104 e-Letters

published between 2016 and 2019

  • Adrenal function also needs to be evaluated in hypothyroidism-related pericardial effusion(revised version of my recent rapid response)

    Under the "diagnosis" heading the authors asserted that "hypothyroidism can be deemed the aetiology of pericardial effusion or cardiac tamponade if a high TSH level has been found, after excluding other secondary causes like a neoplastic, bacterial or an inflammatory process"(1).. I would add that, if the patient's hypothyroidism is of autoimmune aetiology, Addison's disease is a secondary cause that also requires urgent exclusion(2).
    In one report, a 21 year old man presented with cardiac tamponade, in association with a TSH level of 17.9 microUnits/L(normal range 0.35-5.0 microUnits/L), and serum thyroxine and serum tri-iodothyronine levels which were both at the lower limit of the normal range. Serum cortisol, however, was 0.5 micrograms/dl(normal range 3.0-23.0 mcd/dl). Tests for thyroid and adrenal autoantibodies were positive, thereby fulfilling the criteria for Type 2 autoimmune polyglandular syndrome(Type-2 APS).
    On the basis of the above observations the work-up of patients with pericardial effusion of presumed hypothyroid aetiology should include evaluation of adrenal function, because Addison's disease can, in its own right, be the underlying cause of cardiac tamponade(3). Furthermore, irrespective of hormonal status, pericardial effusion in a patient with Type 2 APS may ultimately be attributable to the "serositis" component of that syndrome, rendering the effusion capable of relapsing...

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  • The effect of chronic total occlusion revascularisation to the long-term outcome: what is the reason?

    To the Editor

    We read the article by Godino et al describing the risk of non-revascularisation of a coronary chronic total occlusion (CTO) for the cardiac death, sudden cardiac death and sustained ventricular arrhythmias (SCD/SVA) with great interest 1. After reading in detail, we have the following comments.
    At first, although the authors mentioned a little in the DISCUSSION, the effect of medications for the prevention of cardiac death and SCD/SVA may better be clarified in the subjects. As they stated, because those who received CTO lesion revascularisation tend to have longer dual antiplatelet therapy and receive more hospital visit for follow-up coronary angiography to recheck, there might be such confounding factors. For example, the third generation P2Y12 class of adenosine diphosphate (ADP) receptors inhibitor was approved in 2009 in Europe 2. How was its distribution compared to conventional clopidogrel treatment? And appropriate statin treatment would be also associated with plaque stability and reduced cardiac adverse events as well as the beta-blocker administration for the prevention of SCD/SVA 3. Because the follow-up period was long as up to 12-years, the difference of these medication strategies between two groups should be clarified. The same also applies to the used stent types. The importance of current manuscript would be much better after these concerns were clarified.
    Second, the multivariate analysis of Table 3 contains 2 factors,...

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  • Home-based programmes for heart failure can make cardiac rehabilitation more available and affordable

    Editor, We agree with Lavie et al that the current standard model of delivering cardiac rehabilitation (CR) predominantly in hospital or centre based facilities has reached saturation and we should be looking at offering alternatives which could improve the global suboptimal rates of participation in CR. [1] Uptake of CR in heart failure remains particularly poor with rates of less than 20% in Europe. [2].
    Clinicians and commissioners should consider implementing the findings of a UK based multicentre trial on home-based CR [3] which responds to the updated 2018 NICE guidance recommendation that adults with heart failure are offered a “..personalised, exercise-based CR programme – in a format and setting (at home, in the community or in the hospital) that is easily accessible” [https://www.nice.org.uk/guidance/ng106/chapter/Recommendations#cardiac-r... ]
    We believe REACH HF to be the largest randomised trial of home based CR (co-developed by clinicians, academics, caregivers and patients) in heart failure with reduced ejection fraction and it provides important new evidence for a novel home-based CR programme in terms of benefit to patients and their caregivers. [3]
    The results of the REACH HF trial show that it is possible to significantly improve patients’ health related quality of life and that the intervention has a cost of £418 per patient, within th...

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  • challenges to be addressed by the cuffless device

    Given the fact that the entire purpose of blood pressure measurement is to identify the cut-off level of blood pressure that increases the risk for cerebral, cardiac, and renal events, and that "brachial blood pressure can be an imperfect surrogate for central aortic pressure"(1), the latter being independently correlated with incident cardiovascular disease and cardiovascular risk(2), the ultimate test of the utility of the novel cuffless device is the degree to which it deviates from central blood pressure. Only 33% of conventional brachial blood pressure values have been found to lie within 5 mm Hg below or above intra-arterial values(3). The other challenge is the validity of cuffless blood pressure measurements obtained from patients with atrial fibrillation
    (1)Messerli F., Williams B., Ritz E
    Essential hypertension
    Lancet 2007;370:591-603
    (2) Agabiti-Rosei E., Mancia G., O'Rourke MF et al
    Cntral blood pressure measurements and antihypertensive therapy: A consensus statement
    Hypertension 2007;50:154-160
    (3)Manios E., Vemmos K., Tsivgoulis G et al
    Comparison of noninvasive oscillometric and intraarterial blood pressure measurements in hyperacute stroke
    Blood Press Monit 2007;12:149-156

  • Predictive value of cardiac auscultation for the assessment of valvular heart disease

    Gardezi and colleagues (1) report on the limited accuracy for detection of valvular heart disease (VHD) by cardiac auscultation in asymptomatic patients in primary care. VHD was categorized as either mild or significant and cardiac auscultation was dichotomized in either a present or absent murmur. The authors propose a low sensitivity and modest specificity of cardiac auscultation by general practitioners and by cardiologists to assess VHD.
    However, the authors underestimated the specificity and positive predictive value of cardiac auscultation for the assessment of VHD. Patients with a cardiac murmur in whom, by transthoracic echocardiography, mild VHD was detected were included in the ‘negative’ group for assessing significant VHD and more importantly, vice versa. By doing so, many murmurs are classified as false-positive although VHD was present, either mild or significant. We believe that the “true negative” group only includes those patients without any VHD on echocardiography. This would increase the specificity of cardiac auscultation by general practitioners from 67% to 76% and from 81% to 93% for cardiologists, which results in much higher positive predictive values for significant VHD. While it does not change the reported low sensitivity of cardiac auscultation, which remains rather unsatisfactory, this perspective would make the conclusions of this paper at least a little less detrimental to the good old stethoscope.

    1. Gardezi S...

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  • caveats to reliance on natriuretic peptide levels to trigger referral to secondary care

    An imprtant caveat to reliance on brain natriuretic peptide(BNP) levels > 100 pg/ml to trigger referral to secondary care(1) is that there exists a clinical phenotype of congestive heart failure(CHF) characterised by BNP equal to or less than 100 pg/ml(2).. In the latter study 46 out of 1159 subjects with CHF and left ventricular ejection fraction(LVEF) > 50%, 46 subjects were characterised by BNP equal to or less than 100 pg/ml. Heart failure symptoms such as effort dyspnoea were equally prevalent(93% vs 90%) in subject with BNP equal to or less than 100 pg/ml vs counterparts with BNP > 100 pg/ml(2). The same was true of orthopnoea(48% vs 48%) and paroxysmal nocturanal dyspnoea(28% vs 29%)(2).
    The other caveat is that constrictive pericarditis(CP), an entity characterised by symptoms such as effort dyspnoea and pedal oedema, similar to those in CHF, may be characterised by BNP as low as 50 pg/ml and 88 pg/ml, respectively, in spite of coexistence of New York Heart Association functional class III and IV symptoms(3), and natriuretic propeptide tyype B 147 pg/ml in spite of worsening dyspnoea(4). An overriding consideration is the "diagnostic value of physical examination....in primary care"(5) which includes evaluation of jugular venous pressure(JVP)(5). In the latter study elevation of JVP contributed 12 points towards a score of >54 needed to generate a >70% probability of CHF(5). In CP marked elevation of JVP is almost universal(6)....

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  • Iatrogenic atrial septal defect: size matters

    To the Editor,
    We read with interest the paper by Ikenaga et al. (1), who must be commended for their detailed report on the determinants of persistent iatrogenic atrial septal defect (iASD) following percutaneous mitral valve clip (MV clip) placement. The authors found that elevated left atrial (LA) pressure after the MV clip procedure was the main determinant of persistent iASD during follow-up. Remarkably, in spite of their poorer clinical condition, patients with and without persistent iASD had similar outcomes during follow-up. This suggested that interatrial shunt has a benefit in some MV clip patients. Previous studies that evaluated the usefulness of an interatrial shunt device for treating heart failure patients without valve disease also showed a significant benefit of the shunt in patients with high LA pressure (2, 3).
    However, these findings disagree with other findings of the persistence of iASD after MV clip placement with negative outcomes, mainly due to right ventricle (RV) claudication (4). Indeed, previous studies of the interatrial shunt device suggest that the size of the shunt plays a key role in outcomes. Indeed, the ideal shunt size should allow the reduction of LA pressure without hampering right heart function. The maximum interatrial shunt devices are 5 mm2 (3); too large iASDs may increase the Qp/Qs enough to cause RV failure, while too small iASDs may be have negligible hemodynamical and clinical results. No MV clip studies reported...

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  • misattribution of the source of an aortic systolic murmur

    One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
    Severe AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).

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  • a role for point of care scanning in the emergency context

    Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
    (i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
    (ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
    (1) Stout KK., Verrier ED
    Acute valvular regurgitation
    Circulation 2009;119:3232-3241
    (2) Hamirani YS., Dietl CA., Voyles V et al
    Acute aortic regurgitation
    Circulation 2012;126:1121-1126
    (3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
    Clinical characteristics and thrombolytic outc...

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  • Complete AV block…. but also partial interatrial block

    Martínez –Milla el al, report an interesting case of cardiac lymphoma, presenting as complete AV block.
    A close look at the electrocardiogram, reveals a P wave with a normal frontal axis, broad (duration > 120 ms), and bimodal ( notched). These are the diagnostic hallmarks of partial interatrial block (IAB).
    In this patient, the lymphoma probably infiltrates the Bachmann’s bundle, interrupting the preferential pathway of left atrial activation, causing partial IAB.
    Although often overlooked, IAB is frequent in the elderly, and it is associated with atrial arrhythmias and stroke.
    Because the diagnosis of IAB relies on the morphology and duration of the P wave, a meticulous analysis of the electrocardiogram is mandatory.