gradual increase of doses of the sedatives during sedation may be needed which may possibly increase the procedure duration. Did authors ascertain any prolongation of the procedures due to sedative administration?
Furthermore, sedation may diminish arrythmia induction during EP procedures, particularly in patients with catecholamine-sensitive ventricular tachycardias (2). Did authors have any data questioning this issue?
As a conclusion, the aim of sedation is to diminish the anxiety and to relieve the pain during the procedure. Therefore, using moderate sedation selectively in patients with anxiety or hyperalgesia may be more practical and rational rather than its routine use due to the fact that as mentioned in the article, researches and audit demonstrate continued avoidabl...
Sawhney et al. reported that nurse-led, physician-directed moderate sedation during cardiac electrophysiology procedures is safe (1). All of the patients undergoing cardiac electrophysiological (EP) procedures and cardiac implantable electronic device (CIED) implantation during the last 12 years were moderately sedated. Since this study is a retrospective study, we could not comprehend why all patients were sedated despite the fact that routine sedation during all cardiac EP procedures and all CIED implantation is not recommended.
Moreover, as mentioned in the article, sedation is a continuum and it is not always possible to predict how individual patients will respond. Therefore, a gradual increase of doses of the sedatives during sedation may be needed which may possibly increase the procedure duration. Did authors ascertain any prolongation of the procedures due to sedative administration?
Furthermore, sedation may diminish arrythmia induction during EP procedures, particularly in patients with catecholamine-sensitive ventricular tachycardias (2). Did authors have any data questioning this issue?
As a conclusion, the aim of sedation is to diminish the anxiety and to relieve the pain during the procedure. Therefore, using moderate sedation selectively in patients with anxiety or hyperalgesia may be more practical and rational rather than its routine use due to the fact that as mentioned in the article, researches and audit demonstrate continued avoidable morbidity and mortality from sedation.
Kind Regards
REFERENCES
1) Sawhney V, Bacuetes E, Wray M, et al. Moderate sedation in cardiac electrophysiology laboratory: a retrospective safety analysis. Heart. 2017 Mar 1. pii: heartjnl-2016-310676. doi: 10.1136/heartjnl-2016-310676.
2) EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhytmias. Aliot EM, Stevenson WG, Almendral-Garrote JM, et al. Europace. 2009 Jun;11(6):771-817. doi: 10.1093/europace/eup098.
We have read with great interest the paper “Chocolate intake and risk of clinically apparent atrial
fibrillation: the Danish Diet, Cancer, and Health Study” by Elizabeth Mostofsky and coworkers [1] and we found their conclusion of importance with a view to clinical prevention.
With reference to the findings reported in the paper, we would like to make the following contribution to the discussion. In a recent analysis performed on 650 healthy women in pre-menopausal age (age range 45-54 years) chocolate intake was higher in women in the low quartile of adherence to Mediterranean Diet (low Med Score). This subgroup of women showed a lower ABI index compared to women with higher Med Score. The analysis of sources of antioxidants showed a greater intake from fruit and vegetables in the higher quartiles of Med Score. Coffee and tea were similarly distributed among the quartiles of Med Score [2]. Analysis from diet recall had the major limitation of missing data regarding out-of-mealtime snacking and drinking.
In Mediterranean countries, wine is a strong antioxidant source and the synergistic effect of drinking wine during meals and antioxidant bioavailability is well known. We clearly understand that nutritional habits in Northern Europe differ from Mediterranean ones. However, we would like to underline that in a Mediterranean lifestyle characterized by high intake of antioxidants,...
We have read with great interest the paper “Chocolate intake and risk of clinically apparent atrial
fibrillation: the Danish Diet, Cancer, and Health Study” by Elizabeth Mostofsky and coworkers [1] and we found their conclusion of importance with a view to clinical prevention.
With reference to the findings reported in the paper, we would like to make the following contribution to the discussion. In a recent analysis performed on 650 healthy women in pre-menopausal age (age range 45-54 years) chocolate intake was higher in women in the low quartile of adherence to Mediterranean Diet (low Med Score). This subgroup of women showed a lower ABI index compared to women with higher Med Score. The analysis of sources of antioxidants showed a greater intake from fruit and vegetables in the higher quartiles of Med Score. Coffee and tea were similarly distributed among the quartiles of Med Score [2]. Analysis from diet recall had the major limitation of missing data regarding out-of-mealtime snacking and drinking.
In Mediterranean countries, wine is a strong antioxidant source and the synergistic effect of drinking wine during meals and antioxidant bioavailability is well known. We clearly understand that nutritional habits in Northern Europe differ from Mediterranean ones. However, we would like to underline that in a Mediterranean lifestyle characterized by high intake of antioxidants, chocolate represents only a small percentage with a low impact on total antioxidant intake. [3]
Moreover, It is well known that chocolate bars contain a low level of caffeine. In a previous report on hypertensive patients we found that those who reduced coffee intake had a higher chocolate bar consumption which affected total caffeine intake [3]. Due to the controversial results of the effect of caffeine on atrial fibrillation, we cannot therefore exclude the potential effects of this on arrhythmias [4].
Anna Vittoria Mattioli MD PhD, Alberto Farinetti MD, Antonio Manenti MD.
Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine
University of Modena and Reggio Emilia (Italy)
1. Mostofsky E, Berg Johansen M, Tjønneland A, Chahal HS, Mittleman MA, Overvad K. Chocolate intake and risk of clinically apparent atrial fibrillation: the Danish Diet, Cancer, and Health Study. Heart 2017;0:1–5. doi:10.1136/heartjnl-2016-310357.
2. Mattioli AV, Pennella S, Manenti A, Migaldi M, Farinetti A. Mediterranean Diet and antioxidants intake: relationship with asymptomatic peripheral arterial disease in a population of pre-menopausal women. Abstract presented at ESC Congress August 2016
3. Mattioli AV, Farinetti A, Miloro C, Pedrazzi P, Mattioli G. Influence of coffee and caffeine consumption on atrial fibrillation in hypertensive patients. Nutr Metab Cardiovasc Dis. 2010 Feb 16. [Epub ahead of print] doi:10.1016/j.numecd.2009.11.003
4. Bhave PD, Hoffmayer K. Caffeine and atrial fibrillation: friends or foes? Heart. 2013 Oct;99(19):1377-8. doi: 10.1136/heartjnl-2013-304543.
To the Editor,
We read with interest the work presented by Cahill et al. [1] in which the authors evaluate the impact of antibiotic prophylaxis to prevent bacteremia and infective endocarditis in patients undergoing dental procedures. The analysis was performed based on 36 studies, including 21 bacteremia studies, five case controls and cohort studies, and 10 time trend studies.
It is generally well established that dental cares cause bacteremia, and that most are due to streptococcal strains [1,2]. It is, consequently, reasonable to think that prescribing antibiotics before dental cares decreases the incidence of such bacteremia. Globally, the discordant results between the different kinds of studies analyzed in the paper by Cahill et al. [1] are clearly insufficient to conclude that antibiotic prophylaxis prevents bacteremia due to streptococci. In our view, this observation can be explained by the fact that dental care is not the only cause of streptococcal bacteremia. Indeed, such bacteremia are extremely common, and it has been demonstrated that they can occur after chewing and after brushing in patients with periodontitis (cumulatively in 25% and 20% of cases, respectively) [2]. It is, therefore, fairly unlikely that bacteremias due to dental cares are more responsible for endocarditis than other kinds of bacteremias. In practice, this implies that the only reasonable antibiotic prophylaxis to prevent almost every bacteremia due to oral streptococci wou...
To the Editor,
We read with interest the work presented by Cahill et al. [1] in which the authors evaluate the impact of antibiotic prophylaxis to prevent bacteremia and infective endocarditis in patients undergoing dental procedures. The analysis was performed based on 36 studies, including 21 bacteremia studies, five case controls and cohort studies, and 10 time trend studies.
It is generally well established that dental cares cause bacteremia, and that most are due to streptococcal strains [1,2]. It is, consequently, reasonable to think that prescribing antibiotics before dental cares decreases the incidence of such bacteremia. Globally, the discordant results between the different kinds of studies analyzed in the paper by Cahill et al. [1] are clearly insufficient to conclude that antibiotic prophylaxis prevents bacteremia due to streptococci. In our view, this observation can be explained by the fact that dental care is not the only cause of streptococcal bacteremia. Indeed, such bacteremia are extremely common, and it has been demonstrated that they can occur after chewing and after brushing in patients with periodontitis (cumulatively in 25% and 20% of cases, respectively) [2]. It is, therefore, fairly unlikely that bacteremias due to dental cares are more responsible for endocarditis than other kinds of bacteremias. In practice, this implies that the only reasonable antibiotic prophylaxis to prevent almost every bacteremia due to oral streptococci would be lifetime treatment with penicillin or ampicillin [3]. However, even doing so, it would be impossible to prevent all infective endocarditis, as the authors observe[1].
The main limitation of the study by Cahill et al. [1] is that it did not include negative controls for bacteremia and that the frequency of bacteremia was measured only after dental care rather than after different day-to-day situations. This is an important methodological error which makes it an unreasonable basis for justifying particular conclusions.
Thus, and for the reasons mentioned above, there is still no evidence that dental prophylaxis during dental care changes the incidence of infective endocarditis [4], and this is the only reasonable conclusion of this study.
References
[1] Cahill TJ, Harrison JL, Jewell P, Onakpoya I, Chambers JB, Dayer M, et al. Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis. Heart 2017;103:937–44. doi:10.1136/heartjnl-2015-309102.
[2] Forner L, Larsen T, Kilian M, Holmstrup P. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. J Clin Periodontol 2006;33:401–7. doi:10.1111/j.1600-051X.2006.00924.x.
[3] Diene SM, Abat C, Rolain J-M, Raoult D. How artificial is the antibiotic resistance definition? Lancet Infect Dis 2017;17:690. doi:10.1016/S1473-3099(17)30338-9.
[4] Million M, Grisoli D, Griffiths K, Raoult D. Antibiotic prophylaxis of endocarditis. Lancet Infect Dis 2016;16:773–4. doi:10.1016/S1473-3099(16)30084-6.
Dear Editor,
We have read the article by dr. Ghannam with interest. We appreciate their summary of the available data on anticoagulant treatment in special patient populations. However, with the rapidly increasing evidence in this field, some recent relevant studies were not mentioned.
Show MoreFor instance, in patients undergoing cardioversion, the authors suggest treatment with VKA or rivaroxaban, based on the statement that this is the only available NOAC studied prospectively in this setting. Last year, the data of the ENSURE-AF with edoxaban were presented, which provide similar evidence for the use of edoxaban in this setting (1). Furthermore, the recently published EMANATE-AF study adds solid evidence for the use of apixaban in this setting (2).
Similarly, in patients undergoing catheter ablation, the RE-CIRCUIT study published earlier this year provides very reassuring prospective data on the uninterrupted use of dabigatran in patients undergoing catheter ablation (3), yet this is not mentioned in the article. At the ESC in 2017, the data of the RE-DUAL PCI study provide insight in different strategies on how to combine dabigatran with single or dual antiplatelet therapy in patients undergoing percutaneous coronary interventions (4). Similar data for rivaroxaban were described in the PIONEER study (5), and the results of the ongoing AUGUSTUS study with apixaban are expected within the next years.
In summary, the very large number of patients studied...
Dear Professor Otto –
In a recent edition of Heart, Potier et al reported the results of a large, observational analysis of the REACH registry[1]. The authors sought to retrospectively compare clinical outcomes in angiotensin receptor blocker (ARB), and angiotensin converting enzyme inhibitor (ACEi) treated patients, using propensity score matching to reduce confounding by indication. They conclude that treatment with ARB was more effective than with ACEi, across a wide spectrum of cardiovascular diseases and with regard to a number of different clinical outcomes. However, we believe that their methodology falls short of the standards expected from a well-conducted pharmacoepidemiological analysis[2].
Although the REACH Registry is a well-powered cohort of patients at risk of adverse cardiovascular outcomes, several characteristics make it disadvantageous in the context of comparative drug efficacy analysis. Firstly, exposure to ACEi or ARB was established at baseline; all participants were prevalent users of these agents. Much evidence exists to suggest that bias is introduced by such an approach; the characteristics of prevalent users may be affected by the drug itself[3]. A new-user design would have eliminated such concerns.
The indication for ACE inhibition and angiotensin receptor blockade differed greatly in this cohort of patients, recruited in 2003 and 2004. During this time, the evidence base for the use of ARBs was limited; most patients wo...
Show MoreTo the Editor:
We thank Dr. Launey Y et al for their constructive comments regarding our recent report.[1] We also greatly appreciate their shared interests in traumatic intra-cranial hemorrhage (ICH) and the subsequent incidence of atrial fibrillation (AF).
Dr Launey and colleagues concerned about the acute effects of inflammation on the onset of AF.[2] In our study, the mean follow-up period was 4.36 (standard deviation, SD=3.41) and 5.35 (SD=3.19) years in traumatic ICH group and control group, respectively. Interestingly, the mean follow-up period of the onset of AF was 2.94 years (SD=2.64) in traumatic ICH group, which is significantly less than 3.57 (SD=2.67) years in control group (Table 1) (p<0.001). Although acute inflammation plays a role on the onset of AF,[3, 4] our study along with previous evidence indicate the chronic persistent inflammation, which occurs after traumatic brain injury (TBI), contributes the development of AF.[1, 5] This partly explains the results of AF occurrence on TBI patients in our study.
We agree that sepsis may contribute to the development of AF. In this study, after adjustment for age, sex, and comorbidities including sepsis and ventilator associated pneumonia, the adjusted HR (aHR) for developing AF was 1.24-fold higher (95% CI = 1.18-1.31) for patients with traumatic ICH compared with the control cohorts in multivariable cox regression models (Table 2). These results further support the association betwee...
Show MoreThe study of Olmos et al., on prediction of in-hospital mortality in patients with active infective endocarditis undergoing cardiac surgery, is of great interest.1
Show MoreIndeed, this topic is fascinating because it is complicated to make a choice in so dramatic and not so rare situation.
To help with this decision-making, the authors proposed a model for predicting hospital mortality: a classic multivariate logistic regression model.
However, the editorial published with this article evokes in the title a new method: machine learning.2 Machine learning, which is a field of artificial intelligence, has already been used for predicting hospital mortality after elective cardiac surgery.3 This study aimed at comparing a machine learning model, a classic logistic regression model and EuroSCORE II on a cohort including 6,520 patients. The comparison of these models was based on ROC curves and decision curve analysis (DCA).4 Whatever the method of comparison, machine learning model was more accurate than other models.
Our experience in this area probably allows us to make some comments on this editorial. Considering, the increase of studies comparing machine learning with logistic regression, it is now known that supervised machine learning algorithms improve the prediction of post-operative mortality. However, the size of the cohort used in the present study makes it difficult to apply machine learning algorithms. Indeed, this cohort comprised 671 patients who...
We read with great interest this paper which demonstrated erectile dysfunction (ED), not only as a preclinical predictor of cardiovascular disease (CVD), treatment for ED. But also has a role in a reduced mortality and heart failure hospitalization1.However, a multi-country and region population-based survey indicated that the majority of Asian men have never sought treatment for ED because of cultural factors or sexual conservatism2.
Show MoreUnfortunately, this situation is more serious in China. A multi-center investigation of 3327 subjects showed that although the proportion of severe cases (IIEF＜8) among the Chinese elderly is the highest in all age groups, most elderly men are reluctant to visit the hospital just for the loss of erectile function (EF). They consider the loss of libido and EF with increasing age to be a natural process of aging3. Moreover, even the old men who seek help for ED were more concerned about the side effects of Western medicine (e.g., PDE5i); only a few of them (19%) used Western medicine as the first choice4. Furthermore, Chinese physicians seldom ask patients about their sexual health during routine consultations, their neglect of the health education about ED also aggravated this vicious circle2, 4.
Hence, there is a substantial need for promoting Andersson et al 's 1 findings on health education of elderly ED patients in China. The improved awareness and cultural factors would lead more Chinese elderly to visit the hospi...
We read the study of Wei-Shiang Lin et al.[1] with a great interest. In their large-scale cohort retrospective study, they found that traumatic intracranial hemorrhage was associated with an increased risk of atrial fibrillation (AF) and hypothesized that inflammation and/or secondary cardiac insult due to the traumatic brain injury (TBI) may cause AF. Nevertheless, several points should be discussed. First, acute inflammation is well-known to be related to AF in trauma patients. The risk of new-onset AF is reasonably expected to occur at the acute phase following the trauma. This point has already been previously demonstrated to occur during the days following cardiac surgery or septic shock onset.[2] In the same way, cardiac insult occurs at the very early phase of TBI and the consecutive cardiac systolic dysfunction was reported to be reversible within the first week after the trauma. [3] In this perspective, how to explain that the risk of AF persists one year after the trauma? It would be very helpful if the authors could provide data on the delay between the day of trauma and the day of new-onset AF. Furthermore, inflammation and cardiac dysfunction are related to the TBI severity and it would be valuable to know whether the more severe TBI patients are more prone to develop AF than mild or moderate TBI. Finally, in their statistical model, the authors have taken into account comorbidities which are also known to favor AF. But others factors, such as sepsis and relat...
Show MoreSir,
We congratulate McDowell et al. on their educational and interesting case report.1 However, we would like to comment on their use of the term ‘near-drowning’. This, and other confusing and older terms which caused inconsistencies in the literature, have been abandoned by organisations such as the International Liaison Committee on Resuscitation (ILCOR) and the World Health Organisation (WHO) who recommend a more structured and clearer way of reporting drowning incidents.2,3 For several years now, drowning has been defined as ‘a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident’. 2,3 We would thus recommend that the authors and readers of your journal follow ILCOR and WHO recommendations, and simply use the term ‘drowning’ irrespective of the patient outcome. While this may seem pedantic, we do believe that it will assist with standardisation in drowning research and literature.
References
1. McDowell K, Carrick D, Weir R. Heart Published Online First: 18 may 2017. doi:10.1136/heartjnl-2016-311043.
Show More2. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe...
Sawhney et al. reported that nurse-led, physician-directed moderate sedation during cardiac electrophysiology procedures is safe (1). All of the patients undergoing cardiac electrophysiological (EP) procedures and cardiac implantable electronic device (CIED) implantation during the last 12 years were moderately sedated. Since this study is a retrospective study, we could not comprehend why all patients were sedated despite the fact that routine sedation during all cardiac EP procedures and all CIED implantation is not recommended.
Show MoreMoreover, as mentioned in the article, sedation is a continuum and it is not always possible to predict how individual patients will respond. Therefore, a gradual increase of doses of the sedatives during sedation may be needed which may possibly increase the procedure duration. Did authors ascertain any prolongation of the procedures due to sedative administration?
Furthermore, sedation may diminish arrythmia induction during EP procedures, particularly in patients with catecholamine-sensitive ventricular tachycardias (2). Did authors have any data questioning this issue?
As a conclusion, the aim of sedation is to diminish the anxiety and to relieve the pain during the procedure. Therefore, using moderate sedation selectively in patients with anxiety or hyperalgesia may be more practical and rational rather than its routine use due to the fact that as mentioned in the article, researches and audit demonstrate continued avoidabl...
Chocolate intake and risk of atrial fibrillation
Dear Editor,
We have read with great interest the paper “Chocolate intake and risk of clinically apparent atrial
fibrillation: the Danish Diet, Cancer, and Health Study” by Elizabeth Mostofsky and coworkers [1] and we found their conclusion of importance with a view to clinical prevention.
With reference to the findings reported in the paper, we would like to make the following contribution to the discussion. In a recent analysis performed on 650 healthy women in pre-menopausal age (age range 45-54 years) chocolate intake was higher in women in the low quartile of adherence to Mediterranean Diet (low Med Score). This subgroup of women showed a lower ABI index compared to women with higher Med Score. The analysis of sources of antioxidants showed a greater intake from fruit and vegetables in the higher quartiles of Med Score. Coffee and tea were similarly distributed among the quartiles of Med Score [2]. Analysis from diet recall had the major limitation of missing data regarding out-of-mealtime snacking and drinking.
Show MoreIn Mediterranean countries, wine is a strong antioxidant source and the synergistic effect of drinking wine during meals and antioxidant bioavailability is well known. We clearly understand that nutritional habits in Northern Europe differ from Mediterranean ones. However, we would like to underline that in a Mediterranean lifestyle characterized by high intake of antioxidants,...
To the Editor,
Show MoreWe read with interest the work presented by Cahill et al. [1] in which the authors evaluate the impact of antibiotic prophylaxis to prevent bacteremia and infective endocarditis in patients undergoing dental procedures. The analysis was performed based on 36 studies, including 21 bacteremia studies, five case controls and cohort studies, and 10 time trend studies.
It is generally well established that dental cares cause bacteremia, and that most are due to streptococcal strains [1,2]. It is, consequently, reasonable to think that prescribing antibiotics before dental cares decreases the incidence of such bacteremia. Globally, the discordant results between the different kinds of studies analyzed in the paper by Cahill et al. [1] are clearly insufficient to conclude that antibiotic prophylaxis prevents bacteremia due to streptococci. In our view, this observation can be explained by the fact that dental care is not the only cause of streptococcal bacteremia. Indeed, such bacteremia are extremely common, and it has been demonstrated that they can occur after chewing and after brushing in patients with periodontitis (cumulatively in 25% and 20% of cases, respectively) [2]. It is, therefore, fairly unlikely that bacteremias due to dental cares are more responsible for endocarditis than other kinds of bacteremias. In practice, this implies that the only reasonable antibiotic prophylaxis to prevent almost every bacteremia due to oral streptococci wou...
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