To the Editor: I read with interest, the article by Christian J M
Vrints (1) on spontaneous coronary artery dissection (SCAD). The images
from current imaging modalities are impressive. The author has given an
useful and practical approach to managing patients with SCAD.
The author has recommended medical therapy for asymptomatic patients
with SCAD, followed by computed tomogram on follow up. Myocardial
perfu...
To the Editor: I read with interest, the article by Christian J M
Vrints (1) on spontaneous coronary artery dissection (SCAD). The images
from current imaging modalities are impressive. The author has given an
useful and practical approach to managing patients with SCAD.
The author has recommended medical therapy for asymptomatic patients
with SCAD, followed by computed tomogram on follow up. Myocardial
perfusion imaging (MPI) with Single Photon Emissin Computed Tomography
(SPECT) or Positron Emission Tomography (PET) is an useful tool for risk
stratifying asymptomatic patients with SCAD. MPI provides valuable data
regarding myocardial viability as well as extend of myocardium at
jeopardy. Revascularization is warranted even in asymptomatic patients if
there is evidence of inducible ischemia or if there is viable myocardium
in patients with left ventricular systolic dysfunction. On the contrary,
conservative treatment is sufficient if MPI reveals absence of inducible
ischemia or infarcted myocardium.
We had reported a case of asymptomatic SCAD in a 25-years-old male,
who had sustained a silent anterior wall myocardial infarction (2). Though
the patient refused MPI, he remains asymptomatic at 4 years of follow up,
on medical therapy.
References:
1) Christian J M Vrints Acute coronary syndromes: Spontaneous
coronary artery dissection Heart 2010;96:801-808
doi:10.1136/hrt.2008.162073
2) Shankarappa RK, Panneerselvam A, Dwarakaprasad R, Karur S,
Krishnanaik GB, Nanjappa MC Spontaneous asymptomatic coronary artery
dissection in a young man. J Cardiol 2009; 54 (3),499-502
Our ischaemic cardiopathy study group have read with interest the
article written by Lawesson
et al (1). First of all, the occurrence of ST-elevation myocardial
infarction in young women is
rare and the tobacco nocive role is well established in the medical
literature. However, we
would like to emphasize that smoking in women is growing nowadays.
According to World
Health Organization, there are 1,2 billion smokers around...
Our ischaemic cardiopathy study group have read with interest the
article written by Lawesson
et al (1). First of all, the occurrence of ST-elevation myocardial
infarction in young women is
rare and the tobacco nocive role is well established in the medical
literature. However, we
would like to emphasize that smoking in women is growing nowadays.
According to World
Health Organization, there are 1,2 billion smokers around the world, in
which 200 million are
women (2). Even with this, in the article, the women are not having
infarctions more often.
Regarding this, we would like to know the position of the authors on the
following questions
judged relevant by our group: first, what is the prevalence of early
coronary diseases in the
first grade relatives of these women? And second, knowing that the use of
drugs or vasoactive
substances and having AIDS are related to the occurrence of myocardial
infarction in youngs,
we ask if these factors were present in the studied female population.
REFERENCES
1.Lawesson SS, Stenestrand U, Lagerqvist B et al. Gender perspective on
risk factors,
coronary lesions and long-term outcome in young patients with ST-elevation
myocardial
infarction. Heart 2010;96:453-459
2.Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med
1999;107:254e61. 3.World Health Organization (WHO). Tobbaco Free
Iniciative.
http://www.who.int/tobacco/en
We have read with interest the article written by Bramlage et al (1)
and we want to congratulate the authors and manifest our agreement with
the findings of lower mortality in patients receiving optimal medical
therapy (OMT) with statins, aspirin, clopidogrel, b-blockers, rennin
angiotensin system blockers/ angiotensin-receptor blockers.
However, we think appropriate to mention that patients who received OMT
probably nee...
We have read with interest the article written by Bramlage et al (1)
and we want to congratulate the authors and manifest our agreement with
the findings of lower mortality in patients receiving optimal medical
therapy (OMT) with statins, aspirin, clopidogrel, b-blockers, rennin
angiotensin system blockers/ angiotensin-receptor blockers.
However, we think appropriate to mention that patients who received OMT
probably needed to have medical conditions that could support this type
of approach, such as blood pressure levels that tolerate hypotensive
drugs, having adequate ventricular function to receive negative inotropic
agents or the coagulation system working properly to receive anticoagulant
/ antiplatelet drugs, among other conditions that allow the use of these
and other classes of medications (2). Hence, patients that can receive the
OMT are already better, and thus will have better outcomes.
Regarding the use of statin, which is a medication commonly used (3), we
would like to know the position of the authors on the following question:
what are the reasons in this study for its limited use, especially in
suboptimal group?
References
1. Bramlage P, Messer C, Bitterlich N, Pohlmann C, Cuneo A, Stammwitz E,
et al. The effect of optimal medical therapy on 1-year mortality after
acute myocardial infarction. Heart. 2010 Apr;96(8):604-9.
2. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS,
et al. ACC/AHA guideline update for the management of patients with
unstable angina and non-ST-segment elevation myocardial infarction--2002:
summary article: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee on the
Management of Patients With Unstable Angina). Circulation. 2002 Oct
1;106(14):1893-900.
3. Wiviott SD, Cannon CP, Morrow DA, Ray KK, Pfeffer MA, Braunwald E. Can
low-density lipoprotein be too low? The safety and efficacy of achieving
very low low-density lipoprotein with intensive statin therapy: a PROVE IT
-TIMI 22 substudy. J Am Coll Cardiol. 2005 Oct 18;46(8):1411-6.
We read with interest the work "A randomised trial of target-vessel
versus multi-vessel revascularisation in ST-elevation myocardial
infarction: major adverse cardiac events during long-term follow-up"by
Luigi Politi. According to the conclusion of the article, culprit vessel-
only angioplasty was associated with the highest rate of long-term MACE
compared with multivessel treatment including simultaneous
revascularizati...
We read with interest the work "A randomised trial of target-vessel
versus multi-vessel revascularisation in ST-elevation myocardial
infarction: major adverse cardiac events during long-term follow-up"by
Luigi Politi. According to the conclusion of the article, culprit vessel-
only angioplasty was associated with the highest rate of long-term MACE
compared with multivessel treatment including simultaneous
revascularization and staged revascularization[1].
This is the first prospective study in which the culprit-only
revascularisation was separated as a isolated group(excluded the staged
revascularization) while previous studies divided patients into two
groups[2][3]. Is this classification reasonable?
According to the ACC/AHA recommendation[4], the culprit vessel should
be treated in the primary procedure, and staged PCI can be performed in an
elective procedure for the STEMI patients with multivessel disease. But in
this study, staged PCI had not been considered in the COR group for 2.5
years.So the higher incidence of re-PCI and re-hospitalization was
inevitable. The investigators aslo admitted that the incidence of repeat
revascularisation and re-hospitalisation was significantly higher only in
the COR group, whereas there was no significant difference in other
outcomes among the three groups. Under the circumstances, the higher rate
of long-term MACE in COR group is a really convinced conclusion?
references
[1] Luigi Politi, Fabio Sgura, Rosario Rossi, et al.A randomised trial of
target-vessel versus multi-vessel revascularisation in ST-elevation
myocardial infarction: major adverse cardiac events during long-term
follow-up.heart 2010;96:662-667.
[2] Di Mario C, Mara S, Flavio A, et al. Single vs multivessel treatment
during primary angioplasty: results of the multicentre randomised HEpacoat
for cuLPrit or multivessel stenting for Acute Myocardial Infarction ((HELP
AMI) Study. Int J Cardiovasc Intervent 2004;6:128-133.
[3] Khattab AA, Abdel-Wahab M, Rother C, et al. Multi-vessel stenting
during primary percutaneous coronary intervention for acute myocardial
infarction: A single-
center experience.Clin Res Cardiol 2008;97:32-38.
[4] Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the
ACC/AHA 2004 guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. J
Am Coll Cardiol 2008;51:210-47.
Sir, in their elegant evaluation of primary angioplasty vs
thrombolysis cost-effectiveness,
Wailoo and Coll. conclude that primary angioplasty-based care is highly
likely to be costeffective,
particularly if patients are admitted directly to the cardiac catheter
laboratory 1.
These conclusions will certainly trigger the opening of new
catheterization laboratories
across the UK and elsewhere as well. As a consequence, the...
Sir, in their elegant evaluation of primary angioplasty vs
thrombolysis cost-effectiveness,
Wailoo and Coll. conclude that primary angioplasty-based care is highly
likely to be costeffective,
particularly if patients are admitted directly to the cardiac catheter
laboratory 1.
These conclusions will certainly trigger the opening of new
catheterization laboratories
across the UK and elsewhere as well. As a consequence, the manoeuvre will
increase not
only the number of primary angioplasties being performed, but also and
above all the
number of cardiac catheterization procedures performed for reason other
than treating
myocardial infarction 2.
We believe that shifting the strategy model from thrombolysis to primary
angioplasty
implies costs far exceedings those calculated in their sensitivity
analysis by Wailoo and
Coll.
1. Wailoo A, Goodacre S, Sampson F, Alava MnHn, Asseburg C, Palmer S, Sculpher M,
Abrams K, de Belder M, Gray H. Primary angioplasty versus thrombolysis for acute
ST-elevation myocardial infarction: an economic analysis of the National Infarct
Angioplasty project
10.1136/hrt.2009.167130. Heart. 2010;96:668-672.
2. Nallamothu BK, Rogers MAM, Chernew ME, Krumholz HM, Eagle KA, Birkmeyer JD.
Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in
Medicare Beneficiaries
10.1001/jama.297.9.962. JAMA. 2007;297:962-968.
Paolo Alboni et al concluded that the patient's tolerance of intravenous
administration of flecainide or propafenone does not seem to predict
adverse effects during out-of-hospital self administration of these drugs
(1). However, it is important to note that the number of patients in the
study were only 122 with a 5% incidence of major adverse effects.
Patients without structural heart disease would benefit from propafeno...
Paolo Alboni et al concluded that the patient's tolerance of intravenous
administration of flecainide or propafenone does not seem to predict
adverse effects during out-of-hospital self administration of these drugs
(1). However, it is important to note that the number of patients in the
study were only 122 with a 5% incidence of major adverse effects.
Patients without structural heart disease would benefit from propafenone
or flecainide (2) but in this current study, the left atrial diameter
ranged from 35-45mm. This could have contributed to the high incidence of
adverse events.
A previous study defined enlarged left atrium as diameter >38mm in
women (56%) and >42mm in men (38%) with p<0.01 (3).
Also the author rightly pointed out that the pharmacodynamic effects of
oral vs intravenous forms of flecainide and propafenone work differently
(4). Hence, evaluating the effects of both drugs in the same study may not
give the best results.
References
1. Alboni P, Botto GL, et al. Intravenous administration of flecanide or
propafenone in patients with recent-onset atrial fibrillation does not
predict adverse effects during "pill-in-the- pocket" treatment. Heart 2010;96:546-549
2. Naccarelli GV, Wolbrette DL, et al. Old and new antiarrhythmic drugs
for converting and maintaining sinus rhythm in atrial fibrillation:
comparative efficacy and results of trials. Am J Cardiol. 2003 Mar
20;91(6A):15D-26D
3. Gerdts E, Oikarinen L, et al. Correlated of Left Atrial Size in
Hypertensive Patients with Left Ventricular Hypertrophy (LIFE) Study.
Hypertension 2002;39:739-743
4. Alp NJ, Bell JA, Shahi M. Randomised double blind trial of oral versus
intravenous flecanide for the conversion of acute atrial fibrillation.
Heart 2000;84:37-40
Our ischaemic cardiopathy study group have read with interest the article written by Lawesson et al (1).
First of all, the occurrence of ST-elevation myocardial infarction in young women is rare and the tobacco nocive role is well established in the medical literature. However, we would like to emphasize that smoking in women is growing nowadays. According to World Health Organization, there are 1,2 billion smokers around the wo...
Our ischaemic cardiopathy study group have read with interest the article written by Lawesson et al (1).
First of all, the occurrence of ST-elevation myocardial infarction in young women is rare and the tobacco nocive role is well established in the medical literature. However, we would like to emphasize that smoking in women is growing nowadays. According to World Health Organization, there are 1,2 billion smokers around the world, in which 200 million are women (2,3). Even with this, in the article, the women are not having infarctions more often. Regarding this, we would like to know the position of the authors on the following questions judged relevant by our group: first, what is the prevalence of early coronary diseases in the first grade relatives of these women? And second, knowing that the use of drugs or vasoactive substances and having AIDS are related to the occurrence of myocardial infarction in youngs, we ask if these factors were present in the studied female population.
REFERENCES
1.Lawesson SS, Stenestrand U, Lagerqvist B et al. Gender perspective on risk factors, coronary lesions and long-term outcome in young patients with ST-elevation myocardial infarction. Heart 2010;96:453-459
2.Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med 1999;107:254e61.
3.World Health Organization (WHO). Tobbaco Free Iniciative. http://www.who.int/tobacco/en
With great interest we have read the article by Politi et al(1) on
revascularisation of patients with ST-elevation myocardial infarction and
multivessel disease. The authors are to be complimented with the largest
randomised trial on this subject, with the longest follow-up.
However, we question whether this study is the 'justification for
complete revascularisation at the time of primary angioplasty', as the
p...
With great interest we have read the article by Politi et al(1) on
revascularisation of patients with ST-elevation myocardial infarction and
multivessel disease. The authors are to be complimented with the largest
randomised trial on this subject, with the longest follow-up.
However, we question whether this study is the 'justification for
complete revascularisation at the time of primary angioplasty', as the
paper is labeled by the accompanying Editorial. Apart from the
considerable imbalance in patient numbers, which remains unexplained,
there are several other major concerns.
First, there is no mentioning of routine non-invasive testing for
ischemia after discharge in the COR group, as is currently advocated by
the guidelines(2). Thus, it is not clear if the additional PCI procedures
in the COR group were unexpected events or a result of planned non-
invasive testing. All these events were considered MACEs in the COR group,
while planned revascularisations in the SR group were not.
Second, testing for ischemia is relevant since 40% of non-culprit
lesions do not produce ischemia, as we demonstrated in a recent randomised
trial of FFR-guided early (7.5 days) additional revascularisation versus
culprit-only revascularisation(3). Also, we found that after 6 months
death and MI had occurred only in the early treatment group. This
underlines that early additional treatment is probably not without risk,
while benefit is not to be expected in a considerable number of patients.
Third, the importance of complete revascularisation is emphasized in
the discussion, but it is not clear in how many patients of the CR or SR
group this was actually achieved. Since more complex lesions are to be
expected in a population with multivessel disease, in which for instance
about 30% of the patients have a CTO, this is a relevant question. It has
been suggested that the presence of a CTO is the only independent factor
that determines the additional risk in patients with multivessel
disease(4).
For now, it seems that staged PCI of non-culprit lesions guided by
ischemia testing is still the most reasonable treatment strategy for
patients with multivessel disease and STEMI. We agree with the authors
that clearly more research is needed to define the optimal treatment in
these patients.
References
1. A randomised trial of target-vessel versus multi-vessel
revascularisation in ST-elevation myocardial infarction: major adverse
cardiac events during long-term follow-up. Politi L, Sgura F, Rossi R, et
al. Heart 2010 96: 662-667.
2. Management of acute myocardial infarction in patients presenting
with persistent ST-segment elevation: the Task Force on the Management of
ST-Segment Elevation Acute Myocardial Infarction of the European Society
of Cardiology. Van de Werf F, Bax J, Betriu A, et al. Eur Heart J 2008
Dec;29(23):2909-45.
3. Non-culprit lesions detected during primary PCI: treat invasively
or follow the guidelines? Dambrink JHE, Debrauwere JP, van 't Hof AWJ, et
al. Eurointervention 2010; 5:968-975.
4. Impact of multivessel coronary disease on long-term mortality in
patients with ST-elevation myocardial infarction is due to the presence of
a chronic total occlusion. Van der Schaaf RJ, Vis MM, Sjauw KD, et al. Am
J Cardiol 2006;98:1165-1169.
To the editor: I would like to thank Dr Lerman for his reply to our
measurement question [1]. I am acutely aware of Dr Lerman's fantastic
research pedigree and the excellent ground breaking work produced by the
Mayo clinic group, which swamps my paltry contribution to this area.
However, My specific question in the previous letter [2] was not related
to the ability of the IVUS-VH classification tree to determine plaque...
To the editor: I would like to thank Dr Lerman for his reply to our
measurement question [1]. I am acutely aware of Dr Lerman's fantastic
research pedigree and the excellent ground breaking work produced by the
Mayo clinic group, which swamps my paltry contribution to this area.
However, My specific question in the previous letter [2] was not related
to the ability of the IVUS-VH classification tree to determine plaque
characteristics accurately, as I feel that this has been previously well
investigated (as cited in your reply)[3-5] The question was more related
to your own inter-observer variability of IVUS-VH necrotic core analyses.
For example: The Thoraxcenter group have published the limits of
agreement around the measurement of necrotic core area [6]. They have
quoted an inter-observer range between 0.16mm2 and -0.20mm2. This is a
potential swing of 0.36mm2 of necrotic core across individual analyses
between operators. Although this inter-observer variability appears very
good, Rodriguez-Granillo do state in their discussion that "Overall, the
inter-catheter and inter-observer differences shown might provide
boundaries over which changes are statistically significant.The inter-
observer relative difference in plaque CSA measurements was 10%, This can
aid investigators to perform precise power calculations for longitudinal
studies"
The differences quoted in necrotic core within your study[7] was 0.13
(IQR 0.03-0.33) mm2 versus 0.0 (IQR 0.0-0.07) mm2, p<0.001. This
difference in real terms could be calculated as 0.13mm2 (IQR 0.03-0.26)
which is within Rodriguez-Granillo's range for simple inter-observer
variability (0.36mm2).
In short, is it possible that changes in necrotic core between the
groups with and without endothelial dysfunction (in your paper) were
simply a factor of inherent measurement variability? The absolute values
are very small and I appreciate this is difficult when studying coronary
segments with minimal disease.
I must apologise for forcing this debate to a conclusion, however
this measurement issue does have an effect on my own work in this area and
also future pharmacological and clinical trials using necrotic core as a
potential endpoint.
Best Wishes
Dr SW Murray
References
1. Amir Lerman Endothelial dysfunction and necrotic core plaques.
Heart 2010 96:551
2. Murray SW,Palmer ND Segmental coronary endothelial dysfunction in
patients with minimal atherosclerosis. Heart 2010;96:550.
3. Nasu K, Tsuchikane E, Katoh O, et al. Accuracy of in
vivo coronary plaque morphology assessment:a validation study of in vivo
virtual histology compared with in vitro histopathology. J Am Coll Cardiol
2006;47:2405e12.
4. Granada JF, Wallace-Bradley D, Win HK, et al. In vivo plaque
characterization using intravascular ultrasound virtual histology in a
porcine model of complex coronary lesions. Arterioscler Thromb Vasc Biol
2007;27:387e93.
5. Nasu K, Tsuchikane E, Katoh O, et al. Plaque
characterisation by virtual histology intravascular
ultrasound analysis in patients with type 2 diabetes.
Heart 94;2008:429e33.
6.Gaston A. Rodriguez-Granillo, Sophia Vaina, Hector M. Garcia-Garcia
et al Reproducibility of intravascular ultrasound radiofrequency data
analysis: implications for the design of longitudinal studies The
International Journal of Cardiovascular Imaging (2006) 22: 621-631
7. Lavi S, Bae JH, Rihal CS et al Segmental coronary endothelial
dysfunction in patients with minimal atherosclerosis is associated with
necrotic core plaques. Heart 2009;95:525-30
We have read with interest the article written by Piscione et al1
related with direct stenting. The authors have performed a meta-analysis
of 24 randomised controlled trials of direct stenting vs. stenting with
predilatation and the conclusion is a 23 % reduction in the odds of
myocardial infarction. In our opinion, direct stenting should be the
approach of choice in all the susceptible cases because this important
bene...
We have read with interest the article written by Piscione et al1
related with direct stenting. The authors have performed a meta-analysis
of 24 randomised controlled trials of direct stenting vs. stenting with
predilatation and the conclusion is a 23 % reduction in the odds of
myocardial infarction. In our opinion, direct stenting should be the
approach of choice in all the susceptible cases because this important
benefit is not associated with an increase in mortality, restenosis or
stent expansion2 3, and also direct stenting saves time and reduces
significantly procedural costs. In the current context with a strict
reduction in economical resources every approach directed to reduce costs
should always be attempted. A typical case of direct stenting can usually
be performed with one guiding catheter, one coronary wire and one stent.
In our country the use of one balloon will represent aproximately 28 % of
the cost of the procedure if the stent is bare metal and 20 % if is a drug
eluting stent. Few actions in medicine allow us to save such percentage
with the same or even better results. Stent dislodgment is extremely
unfrequent with the current stent designs and there are guiding catheters
dedicated to accomplish active intubation that facilitates direct
stenting. Moreover, if postdilatation needs to be performed to complete
the procedure, new balloons which can be inflated up to 40 atmospheres can
be found in the market. We believe that there are not arguments to perform
predilatation if direct stenting is potentially possible.
REFERENCES
1. Piscione F, Piccolo R, Cassese S, Galasso G, D'Andrea C, De Rosa
R et al. Is direct stenting superior to stenting with predilation in
patients treated with percutaneous coronary intervention? Results from a
meta-analysis of 24 randomised controlled trials. Heart 2010;96:588-94.
2. Le Breton H, Boschat J, Commeau P, Brunel P, Gilard M, Breut C et
al. Randomised comparison of coronary stenting with and without balloon
predilatation in selected patients. Heart 2001;86:302-8.
3. Lopez-Palop R, Pinar E, Lozano I, Carrillo P, Cortes R, Saura D
et al. Comparison of intracoronary ultrasound expansion parameters in
coronary stents implanted with or without balloon predilatation. A
randomized intravascular ultrasound study. Rev Esp.Cardiol 2004;57:403-11.
To the Editor: I read with interest, the article by Christian J M Vrints (1) on spontaneous coronary artery dissection (SCAD). The images from current imaging modalities are impressive. The author has given an useful and practical approach to managing patients with SCAD.
The author has recommended medical therapy for asymptomatic patients with SCAD, followed by computed tomogram on follow up. Myocardial perfu...
Our ischaemic cardiopathy study group have read with interest the article written by Lawesson et al (1). First of all, the occurrence of ST-elevation myocardial infarction in young women is rare and the tobacco nocive role is well established in the medical literature. However, we would like to emphasize that smoking in women is growing nowadays. According to World Health Organization, there are 1,2 billion smokers around...
We have read with interest the article written by Bramlage et al (1) and we want to congratulate the authors and manifest our agreement with the findings of lower mortality in patients receiving optimal medical therapy (OMT) with statins, aspirin, clopidogrel, b-blockers, rennin angiotensin system blockers/ angiotensin-receptor blockers. However, we think appropriate to mention that patients who received OMT probably nee...
We read with interest the work "A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up"by Luigi Politi. According to the conclusion of the article, culprit vessel- only angioplasty was associated with the highest rate of long-term MACE compared with multivessel treatment including simultaneous revascularizati...
Sir, in their elegant evaluation of primary angioplasty vs thrombolysis cost-effectiveness, Wailoo and Coll. conclude that primary angioplasty-based care is highly likely to be costeffective, particularly if patients are admitted directly to the cardiac catheter laboratory 1. These conclusions will certainly trigger the opening of new catheterization laboratories across the UK and elsewhere as well. As a consequence, the...
Paolo Alboni et al concluded that the patient's tolerance of intravenous administration of flecainide or propafenone does not seem to predict adverse effects during out-of-hospital self administration of these drugs (1). However, it is important to note that the number of patients in the study were only 122 with a 5% incidence of major adverse effects. Patients without structural heart disease would benefit from propafeno...
With great interest we have read the article by Politi et al(1) on revascularisation of patients with ST-elevation myocardial infarction and multivessel disease. The authors are to be complimented with the largest randomised trial on this subject, with the longest follow-up.
However, we question whether this study is the 'justification for complete revascularisation at the time of primary angioplasty', as the p...
To the editor: I would like to thank Dr Lerman for his reply to our measurement question [1]. I am acutely aware of Dr Lerman's fantastic research pedigree and the excellent ground breaking work produced by the Mayo clinic group, which swamps my paltry contribution to this area. However, My specific question in the previous letter [2] was not related to the ability of the IVUS-VH classification tree to determine plaque...
We have read with interest the article written by Piscione et al1 related with direct stenting. The authors have performed a meta-analysis of 24 randomised controlled trials of direct stenting vs. stenting with predilatation and the conclusion is a 23 % reduction in the odds of myocardial infarction. In our opinion, direct stenting should be the approach of choice in all the susceptible cases because this important bene...
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