I read the article by Kasula and colleagues with great interest. I
firmly believe that this is a novel finding and of great clinical
significance (1).
Utility of Fractional flow reserve (FFR) is firmly established in
stable coronary artery disease but has been widely debated in patients
with acute MI particularly in the culprit vessel (2, 3). FFR measurements
require maximal coronary hyperaemia which may be les...
I read the article by Kasula and colleagues with great interest. I
firmly believe that this is a novel finding and of great clinical
significance (1).
Utility of Fractional flow reserve (FFR) is firmly established in
stable coronary artery disease but has been widely debated in patients
with acute MI particularly in the culprit vessel (2, 3). FFR measurements
require maximal coronary hyperaemia which may be less readily achieved in
patients with acute coronary disease because of coronary microvascular
dysfunction. This in turn may result in a falsely higher FFR value. This
will be of particular concern while assessing FFR value post-PCI since
coronary stenting of a 'hot' culprit lesion in acute coronary syndrome
would inevitably carry risk of some distal embolization which may further
exacerbate this issue.
Since, microvascular obstruction carries a poor prognosis, a direct (in
contrast to an inverse relationship) relationship between post-PCI FFR
value and adverse outcome would have supported this theoretical limitation
of FFR in patients with MI (4). However, it was reassuring to see that
these concerns appear unfounded in the current study. The fact that FFR
value had an inverse relationship with future adverse events is an in-
direct evidence that FFR value is still valid even in culprit vessel in
patients with NSTEMI.
References:
1) Clinical and prognostic value of poststenting fractional flow reserve
in acute coronary syndromes
2) Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ,
Bartunek J, Koolen JJ, Koolen JJ. Measurement of fractional flow reserve
to assess the functional severity of coronary-artery stenoses. N Engl J
Med 1996;334:1703-1708.
3) Tonino P.A., De Bruyne B., Pijls N.H., et al; Fractional flow
reserve versus angiography for guiding percutaneous coronary intervention.
N Engl J Med. 2009;360:213-224
4) Fearon W.F., Low A.F., Yong A.S., et al; Prognostic value of
the Index of Microcirculatory Resistance measured after primary
percutaneous coronary intervention. Circulation. 2013;127:2436-2441.
We thank Ripley and colleagues for their interest in our paper and
agree that T1 mapping with CMR is an emerging imaging biomarker that is
increasingly being investigated for its potential role in hypertrophic
cardiomyopathy and cardiac hypertrophy in general. Convincing data have
been published concerning hypertensive heart disease(Hinojar et al.,
2015), hypertrophic and dilated cardiomyopathy (Puntmann et al., 2013),...
We thank Ripley and colleagues for their interest in our paper and
agree that T1 mapping with CMR is an emerging imaging biomarker that is
increasingly being investigated for its potential role in hypertrophic
cardiomyopathy and cardiac hypertrophy in general. Convincing data have
been published concerning hypertensive heart disease(Hinojar et al.,
2015), hypertrophic and dilated cardiomyopathy (Puntmann et al., 2013),
transthyretin amyloidosis (Fontana et al., 2014) and Anderson-Fabry
disease (Pica et al., 2014). We have not found any specific published data
examining the role of T1 mapping in distinguishing ventricular septal
bulge in an elderly population from other etiologies of hypertrophy. We
therefore decided not to include T1 mapping in our review (Canepa et al.,
2016) but concur that this technique may be potentially useful in the
evaluation of ventricular septal bulge.
Canepa, M., Pozios, I., Vianello, P. F., Ameri, P., Brunelli, C.,
Ferrucci, L., & Abraham, T. P. (2016). Distinguishing ventricular
septal bulge versus hypertrophic cardiomyopathy in the elderly. Heart,
102(14), 1087-1094. doi:10.1136/heartjnl-2015-308764
Fontana, M., Banypersad, S. M., Treibel, T. A., Maestrini, V., Sado,
D. M., White, S. K., ... Moon, J. C. (2014). Native T1 Mapping in
Transthyretin Amyloidosis. JACC: Cardiovascular Imaging, 7(2), 157-165.
doi:10.1016/j.jcmg.2013.10.008
Hinojar, R., Varma, N., Child, N., Goodman, B., Jabbour, A., Yu, C.-
Y., Puntmann, V. O. (2015). T1 Mapping in Discrimination of Hypertrophic
Phenotypes: Hypertensive Heart Disease and Hypertrophic Cardiomyopathy:
Findings From the International T1 Multicenter Cardiovascular Magnetic
Resonance Study . Circulation: Cardiovascular Imaging , 8 (12
).doi:10.1161/CIRCIMAGING.115.003285
Pica, S., Sado, D. M., Maestrini, V., Fontana, M., White, S. K.,
Treibel, T., Moon, J. C. (2014). Reproducibility of native myocardial T1
mapping in the assessment of Fabry disease and its role in early detection
of cardiac involvement by cardiovascular magnetic resonance. Journal of
Cardiovascular Magnetic Resonance?: Official Journal of the Society for
Cardiovascular Magnetic Resonance, 16(1), 99. doi:10.1186/s12968-014-0099-
4
Puntmann, V. O., Voigt, T., Chen, Z., Mayr, M., Karim, R., Rhode, K.,
Nagel, E. (2013). Native T1 Mapping in Differentiation of Normal
Myocardium From Diffuse Disease in Hypertrophic and Dilated
Cardiomyopathy. JACC: Cardiovascular Imaging, 6(4), 475-484.
doi:10.1016/j.jcmg.2012.08.019
Honarbakhsh et al should be congratulated upon their innovative
research in improving the care for patients with arrhythmias. Their paper
not only demonstrates an effective community treatment strategy but
importantly is cost effective during the current austerity. Potential
further cost savings and enhanced patient experiences could be anticipated
by encouraging General Practitioners to subsequently refer patients
wishi...
Honarbakhsh et al should be congratulated upon their innovative
research in improving the care for patients with arrhythmias. Their paper
not only demonstrates an effective community treatment strategy but
importantly is cost effective during the current austerity. Potential
further cost savings and enhanced patient experiences could be anticipated
by encouraging General Practitioners to subsequently refer patients
wishing for a curative strategy directly to Electrophysiologists for
consideration of an ablation.
Patients affected by SVTs usually experience frustrating recurrent
attendances at Accident and Emergency departments prior to referral to
Electrophysiologists, despite our knowledge that ablations are successful
in 95% at the first procedure. Similarly, many journeys to the AED are
aborted as the symptoms self terminate prior to arrival or have abated by
the time of medical review. Thus frequently ECGs fail to capture their
arrhythmia and clinch the diagnosis, protracting the time to effective
treatment.
The PARA group had a statistically significant greater chance of receiving
a copy of their ECG (85% v 63%, p-value 0.035) and therefore this often
illusive information would have a greater chance of being available for
inclusion in the onward referral to the Cardiologist or
Electrophysiologist.
Partnerships between community and tertiary care services can
expedite and improve arrhythmia care, reducing some of the burden on over
stretched Emergency Departments.
We have read with interest the article written by Emdin et al (1)
using multilevel regression analysis of variance to investigate hospital
performance for heart failure management. We were pleased to note that the
authors apply and refer to our previous methodological work concerning the
use of the Intraclass Correlation (ICC) and Median Odds Ratio (MOR).(2)
However, the authors did not consider a re...
We have read with interest the article written by Emdin et al (1)
using multilevel regression analysis of variance to investigate hospital
performance for heart failure management. We were pleased to note that the
authors apply and refer to our previous methodological work concerning the
use of the Intraclass Correlation (ICC) and Median Odds Ratio (MOR).(2)
However, the authors did not consider a recent paper of ours investigating
survival after heart failure hospitalization and applying a modern
multilevel analytical framework.(3)
Nevertheless, the article by Emdin et al (1) actually applies a
similar way of reasoning that we presented in our previous article.(3) In
this respect, we would like to take this opportunity to comment on their
study.(1)
First, much of variation in performance identified by the authors
could be attributed to the ward rather than to the hospital level since
the ward-level is where the genuine organisational effect could take
place. In our recent study we found that the ward ICC (around 5.3%) was
much larger than the hospital ICC (0.04%).(3)
Second, while the issue of confounding, and hence the need to adjust
for patient case-mix, is a cause of concern in the case of outcome
indicator, it is normally not a concern when it comes to process
indicators (4) and the authors should have discussed this aspect.
Third, the authors used backward stepwise single-level regression to
identify the hospital characteristics that "were significantly associated
with a better performance score". We think this identification should be
based on a priori theory rather than on a posteriori finding of
statistical significance. Besides, the use of single level regression
analysis for this task is unsuitable as it does not consider the intra-
hospital correlation and provides spurious "significant" associations.(2)
Otherwise we agree with Emdin et al(1) methodological approach and
interpretation of the results. However, a reference to our previous
article (3) should have been made.
Kind Regards,
Nermin Ghith, PHD candidate, Research Unit of Chronic Conditions,
Bispebjerg Hospital, Copenhagen.
Prof. Juan Merlo MD, PhD, Head of the Research Unit for Social
Epidemiology, Dept. Clin. Sci.(Malmo), Faculty of Medicine, Lund
University, Sweden
-References
1. Emdin CA, Conrad N, Kiran A, Salimi-Khorshidi G, Woodward M,
Anderson SG, et al. Variation in hospital performance for heart failure
management in the National Heart Failure Audit for England and Wales.
Heart. 2016.
2. Merlo J, Chaix B, Ohlsson H, Beckman A, Johnell K, Hjerpe P, et
al. A brief conceptual tutorial of multilevel analysis in social
epidemiology: using measures of clustering in multilevel logistic
regression to investigate contextual phenomena. Journal of Epidemiology
and Community Health. 2006;60(4):290-7.
3. Ghith N, Wagner P, Fr?lich A, Merlo J. Short Term Survival after
Admission for Heart Failure in Sweden: Applying Multilevel Analyses of
Discriminatory Accuracy to Evaluate Institutional Performance. PLoS ONE.
2016;11(2):e0148187.
4. Rubin HR, Pronovost P, Diette GB. The advantages and disadvantages
of process?based measures of health care quality. International Journal
for Quality in Health Care. 2001;13(6):469-74.
We read the educational review on distinguishing ventricular septal
bulge (VSB) versus hypertrophic cardiomyopathy (HCM) by Canepa et al[1]
with great interest. The authors recognise the increasingly established
role of cardiovascular magnetic resonance (CMR) in the assessment of this
difficult diagnostic dilemma. They describe the gold standard role of CMR
in the quantification of myocardial mass,...
We read the educational review on distinguishing ventricular septal
bulge (VSB) versus hypertrophic cardiomyopathy (HCM) by Canepa et al[1]
with great interest. The authors recognise the increasingly established
role of cardiovascular magnetic resonance (CMR) in the assessment of this
difficult diagnostic dilemma. They describe the gold standard role of CMR
in the quantification of myocardial mass, myocardial fibrosis with late
gadolinium enhancement and the morphological and functional imaging of
mitral valve abnormalities.
T1 mapping with CMR is an emerging clinical biomarker for the
quantification of myocardial disease. The technique is easily measured,
highly reproducible and has recently translated into the clinical
pathway[2]. With the addition of gadolinium based contrast agent the
extracellular volume (ECV) can also be estimated. T1 mapping is clinically
able to identify early phenotypic expression of HCM with both increased
native T1 and higher ECV[3] and has been shown to distinguish between
early phenotypic expression of athlete hearts vs HCM[4]. We would highly
recommend T1 mapping techniques to be performed on all patients undergoing
CMR which will aid the differentiation of VSB vs HCM.
Dr David P. Ripley
Dr Subhi E. Akleh
Dr Alison F. Lee
References:
1. Canepa M, Pozios I, Vianello PF, et al. Distinguishing ventricular
septal bulge versus hypertrophic cardiomyopathy in the elderly. Heart
2016;102(14):1087-94.
2. Sado DM, White SK, Piechnik SK, et al. Identification and assessment of
Anderson-Fabry disease by cardiovascular magnetic resonance noncontrast
myocardial T1 mapping. Circ Cardiovasc Imaging 2013;6(3):392-8.
3. Puntmann VO, Voigt T, Chen Z, et al. Native T1 mapping in
differentiation of normal myocardium from diffuse disease in hypertrophic
and dilated cardiomyopathy. JACC Cardiovasc Imaging 2013;6(4):475-84.
4. Swoboda PP, McDiarmid AK, Erhayiem B, et al. Assessing Myocardial
Extracellular Volume by T1 Mapping to Distinguish Hypertrophic
Cardiomyopathy From Athlete's Heart. J Am Coll Cardiol 2016;67(18):2189-
90.
We read with great interest the elegant work of Kasula et al.
recently published on Heart [1]. The Authors showed that fractional flow
reserve (FFR) may be an effective tool to discriminate the long-term
functional outcome after percutaneous coronary intervention (PCI) in
patients with acute coronary syndrome (ACS) [1].
This retrospective study included exclusively ACS patients for whom FFR
evaluation resulted "flow lim...
We read with great interest the elegant work of Kasula et al.
recently published on Heart [1]. The Authors showed that fractional flow
reserve (FFR) may be an effective tool to discriminate the long-term
functional outcome after percutaneous coronary intervention (PCI) in
patients with acute coronary syndrome (ACS) [1].
This retrospective study included exclusively ACS patients for whom FFR
evaluation resulted "flow limiting" (<0.80). All patients were treated
with PCI and the main finding of the study was that FFR value after PCI
was able to discriminate those at higher risk of adverse events. The
Authors concluded that FFR reliably estimates baseline ischemia and its
subsequent reduction post-PCI in patients with ACS. We totally agree with
the significance of the post-PCI FFR assessment, but any comment regarding
the FFR role in the determination of baseline ischemia in ACS patients
should not be taken for granted. Recently, Lee et al. showed that
deferring the treatment of intermediate coronary stenosis based only on
the FFR value, without taking into account the features of coronary
microcirculation, exposes the patient to an increase of adverse events
[2]. Kasula et al. did not report the long-term outcome of patients for
whom FFR result was "no flow limiting" [1]. Accordingly, the conclusion
that "FFR alone may be an invaluable tool in identifying ischemia
producing lesions" is methodologically incorrect. It is well established
that microvascular disfunction may be the result of: i) pre-existing
condition (e.g. microvascular angina), ii) chronic damage (e.g chronic
kidney disease [3]), iii) acute injury (e.g. ACS) or iv) a mix of these.
Therefore, the impairment in the coronary microcirculation may differ
significantly across ACS patients. Some patients show a partial impairment
that allows an effective adenosine action and then a proper FFR
determination. Contrarily, other patients have an extensive damage and FFR
assessment may result misleading. For this reason, in our opinion, it
seems important to focus our attention on ACS patients with "no flow
limiting" FFR assessment. In these cases, the simultaneous assessment of
the coronary microcirculation (e.g. index of microcirculatory resistance)
may help physicians in the decision-making process [4].
References
1. Kasula S, Agarwal SK, Hacioglu Y, et al. Clinical and prognostic
value of poststenting fractional flow reserve in acute coronary syndromes.
Heart. 2016 Aug 4 doi: 10.1136/heartjnl-2016-309422
2. Lee JM, Jung JH, Hwang D, et al. Coronary Flow Reserve and
Microcirculatory Resistance in Patients With Intermediate Coronary
Stenosis. J Am Coll Cardiol. 2016 15;67(10):1158-69
3. Tebaldi M, Biscaglia S, Fineschi M, et al. Fractional flow reserve
evaluation and chronic kidney disease: Analysis from a multicenter Italian
registry (the FREAK study). Catheter Cardiovasc Interv. 2015 Dec 31. doi:
10.1002/ccd.26364
4. Tebaldi M, Biscaglia S, Pecoraro A, et al. Fractional flow reserve
implementation in daily clinical practice: A European survey. Int J
Cardiol. 2016 15;207:206-7.
re Larsson et al, Chocolate consumption and risk of myocardial
infarction: a prospective study and meta-analysis.
The findings of Larsson et al are fascinating and in line with earlier
reports of cardio-protective effects of chocolate consumption, especially
of dark chocolate. Having noticed this in the literature, a colleague and
I were inspired to measure the vitamin D con...
re Larsson et al, Chocolate consumption and risk of myocardial
infarction: a prospective study and meta-analysis.
The findings of Larsson et al are fascinating and in line with earlier
reports of cardio-protective effects of chocolate consumption, especially
of dark chocolate. Having noticed this in the literature, a colleague and
I were inspired to measure the vitamin D content of dark chocolate, since
it was known that curing cocoa beans in the sun was associated with some
fungal growth and that fungi synthesize vitamin D2, as evidenced in
mushrooms, sometimes irradiated with UV for food fortification, and or-ur
pilot study demonstrated remarkably high vitamin D2 content of the various
dark chocolate samples examined. The reported benefits may, therefore, be
due in part to the contained vitamin D2, since similar protection is
currently being found with better vitamin D status, or supplementation. I
would be interested to know, therefore, whether the cohorts reported upon
happen to have measurements of serum 25(OH)D available that could be
assessed for variation with chocolate consumption, and cardiovascular
events, which would be of great interest, either way.
Barbara J Boucher BSc. MD, FRCP. bboucher@doctors.org.uk
References
Chocolate consumption and cardiometabolic disorders: systematic review and
meta-analysis. BMJ 2011;343:d4488; Response, by Timms PM et al
Dietary vitamin D?--a potentially underestimated contributor to
vitamin D nutritional status of adults? Cashman KD, Kinsella M, McNulty
BA, Walton J, Gibney MJ, Flynn A, Kiely M.
Br J Nutr. 2014 Jul 28;112(2):193-202.
The vitamin D activity of cacao shell: The effect of the fermenting
and drying of cacao on the vitamin D potency of cacao shell. II. The
origin of vitamin D in cacao shell. Knapp AW. Biochem J. 1935
Dec;29(12):2728-35.
We would like to thank Dr Cunnington for his interest in our study
and raising some potentially interesting points . We do not have a
breakdown of patients with heart failure ( HF) who had either preserved
(HFpEF) or reduced ejection fraction (HFrEF) . Since beta-blockers only
have a licensed indication for HFrEF on the basis of an echocardiogram ,
we do not believe that this is likely to be a relevant factor withi...
We would like to thank Dr Cunnington for his interest in our study
and raising some potentially interesting points . We do not have a
breakdown of patients with heart failure ( HF) who had either preserved
(HFpEF) or reduced ejection fraction (HFrEF) . Since beta-blockers only
have a licensed indication for HFrEF on the basis of an echocardiogram ,
we do not believe that this is likely to be a relevant factor within our
dataset . The relative prevalence of hypertension within our cohort was
13.3% verses 11.6% ,and for diabetes was 47.4% verses 41.9% respectively
for HF alone verses HF with COPD . Hence the assertion made regarding a
higher putative comorbidity is not supported by the data presented here .
Consequently prescribing of ACEI/ARB in HF with COPD was not confounded
by comorbidity due to treatment for either diabetes or hypertension . The
higher use of ACEI/ARB without beta-blocker in HF with COPD compared to HF
alone is more likely to reflect a reticence of physicians to prescribe add
on therapy with beta-blockers in the presence of airflow obstruction due
to fears of bronchoconstriction . As such we remain confident in the
strength of our conclusions regarding underuse of beta-blockers in HF with
COPD .
The article by Isogai et al. published in Heart (1) discuss the use
of beta-blockers in patients diagnosed and admitted with takotsubo
cardiomyopathy (TTC).
Although no effective guidelines have been prescribed for the
treatment of TTC, it is suggested that a parable could be drawn by
comparing the use of beta-blocker and angiotensin-converting-enzyme
inhibitors in these patients with that of control subjects a...
The article by Isogai et al. published in Heart (1) discuss the use
of beta-blockers in patients diagnosed and admitted with takotsubo
cardiomyopathy (TTC).
Although no effective guidelines have been prescribed for the
treatment of TTC, it is suggested that a parable could be drawn by
comparing the use of beta-blocker and angiotensin-converting-enzyme
inhibitors in these patients with that of control subjects as well as
those suffering from coronary artery disease. Beta-blockers were
considered more likely to be prescribed to control subjects and patients
diagnosed with coronary artery disease than to patients diagnosed with
TTC. Interestingly, TTC and coronary artery disease patients received
angiotensin-converting-enzyme inhibitors / angiotensin receptor blockers
more often than control subjects. The concluding suggestion that the 5
year mortality is similar in both disease groups and higher than control
subjects furthers our debate on this topic. The large International
Takotsubo Registry reported a 5.6% mortality per-patient year (2) and the
use of angiotensin-converting- enzyme inhibitors or angiotensin receptor-
blockers was associated with improved survival rates. However, evidence
establishing a marked survival benefit with beta-blocker use has yet to be
documented. The pathogenesis of TTC is yet to be fully understood. A
popular hypothesis suggests the involvement of a catecholamine-mediated
mechanism. Although all these trials essentially compared the outcome of
TTC with matched cohorts of patients with coronary artery disease, a
relevant suggestion elucidates the role of an inflammatory and energetic-
metabolic pathway as a possible pathophysiological mechanism (3). We
retrospectively described a collective of 114 consecutive patients
diagnosed with TTC between January 2003 and September 2015 at our
institution. Our data showed that the use of beta-blocker was associated
with improved survival rates over mean follow-up of 5 years (4). These
novel findings necessitate the need for a standardized treatment regimen
in TTC patients. We recommend the urgent need of randomized trials to
clearly define treatment approaches and management strategies in takotsubo
cardiomyopathy thus enabling the practice of evidence-based medicine
within guidelines.
References
1. Isogai T, Matsui H, Tanaka H, et al. Early beta-blocker use and in
-hospital mortality in patients with Takotsubo cardiomyopathy. Heart
2016;102(13):1029-1035. 2 . Templin C, Ghadri JR, Diekmann J, et al.
Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N
Engl J Med 2015;373(10):929-938. 3. Eitel I, von Knobelsdorff-Brenkenhoff
F, Bernhardt P, et al. Clinical characteristics and cardiovascular
magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA
2011;306(3):277-286. 4. Becher T, El-Battrawy I, Baumann S, et al.
Characteristics and long- term outcome of right ventricular involvement in
Takotsubo cardiomyopathy. Int J Cardiol 2016;220:371-375.
In this interesting article, Lipworth and colleagues report that beta
-blockers are underused in patients with heart failure (HF) and COPD,
compared to those with HF alone. However, they do not quote the
proportion of "HF" patients within their dataset who had HF with reduced
ejection fraction (HFrEF; left ventricular ejection fraction (LVEF)
<40%) and HF with preserved ejection fraction (HFpEF; LVEF >50%).
This d...
In this interesting article, Lipworth and colleagues report that beta
-blockers are underused in patients with heart failure (HF) and COPD,
compared to those with HF alone. However, they do not quote the
proportion of "HF" patients within their dataset who had HF with reduced
ejection fraction (HFrEF; left ventricular ejection fraction (LVEF)
<40%) and HF with preserved ejection fraction (HFpEF; LVEF >50%).
This distinction is important, as beta-blockers are only recommended in HF
guidelines for patients with HFrEF (1), owing to a lack of trial data to
support their efficacy in patients with HFpEF.
Furthermore, patients with HFpEF tend to have a higher prevalence of
co-morbidities compared to patients with HFrEF, including COPD,
hypertension and diabetes (2). Thus, it is possible that "HF and COPD"
patients in this dataset may have a higher proportion of HFpEF to HFrEF,
in comparison to patients with "HF alone", and the rates of ACE/ARB
prescribing may be increased in this group owing to treatment of
hypertension and diabetes rather than HF. These considerations may
therefore confound the strength of the authors' conclusions regarding
underuse of beta-blockers in patients with HF and COPD.
References
1. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for
the diagnosis and treatment of acute and chronic heart failure. Eur Heart
J 2016; DOI:
10.1093/eurheartj/ehw128.
2. Ather S, Chan W, Bozkurt B et al. Impact of non-cardiac
comorbidities on morbidity and mortality in a predominantly male
population with heart failure and preserved versus reduced ejection
fraction. J Am Coll Cardiol 2012;59:998-1005.
I read the article by Kasula and colleagues with great interest. I firmly believe that this is a novel finding and of great clinical significance (1).
Utility of Fractional flow reserve (FFR) is firmly established in stable coronary artery disease but has been widely debated in patients with acute MI particularly in the culprit vessel (2, 3). FFR measurements require maximal coronary hyperaemia which may be les...
We thank Ripley and colleagues for their interest in our paper and agree that T1 mapping with CMR is an emerging imaging biomarker that is increasingly being investigated for its potential role in hypertrophic cardiomyopathy and cardiac hypertrophy in general. Convincing data have been published concerning hypertensive heart disease(Hinojar et al., 2015), hypertrophic and dilated cardiomyopathy (Puntmann et al., 2013),...
Honarbakhsh et al should be congratulated upon their innovative research in improving the care for patients with arrhythmias. Their paper not only demonstrates an effective community treatment strategy but importantly is cost effective during the current austerity. Potential further cost savings and enhanced patient experiences could be anticipated by encouraging General Practitioners to subsequently refer patients wishi...
Dear Editor,
We have read with interest the article written by Emdin et al (1) using multilevel regression analysis of variance to investigate hospital performance for heart failure management. We were pleased to note that the authors apply and refer to our previous methodological work concerning the use of the Intraclass Correlation (ICC) and Median Odds Ratio (MOR).(2) However, the authors did not consider a re...
Dear Editor,
We read the educational review on distinguishing ventricular septal bulge (VSB) versus hypertrophic cardiomyopathy (HCM) by Canepa et al[1] with great interest. The authors recognise the increasingly established role of cardiovascular magnetic resonance (CMR) in the assessment of this difficult diagnostic dilemma. They describe the gold standard role of CMR in the quantification of myocardial mass,...
We read with great interest the elegant work of Kasula et al. recently published on Heart [1]. The Authors showed that fractional flow reserve (FFR) may be an effective tool to discriminate the long-term functional outcome after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) [1]. This retrospective study included exclusively ACS patients for whom FFR evaluation resulted "flow lim...
Comment to the Heart Journal website
re Larsson et al, Chocolate consumption and risk of myocardial infarction: a prospective study and meta-analysis. The findings of Larsson et al are fascinating and in line with earlier reports of cardio-protective effects of chocolate consumption, especially of dark chocolate. Having noticed this in the literature, a colleague and I were inspired to measure the vitamin D con...
We would like to thank Dr Cunnington for his interest in our study and raising some potentially interesting points . We do not have a breakdown of patients with heart failure ( HF) who had either preserved (HFpEF) or reduced ejection fraction (HFrEF) . Since beta-blockers only have a licensed indication for HFrEF on the basis of an echocardiogram , we do not believe that this is likely to be a relevant factor withi...
The article by Isogai et al. published in Heart (1) discuss the use of beta-blockers in patients diagnosed and admitted with takotsubo cardiomyopathy (TTC).
Although no effective guidelines have been prescribed for the treatment of TTC, it is suggested that a parable could be drawn by comparing the use of beta-blocker and angiotensin-converting-enzyme inhibitors in these patients with that of control subjects a...
In this interesting article, Lipworth and colleagues report that beta -blockers are underused in patients with heart failure (HF) and COPD, compared to those with HF alone. However, they do not quote the proportion of "HF" patients within their dataset who had HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction (LVEF) <40%) and HF with preserved ejection fraction (HFpEF; LVEF >50%). This d...
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