eLetters

82 e-Letters

published between 2018 and 2021

  • ACUTE OR PRE-EXISTING CORONARY SLOW FLOW IN TAKOTSUBO CARDIOMYOPATHY: DOES IT MATTER ?

    ACUTE OR PRE-EXISTING CORONARY SLOW FLOW IN TAKOTSUBO CARDIOMYOPATHY: DOES IT MATTER ?

    Kenan YALTA, MD a
    Tulin YALTA, MD b
    Muhammet GURDOGAN, MD a

    aTrakya University, Cardiology Department, Edirne, TURKEY
    b Trakya University, Pathology Department, Edirne, TURKEY
    Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
    Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 0090505657985

    In the setting of takotsubo cardiomyopathy (TTC), coronary microvascular dysfunction has been mostly considered as a causative factor (1,2). In their recently published article (1), Montone RA et al have demonstrated, for the first time, the prognostic value of coronary slow flow (CSF) phenomenon in TTC patients. Of note, as we previously discussed, on a theoretical basis, the particular prognostic value of CSF phenomenon in these patients (3), we feel now pleased to notice that this theory has been fully confirmed by a well-designed study (1). Nevertheless, we would like to make a few comments on this issue:
    Firstly; temporal emergence of CSF phenomenon might possibly matter in TTC as well. Accordingly; an acutely evolving CSF pattern (due to severe adrenergic discharge (1)) as compared with a sole pre-existing one (emerging long before the index TTC as part of generalized...

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  • Red flags as an adjunct to clinical decision rules in aortic dissection

    The clinical presentation which simulates ST-segment elevation myocardial infarction(STEMI)(1) is one of the most deceptive manifestations of dissecting aortic aneurysm(DAA), deserving detailed analysis notwithstanding its infrequent(2)(3)(4) occurrence. In Zhu et al DAA was prevalent in only 0.5% of 1576 subjects with suspected STEMI(2). Conversely, Kosuge et al documented a 4%(9 patients) prevalence of ST segment elevation among 233 subjects with confirmed DAA(3). In Hirata et al ST segment elevation was prevalent in 8.2% of 159 subjects with type A aortic dissection(4). When ST segment elevation occurs as a manifestation of DAA, there is a high prevalence of involvement of the inferior leads, exemplified by 6 of the 9 patients in Kosuge et al(3)., and seven of the 13 cases in Hirata et al(4)., arguably because type A aortic dissection is more likely to compromise the ostium of the right coronary artery than the ostium of the left coronary artery(5). In view of the life-threatening nature of DAA clinicians should not rely only on clinical decision rules to raise the index of suspicion. The rationale for a more open-minded approach is that clinical decision rules such as the AAD risk score tend to emphasise typical symptoms, such as the "tearing" character of the back pain(1), almost to the total exclusion of less typical symptoms such as nonspecific back pain, the latter typically radiating from a retrosternal chest pain. For example, a literat...

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  • Low thromboembolic risk does not necessarily rule out risk of complications of undiagnosed coexisting high-grade carotid artery stenosis

    Regardless of the conclusions of the authors regrading thromboembolic risk(1), atrial fibrillation patients with CHA2DS2 Vasc score of zero or 1 cannot be pronounced to be at truly low risk of stroke unless coexisting high-grade carotid artery stenosis(CAS) has been ruled out. According to one study, among patients with nonvalvular atrial fibrillation(NVAF) who are older than 70 years, the frequency of high grade carotid stenosis(stenosis of 50% or more) is 12% in men and 11% in women(2). High-grade CAS, in turn, is an important risk factor for stroke. Potentially modifiable risk factors for CAS-related stroke include smoking, hypertension, diabetes mellitus, and hyperlipidaemia(3). According to an observational study of subjects with asymptomatic high-grade CAS, progression of the severity of CAS can be mitigated by optimally controlling those risk factors(4). Accordingly, the management of NVAF subjects with CHA2DS2 Vasc score of zero or 1 should include screening for CAS, and optimal control of hypertension, diabetes, and low density lipoprotein levels, over and above cessation of smoking, in the event of a diagnosis of coexisting high-grade CAS. There is also a diagnostic advantage from awareness of the coexistence of high-grade CAS in a patients with zero or 1 CHA2DS2 Vasc score. If such a patient experiences an ischaemic stroke characterised by a cerebral infarct ipsilateral to the high-grade CAS the appropriate management would be prompt prescription o...

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  • APICAL ANEURYSM ? OR TRANSIENT APICAL BALLOONING ? : A POTENTIAL DILEMMA IN RISK-STRATIFICATION OF HYPERTROPHIC CARDIOMYOPATHY

    APICAL ANEURYSM ? OR TRANSIENT APICAL BALLOONING ? : A POTENTIAL DILEMMA IN RISK-STRATIFICATION OF HYPERTROPHIC CARDIOMYOPATHY

    Kenan YALTA, MD a
    Muhammet GURDOGAN, MD a
    Orkide PALABIYIK, MD b

    a,Trakya University, Cardiology Department, Edirne, TURKEY
    b Trakya University, Department of Biophysics, Edirne, TURKEY
    Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
    Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 00905056579856

    Left ventricular apical aneurysm (LVAA) formation in the setting of hypertrophic cardiomyopathy (HCM) usually appears to be associated with a significant mid-ventricular obstruction, and is potentially associated with adverse cardiovascular events (1). In their recently published article (1), Ramchand J et al have suggested LVAA as a major risk marker in this setting. Though we fully agree with the authors on this point, we would like to draw attention to certain other conditions including transient LV apical ballooning that might strongly mimick LVAA leading to a potential misdiagnosis in patients with HCM:
    Takotsubo cardiomyopathy (TTC) presenting with a transient apical ballooning pattern has been recently suggested to have a pure mechanical basis in certain patients with pre-existing structural heart diseas...

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  • CHADS2 score and prediction of stroke in heart failure

    Given the fact that some of the patients studied by Chou et al were characterised by the coexistence of , at least, four CHADS2 parameters, namely, Congestive heart failure, Hypertension, Age 75 or more, and Diabetes(1), it is to be expected that some of those patients will have stenotic cerebrovascular disease(both intracranial and extracranial)(2). In the latter study of 780 subjects presenting with stroke in the presence of nonvalvular atrial fibrillation(NVAF), concomitant cerebrovascular stenosis of 50% or more was identified in 231 patients. Multivariate analyses showed that CHADS2 score was an independent predictor of concomitant cerebral atherosclerosis(Odds Ratio 3.121; 95% Confidence Interval 1.770 to 5.504), and also a predictor of the presence of proximal stenosis at the symptomatic artery(OR, 3.043; 95% CI 1.458 to 6.350)(2).
    When the CHADS2 score is associated with coronary heart disease(CHD) , as might have been the case in 1475 of the heart failure patients studied by Chou et al(1), CHADS2 predicts stroke in the total absence of NVAF(3). In the latter study, over a period of 5821 person-years of follow up, 40 out of 916 non anticoagulated patients with stable CHD and no NVAF suffered an ischaemic stroke/transient ischaemic attack. Compared with those with low(0-1) CHADS2 scores, those with progressively higher CHADS2 scores had a stepwise significant increase in rates of stroke/TIA(3). This increase in stroke rate might, arguably, hav...

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  • A minor correction to the variant nomenclature

    As a physician dealing with patients with confirmed or suspected Fabry disease, I've read with great interest this editorial. This is a very thought-provoking article, which introduces the process of reclassification of a prevalent variant in the GLA gene associated with the cardiac variant of Fabry disease. I would like to make only a minor correction regarding the nomenclature of the variant mentioned. As written in the article of Valtola et al, the referred variant is c.427G> A and not c.472G> A¹ (transcript NM_000169.2).

    1. Valtola K, Nino-Quintero J, Hedman M, et al. Cardiomyopathy associated with the Ala143Thr variant of the α-galactosidase A gene. Heart 2020;:heartjnl-2019-315933. doi:10.1136/heartjnl-2019-315933

  • Problems with the clinical director role

    I read with interest the super article by Chris Steadman regarding being a clinical director in the NHS. I would add to this article that a particular problem has now become grossly apparent with taking on such a role which is the amount of pension tax that many will find they have to pay in taking such a role on. Previously, leadership and management roles have often attracted a rise in pensionable salary, which was a clear incentive to take them - as per the article, they clearly result in alot of work to the individual and so should be rewarded for this. However with the pension taper which started in 2016 and a low annual allowance, this creates a major problem, with many stories of doctors taking on such roles and receiving a large tax bill as result. How big a bill this may or may not be will depend on the personal circumstances of the individual and the amount of extra pensionable salary the individual trust is offering. For example, under current rules, a £10,000 increase in pensionable pay would result in me doing such a job at a big financial loss in my first year of doing it! Unless the UK government change the pension tax rules, it has created major disincentive for doctors to take on such roles.

  • LATE CORONARY ANEURYSM FORMATION IN KAWASAKI DISEASE: A SUBTLE PHENOMENON WITH POTENTIAL IMPLICATIONS

    LATE CORONARY ANEURYSM FORMATION IN KAWASAKI DISEASE: A SUBTLE PHENOMENON WITH POTENTIAL IMPLICATIONS

    Kenan YALTA, MD
    Muhammet GURDOGAN, MD
    Gokay TAYLAN, MD

    a,Trakya University, Cardiology Department, Edirne, TURKEY

    Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
    Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 00905056579856

    In clinical practice, coronary artery aneurysms (CAAs) in the setting of Kawasaki disease (KD) mostly evolve in the earlier stages, and generally reach their maximum size by 6 weeks after disease onset (1). Importantly, they are mostly encountered in untreated cases, and are strongly associated with the disease severity (and in particular; the degree of acute necrotizing vasculitis) (1). In their recently published enlightening report (2), Brogan P have discussed long-term management of KD patients with a particular emphasis on CAAs in this setting (2). However, we would like to comment on a specific phenomenon, namely ‘late CAA’ formation that might emerge even several months to years after the index KD:
    Firstly, late CAAs were previously defined as new CAAs emerging at the same location of a previously regressed CAA, and were attributed to hemodynamic and residual pathological abnormalities along the arterial wal...

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  • Lifestyle modifications and their relationship with myocardial stiffness, atrial stiffness and atrial fibrosis

    Some of the risk factors for atrial fibrillation(AF) mentioned by the authors, such as hypertension, diabetes, sleep apnoea, older age, and lack of exercise, respectively(1), are also risk factors for myocardial stiffness(2)(3)(4)(5)(6). Myocardial stiffness, in turn, is a risk factor for atrial remodeling in the canine heart(7), and a parameter associated with paroxysmal AF in structurally normal human hearts(8). What is more, exercise has been shown to be capable of reversing myocardial stiffness, both in animals(9), and in human subjects(10).
    In the more specific context of left atrial stiffness, obesity has emerged as a risk factor for left atrial stiffness(11)(12). Among patients with obesity, hypertension, and diabetes, respectively, a link has been hypothesised between the twin entities of left ventricular stiffness and depressed atrial compliance, on the one hand, and the development of myocardial fibrosis.(12) . The authors of the latter hypothesis proposed that obesity, hypertension and diabetes generated a systemic proinflammatory state which culminated in the emergence of the coexistence of stiff cardiomyocytes and interstitial fibrosis(12). Furthermore, in a study where the assumption was made that the existence of low voltage areas was a surrogate for left atrial fibrosis, the presence of a left atrial low voltage burden exceeding 10% was shown to be associated with significantly(p < 0.0001) higher left atrial stiffness index((LASI)(13)....

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  • Biomarkers to enhance prognosis assessment in transcatheter aortic valve replacement: usefulness of CA125

    We have read with interest the review published by Goldsweig et al of predictors of readmission after transcatheter aortic valve replacement (TAVR) (1). We agree that identifying factors linked with a higher rate of readmission is of utmost importance. In this review, several clinical and procedural factors have been identified as predictors of adverse events after TAVR. However, the potential value of biomarkers for risk stratification in this setting has also been suggested in the literature. Several biomarkers have been tested for prognostic purposes; among them, we would like to highlight the role of Carbohydrate Antigen 125 (CA125). CA125 is a glycoprotein released by the mesothelial cells in response to increased hydrostatic pressures and/or inflammatory stimuli (2). Their levels are elevated in up to two-thirds of decompensated patients and correlated to parameters of clinical and echocardiographic congestion including pulmonary artery and right atrial pressures. Interestingly, its changes after discharge are strongly associated with the risk of adverse clinical events (2). In the setting of TAVR, baseline (pre-implant) CA125 levels were independent predictors of death and MACE (death, myocardial infarction, stroke, and readmission), even after adjusting for well-established prognostic factors, in an observational study (3). Interestingly, increases of CA125 at any time in the follow-up after TAVR were independently related to events, suggesting its usefulness not...

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