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We read with interest this manuscript which demonstrated in a large
clinical registry that patients with chronic kidney disease with
indications for anticoagulation were often treated sub-therapeutically
(1). A more aggressive approach was therefore advocated.
We would like to point out that, while this study should be commended
for including a large number of patients, it did not show data on the key
clinical...
We read with interest this manuscript which demonstrated in a large
clinical registry that patients with chronic kidney disease with
indications for anticoagulation were often treated sub-therapeutically
(1). A more aggressive approach was therefore advocated.
We would like to point out that, while this study should be commended
for including a large number of patients, it did not show data on the key
clinical outcomes of stroke or bleeding. We feel, therefore, that a clear
association cannot be made between low time in the therapeutic range (TTR)
and any negative clinic outcome. In fact, paradoxically, our experience
from a large tertiary cardiac and renal service differs. We agree with the
authors that haemodialysis patients often have a suboptimal TTR, but we
believe there is no convincing data implying that increased time spent in
therapeutic range is beneficial in preventing embolic or thrombotic events
(2).
In addition, there is substantial evidence that haemodialysis
patients are at significantly increased risk of major bleeding events,
contributed to by uraemic platelet dysfunction, hypergastrinaemia and
anticoagulation required for the extracorporeal circuit. This risk of
major bleeding (bleeds into a critical organ, requiring transfusion or
admission, or fatal) is increased compared with non-dialysis patients, and
this risk has been shown to increase with the addition of antiplatelet
treatment or oral anticoagulation (3).
We would, therefore, advocate a cautious approach to anticoagulation
in patients with dialysis-requiring end-stage kidney disease. Our policy
is not to anticoagulate these patients in light of the fact that the
significant bleeding risk per annum in our haemodialysis patients without
addition anticoagulation is already nearly 4% (4). We believe there is an
urgent need for clinical outcome data in order to better inform our
clinical decision making in this complex patient group.
References.
References.
1. Yang et al. Heart online. 2016. doi:10.1136/heartjnl-2016-309266.
2. Chen et al. Circulation. 2016;133:265-272.
3. Holden et al. CJASN. 2008;3:105-110.
4. Nadarajah et al. Clin Nephrology 2015;85(5):274-9.
I read with great interest the article by Morris et al entitled,
"Marginal role for 53 common genetic variants in cardiovascular disease
prediction" (1). The article analyzed a large sample of 11, 851
individuals from 7 prospective studies aimed at primary prevention of
fatal or non-fatal coronary heart disease (CHD) or stroke.
The study incorporated susceptibility variants for CHD and str...
I read with great interest the article by Morris et al entitled,
"Marginal role for 53 common genetic variants in cardiovascular disease
prediction" (1). The article analyzed a large sample of 11, 851
individuals from 7 prospective studies aimed at primary prevention of
fatal or non-fatal coronary heart disease (CHD) or stroke.
The study incorporated susceptibility variants for CHD and stroke
into a genetic risk score (GRS), to match the two conditions predicted by
a conventional risk score QRISK-2. Results for population-wide utility of
the GRS, and estimates from a sequential screening strategy proposed for
individuals at intermediate risk, were provided. The study extrapolated
that 462 intermediate-risk individuals would need to be screened in order
to prevent one coronary heart disease or stroke event in 10 years.
Based on these results, a GRS could become a novel method for
determining which intermediate-risk individuals should be managed
aggressively, if reclassified to high-risk. However, before these results
are adopted in clinical practice, the following should be considered.
First, the extrapolated estimates should be confirmed prospectively.
Second, the 53 variants include 46 for CHD and 7 for stroke. The CHD
variants are not necessarily found to associate with stroke, and vice
versa. This may limit predictions for each disorder. Third, 46 CHD
variants account for 10% of heritability, and do not capture the entire
contribution of genetics estimated at 40-60% (3). Fourth, the GRS included
29 variants unique for CHD, as well as 17 additional variants that also
associate with CHD risk factors, such as cholesterol, blood pressure, and
diabetes (3); these risk factors are already accounted for in QRISK2 and
are not providing independent information. Fifth, the GRS did not
incorporate 10 additional variants recently discovered (4).
Reclassification and discrimination analyses should be redone with only 29
variants (then adding in the 10 new variants) in population-wide analysis
and for intermediate-risk individuals. Finally, a weak effect on mortality
was reported. This is likely due to the GRS being developed using case-
control prevalence and not incidence.
Overall, there is still work to be done before these excellent
results can be implemented.
References
1. Morris RW, Cooper JA, Shah T, Wong A, Drenos F, Engmann J, et al.
Marginal role for 53 common genetic variants in cardiovascular disease
prediction. Heart. 2016 Jun 30. 2. Kullo IJ, Jouni H, Austin EE, Brown SA,
Kruisselbrink TM, Isseh IN, et al. Incorporating a Genetic Risk Score Into
Coronary Heart Disease Risk Estimates: Effect on Low-Density Lipoprotein
Cholesterol Levels (the MI- GENES Clinical Trial). Circulation. 2016
Mar;133(12):1181-8. 3. Deloukas P, Kanoni S, Willenborg C, Farrall M,
Assimes TL, Thompson JR, et al. Large-scale association analysis
identifies new risk loci for coronary artery disease. Nat Genet. 2013
Jan;45(1):25-33. 4. Nikpay M, Goel A, Won HH, Hall LM, Willenborg C,
Kanoni S, et al. A comprehensive 1,000 Genomes-based genome-wide
association meta-analysis of coronary artery disease. Nat Genet. 2015
Oct;47(10):1121-30.
We read with great interest the manuscript by Faden et al. (1)
entitled "A nationwide evaluation of spontaneous coronary artery
dissection in pregnancy and the puerperium" when it was published online
July 13. Using the Healthcare Cost and Utilization Project national
database, the authors evaluated over 4 million pregnancy-related
discharges, looking at the prevalence and outcomes of pregnancy-associated
spontaneous cor...
We read with great interest the manuscript by Faden et al. (1)
entitled "A nationwide evaluation of spontaneous coronary artery
dissection in pregnancy and the puerperium" when it was published online
July 13. Using the Healthcare Cost and Utilization Project national
database, the authors evaluated over 4 million pregnancy-related
discharges, looking at the prevalence and outcomes of pregnancy-associated
spontaneous coronary artery dissection (P-SCAD). By applying the
International Classification of Diseases, 9th Revision (ICD-9) 79 cases of
P-SCAD were identified, resulting in a prevalence of 1.81 per 100,000
pregnancies. Although this study stands out as the largest cohort thus far
assessing P-SCAD, a few shortcomings should be highlighted. First, the
methodology for P-SCAD search and identification included the ICD-9
medical code 412.12 represents a general definition of coronary artery
dissection; there is no specific classification for SCAD in either the ICD
-9 or in the recent ICD-10-CM (diagnosis code I25.42). Therefore, the 79
cases identified by the investigators may have included coronary artery
dissections arising from other causes including atherosclerosis. The
genuine classification of SCAD should be non-atherosclerotic. In addition,
other ambiguous findings by angiography, such as thrombus, may also mimic
SCAD (2). Prior study evaluating pregnant and postpartum women with
myocardial infarction showed that its pathophysiology includes SCAD in 43%
of cases, atherosclerosis in 27%, intracoronary thrombus in 17%, and
normal coronary arteries in 11% (3). Second, despite its well-known
limitations, invasive coronary angiography is still the main tool for
recognizing this condition; other intravascular imaging such as
intravascular ultrasound and optical coherence tomography have been
recently used to enhanced its diagnostic accuracy. Of note, the
pathognomonic appearance of SCAD on angiography--contrast dye staining of
arterial wall with multiple radiolucent lumen--is less prevalent among all
the findings, making the diagnostic ability of invasive angiography
limited and challenging (5). In the present study by Faden et al. there is
no mention about the angiographic findings of those patients, making the
definite and final diagnosis of P-SCAD debatable. Had the authors
reassessed all coronary invasive angiography, the ability to definitively
diagnosis SCDA would have been improved; indeed, 10% of cases did not
undergo invasive angiography, so the final diagnosis P-SCDA could only be
extracted from the data set alone. Finally, when assessing the risk
factors for P-SCAD, the authors demonstrated that chronic hypertension and
lipid profile abnormalities were highly prevalent in relation to SCAD,
which is in disagreement with prior studies showing that most patients had
no risk factors for coronary artery disease (4). Likewise, a high rate of
prior coronary angioplasty and, specifically, coronary artery bypass graft
surgery (34%) in this cohort may suggest the inclusion of patients with
coronary atherosclerosis.
References:
1. Faden MS, Bottega N, Benjamin A, Brown RN. A nationwide evaluation
of spontaneous coronary artery dissection in pregnancy and the puerperium.
Heart 2016;0:1-6. doi:10.1136/heartjnl-2016-309403.
2. Cade JR, Abizaid A, Caixeta A. Organized Thrombus Mimicking
Spontaneous Coronary Artery Dissection. JACC Cardiovasc Interv. 2014;
7(12):1458.
3. Elkayam U, Jalnapurkar S, Barakkat MN, Khatri N, Kealey AJ, Mehra
A, et al. Pregnancy-associated acute myocardial infarction: a review of
contemporary experience in 150 cases between 2006 and 2011. Circulation.
2014;129(16):1695-702.
4. Cade JR, Szarf G, de Siqueira ME, Chaves A, Andrea JC, Figueira
HR, et al. Pregnancy-associated spontaneous coronary artery dissection:
insights from a case series of 13 patients. Eur Heart J Cardiovasc
Imaging. 2016 [Epud ahead of print].
5. Saw J. Coronary angiogram classification of spontaneous coronary
artery dissection. Catheter Cardiovasc Interv. 2014;84(7):1115-22.
On reading the review on coronary revascularisation in the elderly by
Cockburn et al (1) I must agree that more trials are needed to focus on
the benefit of PCI in elderly populations.
When assessing these patients, clinicians should consider the impact
of symptom relief versus procedural risk. If a patient is experiencing
recurrent and debilitating chest pain requiring frequent hospital
a...
On reading the review on coronary revascularisation in the elderly by
Cockburn et al (1) I must agree that more trials are needed to focus on
the benefit of PCI in elderly populations.
When assessing these patients, clinicians should consider the impact
of symptom relief versus procedural risk. If a patient is experiencing
recurrent and debilitating chest pain requiring frequent hospital
admission then the risks of PCI, despite multiple comorbidities, could
easily be rationalised when the benefit to the patient is clear. In such
patients this "palliative PCI" approach, aiming to improve quality of life
but not necessarily prolong it, should be at the forefront of the
clinicians mind. Each patient should be assessed with consideration of the
benefits to the individual and with a clear understanding of the values of
the patient.
An interesting additional consideration not mentioned in the review
is the potential benefit of PCI in elderly patients in terms of cost to
hospitals. Although complications and poor outcomes may be increased in
this population, the burden of elderly patients deemed unfit for PCI
presenting with recurrent admissions due to chest pain must be taken into
account. I noted that in a paragraph on future research the authors
mentioned further trials of PCI in elderly patients that looked at
myocardial infarction and mortality as their primary outcomes. This may no
longer be as relevant in elderly patients where quality of life is more
important than quantity. A trial involving predominantly elderly patients
assessing quality of life both before and after PCI as the primary outcome
could be useful.
References:
1.Cockburn J, Hildick-Smith D, Trivedi U, de Belder A. Heart 2016;0:1-9.
doi:10.1136/heartjnl-2015-308999
Nehme and coworkers tested out the effect of air versus oxygen on
myocardial injury in ST-elevation myocardial infarction (STEMI).1 When
administered in the first 12 hours after STEMI oxygen was associated with
a dose-dependent increase in troponin and creatine kinase. In 2015 the
same group of investigators published a study in Circulation showing that
air instead of oxygen supplementation in STEMI led to improved outco...
Nehme and coworkers tested out the effect of air versus oxygen on
myocardial injury in ST-elevation myocardial infarction (STEMI).1 When
administered in the first 12 hours after STEMI oxygen was associated with
a dose-dependent increase in troponin and creatine kinase. In 2015 the
same group of investigators published a study in Circulation showing that
air instead of oxygen supplementation in STEMI led to improved outcome.
The conclusions of these two studies seem to be that supplemental oxygen
therapy in patients with STEMI but without hypoxia may increase early
myocardial injury and is associated with larger myocardial infarct size
assessed at 6 months.
In 1980 we were the first to suggest that due to production of oxygen free
radicals air could be better than oxygen supplementation during
reoxygenation.2 During the next 30 years we performed a series of studies
demonstrating that air compared to 100% oxygen caused significantly less
oxidative stress and less myocardial and kidney injury, and resulted in
higher survival rates in newborn infants needing resuscitation at birth.
In animal studies we demonstrated that 100% oxygen induced injury or
inflammation of several organs as the brain and heart.3,4 We also have
worked intensively with the basic mechanisms explaining such findings.
Based on these and other studies international recommendations for newborn
resuscitation were changed in 2010 from starting with 100% oxygen to air.
We have always been surprised that colleagues in adult medicine
apparently have not been aware of these results. The mechanisms of
reoxygenation injury are probably similar in adults as in newborn. We are
therefore delighted that Nehme et al1 and Stub et al performed their
studies, although 30 years after we challenged the present oxygen dogma.
It is therefore with surprise we don't find any references in their
publications 1 to our basic experimental and clinical studies. Thirty
years of extensive research with internationally acknowledged
translational results have not been credited by the authors, reviewers as
well as the editors responsible for publishing these results.
We truly believe that now is the time when adult medicine should recognize
progress in neonatal medicine which has helped unravel pathophysiological
mechanisms that have improved the survival and quality of life of human
beings independently of their age.
References
1. Nehme Z, Stub D, Bernard S, et al. Effect of supplemental oxygen
exposure on myocardial injury in ST- elevation myocardial infarction.
Heart 2016;102: 444-51
2. Saugstad OD, Aasen AO. Plasma hypoxanthine concentrations in pigs. A
prognostic aid in hypoxia. Eur Surg Res 1980;12:123-9.
3. Saugstad OD, Ramji S, Vento M. Resuscitation of depressed newborn
infants with ambient air or pure oxygen: a meta-analysis. Biol Neonate
2005;87:27-34
4. Saugstad OD. Resuscitation of newborn infants: from oxygen to room air.
Lancet 2010;376:1970-1
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 interest this manuscript which demonstrated in a large clinical registry that patients with chronic kidney disease with indications for anticoagulation were often treated sub-therapeutically (1). A more aggressive approach was therefore advocated.
We would like to point out that, while this study should be commended for including a large number of patients, it did not show data on the key clinical...
Dear Editor,
I read with great interest the article by Morris et al entitled, "Marginal role for 53 common genetic variants in cardiovascular disease prediction" (1). The article analyzed a large sample of 11, 851 individuals from 7 prospective studies aimed at primary prevention of fatal or non-fatal coronary heart disease (CHD) or stroke.
The study incorporated susceptibility variants for CHD and str...
We read with great interest the manuscript by Faden et al. (1) entitled "A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium" when it was published online July 13. Using the Healthcare Cost and Utilization Project national database, the authors evaluated over 4 million pregnancy-related discharges, looking at the prevalence and outcomes of pregnancy-associated spontaneous cor...
Dear Editor
On reading the review on coronary revascularisation in the elderly by Cockburn et al (1) I must agree that more trials are needed to focus on the benefit of PCI in elderly populations.
When assessing these patients, clinicians should consider the impact of symptom relief versus procedural risk. If a patient is experiencing recurrent and debilitating chest pain requiring frequent hospital a...
Nehme and coworkers tested out the effect of air versus oxygen on myocardial injury in ST-elevation myocardial infarction (STEMI).1 When administered in the first 12 hours after STEMI oxygen was associated with a dose-dependent increase in troponin and creatine kinase. In 2015 the same group of investigators published a study in Circulation showing that air instead of oxygen supplementation in STEMI led to improved outco...
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,...
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