Editor, We agree with Lavie et al that the current standard model of delivering cardiac rehabilitation (CR) predominantly in hospital or centre based facilities has reached saturation and we should be looking at offering alternatives which could improve the global suboptimal rates of participation in CR. [1] Uptake of CR in heart failure remains particularly poor with rates of less than 20% in Europe. [2].
Clinicians and commissioners should consider implementing the findings of a UK based multicentre trial on home-based CR [3] which responds to the updated 2018 NICE guidance recommendation that adults with heart failure are offered a “..personalised, exercise-based CR programme – in a format and setting (at home, in the community or in the hospital) that is easily accessible” [https://www.nice.org.uk/guidance/ng106/chapter/Recommendations#cardiac-r... ]
We believe REACH HF to be the largest randomised trial of home based CR (co-developed by clinicians, academics, caregivers and patients) in heart failure with reduced ejection fraction and it provides important new evidence for a novel home-based CR programme in terms of benefit to patients and their caregivers. [3]
The results of the REACH HF trial show that it is possible to significantly improve patients’ health related quality of life and that the intervention has a cost of £418 per patient, within th...
Editor, We agree with Lavie et al that the current standard model of delivering cardiac rehabilitation (CR) predominantly in hospital or centre based facilities has reached saturation and we should be looking at offering alternatives which could improve the global suboptimal rates of participation in CR. [1] Uptake of CR in heart failure remains particularly poor with rates of less than 20% in Europe. [2].
Clinicians and commissioners should consider implementing the findings of a UK based multicentre trial on home-based CR [3] which responds to the updated 2018 NICE guidance recommendation that adults with heart failure are offered a “..personalised, exercise-based CR programme – in a format and setting (at home, in the community or in the hospital) that is easily accessible” [https://www.nice.org.uk/guidance/ng106/chapter/Recommendations#cardiac-r... ]
We believe REACH HF to be the largest randomised trial of home based CR (co-developed by clinicians, academics, caregivers and patients) in heart failure with reduced ejection fraction and it provides important new evidence for a novel home-based CR programme in terms of benefit to patients and their caregivers. [3]
The results of the REACH HF trial show that it is possible to significantly improve patients’ health related quality of life and that the intervention has a cost of £418 per patient, within the current NHS tariff of £477 for CR. [3]
Importantly, we have recently also demonstrated the long term cost effectiveness of home-based CR programmes like REACH HF in a cost effectiveness modelling analysis [4].This analysis shows that REACH-HF has an average cost per quality adjusted life year gained (QALY) of £1,720 with a 78% probability of being cost effective at the UK accepted threshold of £20,000/QALY gained. [4]
Home based CR programmes allow the delivery of care closer to where people need it and could also help towards achieving the ambitious target of offering CR to 85% of eligible patients set in the recently released NHS long-term plan (https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progres...)
We believe that programmes, such as REACH-HF, can provide an affordable, cost effective CR intervention for service commissioners which can offset the current inequity in access to rehabilitation by patients with heart failure both in the UK and elsewhere.
Authors: Hasnain M Dalal (a, b), Rod S Taylor (a, c), Colin Greaves (d) and Patrick Doherty (e)
Affiliations:(a) Institute of Health Research, University of Exeter Medical School, Exeter, UK (b) Royal Cornwall Hospitals NHS Trust, Truro, UK (c) Institute of Health and Well Being, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow and Institute of Health Research, University of Exeter Medical School, Exeter UK (d) School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, UK (e) Department of Health Sciences, University of York, York, UK
References
1. Lavie CJ, Kachur S and Milani R V. Making cardiac rehabilitation more available and affordable. Heart 2019; 105: 94–95. doi:10.1136/heartjnl-2018-313762
2. Bjarnason-Wehrens B, McGee H, Zwisler AD, Piepoli M, et al. Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey. Eur J Cardiovasc Prev Rehabil 2010;17:410-8. doi.org/10.1097/HJR.0b013e328334f42
3. Dalal HM, Taylor RS, Jolly K, et al. The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial. Eur J Prev Cardiol, Epub ahead of print 10 October 2018. doi.org/ 10.1177/2047487318806358.
4. Taylor RS, Sadler S, Dalal HM et al "The cost effectiveness of REACH-HF and home-based cardiac rehabilitation in the treatment of heart failure with reduced ejection fraction: a decision model-based analysis" Eur J Prev Cardiol, 2019 10.1177/2047487319833507 [In press, accepted 5.2.2019]
Given the fact that the entire purpose of blood pressure measurement is to identify the cut-off level of blood pressure that increases the risk for cerebral, cardiac, and renal events, and that "brachial blood pressure can be an imperfect surrogate for central aortic pressure"(1), the latter being independently correlated with incident cardiovascular disease and cardiovascular risk(2), the ultimate test of the utility of the novel cuffless device is the degree to which it deviates from central blood pressure. Only 33% of conventional brachial blood pressure values have been found to lie within 5 mm Hg below or above intra-arterial values(3). The other challenge is the validity of cuffless blood pressure measurements obtained from patients with atrial fibrillation
References
(1)Messerli F., Williams B., Ritz E
Essential hypertension
Lancet 2007;370:591-603
(2) Agabiti-Rosei E., Mancia G., O'Rourke MF et al
Cntral blood pressure measurements and antihypertensive therapy: A consensus statement
Hypertension 2007;50:154-160
(3)Manios E., Vemmos K., Tsivgoulis G et al
Comparison of noninvasive oscillometric and intraarterial blood pressure measurements in hyperacute stroke
Blood Press Monit 2007;12:149-156
Gardezi and colleagues (1) report on the limited accuracy for detection of valvular heart disease (VHD) by cardiac auscultation in asymptomatic patients in primary care. VHD was categorized as either mild or significant and cardiac auscultation was dichotomized in either a present or absent murmur. The authors propose a low sensitivity and modest specificity of cardiac auscultation by general practitioners and by cardiologists to assess VHD.
However, the authors underestimated the specificity and positive predictive value of cardiac auscultation for the assessment of VHD. Patients with a cardiac murmur in whom, by transthoracic echocardiography, mild VHD was detected were included in the ‘negative’ group for assessing significant VHD and more importantly, vice versa. By doing so, many murmurs are classified as false-positive although VHD was present, either mild or significant. We believe that the “true negative” group only includes those patients without any VHD on echocardiography. This would increase the specificity of cardiac auscultation by general practitioners from 67% to 76% and from 81% to 93% for cardiologists, which results in much higher positive predictive values for significant VHD. While it does not change the reported low sensitivity of cardiac auscultation, which remains rather unsatisfactory, this perspective would make the conclusions of this paper at least a little less detrimental to the good old stethoscope.
Gardezi and colleagues (1) report on the limited accuracy for detection of valvular heart disease (VHD) by cardiac auscultation in asymptomatic patients in primary care. VHD was categorized as either mild or significant and cardiac auscultation was dichotomized in either a present or absent murmur. The authors propose a low sensitivity and modest specificity of cardiac auscultation by general practitioners and by cardiologists to assess VHD.
However, the authors underestimated the specificity and positive predictive value of cardiac auscultation for the assessment of VHD. Patients with a cardiac murmur in whom, by transthoracic echocardiography, mild VHD was detected were included in the ‘negative’ group for assessing significant VHD and more importantly, vice versa. By doing so, many murmurs are classified as false-positive although VHD was present, either mild or significant. We believe that the “true negative” group only includes those patients without any VHD on echocardiography. This would increase the specificity of cardiac auscultation by general practitioners from 67% to 76% and from 81% to 93% for cardiologists, which results in much higher positive predictive values for significant VHD. While it does not change the reported low sensitivity of cardiac auscultation, which remains rather unsatisfactory, this perspective would make the conclusions of this paper at least a little less detrimental to the good old stethoscope.
References
1. Gardezi SKM, Myerson SG, Chambers J, Coffey S, d'Arcy J, Hobbs FDR, et al. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart. 2018;104(22):1832-5.
An imprtant caveat to reliance on brain natriuretic peptide(BNP) levels > 100 pg/ml to trigger referral to secondary care(1) is that there exists a clinical phenotype of congestive heart failure(CHF) characterised by BNP equal to or less than 100 pg/ml(2).. In the latter study 46 out of 1159 subjects with CHF and left ventricular ejection fraction(LVEF) > 50%, 46 subjects were characterised by BNP equal to or less than 100 pg/ml. Heart failure symptoms such as effort dyspnoea were equally prevalent(93% vs 90%) in subject with BNP equal to or less than 100 pg/ml vs counterparts with BNP > 100 pg/ml(2). The same was true of orthopnoea(48% vs 48%) and paroxysmal nocturanal dyspnoea(28% vs 29%)(2).
The other caveat is that constrictive pericarditis(CP), an entity characterised by symptoms such as effort dyspnoea and pedal oedema, similar to those in CHF, may be characterised by BNP as low as 50 pg/ml and 88 pg/ml, respectively, in spite of coexistence of New York Heart Association functional class III and IV symptoms(3), and natriuretic propeptide tyype B 147 pg/ml in spite of worsening dyspnoea(4). An overriding consideration is the "diagnostic value of physical examination....in primary care"(5) which includes evaluation of jugular venous pressure(JVP)(5). In the latter study elevation of JVP contributed 12 points towards a score of >54 needed to generate a >70% probability of CHF(5). In CP marked elevation of JVP is almost universal(6)....
An imprtant caveat to reliance on brain natriuretic peptide(BNP) levels > 100 pg/ml to trigger referral to secondary care(1) is that there exists a clinical phenotype of congestive heart failure(CHF) characterised by BNP equal to or less than 100 pg/ml(2).. In the latter study 46 out of 1159 subjects with CHF and left ventricular ejection fraction(LVEF) > 50%, 46 subjects were characterised by BNP equal to or less than 100 pg/ml. Heart failure symptoms such as effort dyspnoea were equally prevalent(93% vs 90%) in subject with BNP equal to or less than 100 pg/ml vs counterparts with BNP > 100 pg/ml(2). The same was true of orthopnoea(48% vs 48%) and paroxysmal nocturanal dyspnoea(28% vs 29%)(2).
The other caveat is that constrictive pericarditis(CP), an entity characterised by symptoms such as effort dyspnoea and pedal oedema, similar to those in CHF, may be characterised by BNP as low as 50 pg/ml and 88 pg/ml, respectively, in spite of coexistence of New York Heart Association functional class III and IV symptoms(3), and natriuretic propeptide tyype B 147 pg/ml in spite of worsening dyspnoea(4). An overriding consideration is the "diagnostic value of physical examination....in primary care"(5) which includes evaluation of jugular venous pressure(JVP)(5). In the latter study elevation of JVP contributed 12 points towards a score of >54 needed to generate a >70% probability of CHF(5). In CP marked elevation of JVP is almost universal(6). In a simplified procedure for evaluation of JVP, where this parameter was evaluated with the patient sitting bolt upright, a deep venous column visibly distended above the right clavicle had a sensitivity of 65% and a specificity of 85% to identify truly elevated venous pressure, where the "gold standard" was elevation of right atrial pressure(evaluated by catheterisation)(7). Missed diagnosis of CP is highly prevalent even in the UK(8), notwithstanding the fact that CP is a curable cause of CHF(9), characterised by LVEF > 50% in the majority of cases, and by LVEF < 40% in 20.9% of 43 subjects in one study(10). In the UK the index of suspicion for CP should be raised by a history of previous cardiac surgery(11) or radiation treatment(12).
References
(1) Hayhoe B., Kim D., Aykin P., Majeed FA., Cowie MR., Bottle A
Adherence to guidelines in management of symptoms suggestive of heart failure in primary care
Heart 2018 E pub ahead of print
(2) Anjan VY., Loftus TM., Burke MA., Akhter N., Fonarow GC., Gheorghiade M., Shah SF
Prevalence clinical phenotype and outcomes associated with normal B-type ntriuretic peptide levels in heart failure with preserved ejection fraction
Am J Cardiol 2012;110:870-876
(3) Leya FS., Arab D., Joyal D., Shioura KM., Lewis BE., Steen LH., Cho L
The efficacy of brain natriuretic peptide levels in differentiating constrictive pericarditis from restrictive cardiomyopathy
JACC 2005;45:1900-1902
(4)Grabysa R., Widawski T., Przelaskowski P
Don't blindly trust in BNP concentration: A case of constrictive pericarditis
Int J Cardiol 2015;180:50-51
(5)Kelder JC., Cramer MJ., van Wijngaarden J., van Tooren R., Mosterd A., Moons KG., Lammers JW et al
The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure
Circulation 2011;124:2865-2873
(6) Gimlette TMD
Constrictive pericarditis
Brit Heart J 1959;21;9-16
(7)Sinisalo J., Rapola JP., Rossinen J., Kupari M
Simplifying the estimation of jugular venous pressureAm J cardiol 2007;100;1779-1781
(8) Marshall A., Ring N., Lewis T
Constrictive pericarditis lessons from the past five years' experience in the South West Cardiothoracic Centre
ckinical Medicine 2006;6:592-597
(9) Syed FF., Schaff HV., Oh JK
Constricitve pericarditis a curable diastolic failure
Nature Reviews Cardiology 2014;11:530-544
(10) Oreto L., Mayer A., Todaro MC., Mori N., Kress DC., Kleinman LH., Allaqaband S et al
Contemporary clinical spectrum of constricitive pericarditis : a 10 year experience
Int J Cardiol 2013;163:339-341
(11) Gaudino M., Anselmi A., Pavone N., Massetti M
Constrictive pericarditis after cardiac surgery AnnThorac Surg 2013;95;731-736
(12) Szabo G., Schmack B., Bulul C., Soos P., Weymann A., Stadfeld S., Karck M
Constrictive pericarditis risks aetiologies and aoutcomes after total pericardiectomy: 24 years of experience
Europenn Journal of cradiothoracic surgery 2013;44:1023-1028
To the Editor,
We read with interest the paper by Ikenaga et al. (1), who must be commended for their detailed report on the determinants of persistent iatrogenic atrial septal defect (iASD) following percutaneous mitral valve clip (MV clip) placement. The authors found that elevated left atrial (LA) pressure after the MV clip procedure was the main determinant of persistent iASD during follow-up. Remarkably, in spite of their poorer clinical condition, patients with and without persistent iASD had similar outcomes during follow-up. This suggested that interatrial shunt has a benefit in some MV clip patients. Previous studies that evaluated the usefulness of an interatrial shunt device for treating heart failure patients without valve disease also showed a significant benefit of the shunt in patients with high LA pressure (2, 3).
However, these findings disagree with other findings of the persistence of iASD after MV clip placement with negative outcomes, mainly due to right ventricle (RV) claudication (4). Indeed, previous studies of the interatrial shunt device suggest that the size of the shunt plays a key role in outcomes. Indeed, the ideal shunt size should allow the reduction of LA pressure without hampering right heart function. The maximum interatrial shunt devices are 5 mm2 (3); too large iASDs may increase the Qp/Qs enough to cause RV failure, while too small iASDs may be have negligible hemodynamical and clinical results. No MV clip studies reported...
To the Editor,
We read with interest the paper by Ikenaga et al. (1), who must be commended for their detailed report on the determinants of persistent iatrogenic atrial septal defect (iASD) following percutaneous mitral valve clip (MV clip) placement. The authors found that elevated left atrial (LA) pressure after the MV clip procedure was the main determinant of persistent iASD during follow-up. Remarkably, in spite of their poorer clinical condition, patients with and without persistent iASD had similar outcomes during follow-up. This suggested that interatrial shunt has a benefit in some MV clip patients. Previous studies that evaluated the usefulness of an interatrial shunt device for treating heart failure patients without valve disease also showed a significant benefit of the shunt in patients with high LA pressure (2, 3).
However, these findings disagree with other findings of the persistence of iASD after MV clip placement with negative outcomes, mainly due to right ventricle (RV) claudication (4). Indeed, previous studies of the interatrial shunt device suggest that the size of the shunt plays a key role in outcomes. Indeed, the ideal shunt size should allow the reduction of LA pressure without hampering right heart function. The maximum interatrial shunt devices are 5 mm2 (3); too large iASDs may increase the Qp/Qs enough to cause RV failure, while too small iASDs may be have negligible hemodynamical and clinical results. No MV clip studies reported iASD size, which can easily be estimated by Doppler. Thus, sizing the residual iASD may be appropriate following a MV clip procedure. Furthermore, MV disease is often associated with significant pulmonary hypertension and with right heart damage (i.e. tricuspid regurgitation). Thus, even a small interatrial shunt may be deleterious, causing progressive right heart overload and dysfunction. This is the likely scenario in a significant number of MV clip patients (2,3).
Ongoing phase 3 randomized clinical trials in heart failure should provide further insights into the effects of an interatrial shunt. REDUCE LAP-HF II (NCT03088033) is a randomized controlled trial comparing the clinical efficacy of an interatrial shunt device versus optimal medical treatment in symptomatic patients with left ventricular ejection fraction (LVEF) >40%. REDUCE LAP HF-III (NCT03191656) is recruiting patients with preserved or mildly reduced LVEF to determine the benefits (functional status, quality of life) of this therapy at a 12-month follow-up. RELIEVE-HF (NCT03499236) is a randomized controlled trial comparing the second generation (valveless) V-Wave device with optimal medical therapy in patients with preserved or reduced LVEF.
REFERENCES
1 Ikenaga H, Hayashi A, Nagaura T, Yamaguchi S, Yoshida J, Rader F, Siegel RJ, Kar S, Shiota T. Left atrial pressure is associated with iatrogenic atrial septal defect after mitral valve clip. Heart. 2018. pii: heartjnl-2018-313839. doi: 10.1136/heartjnl-2018-313839. [Epub ahead of print]
2 Rodés-Cabau J, Bernier M, Amat-Santos IJ, Ben Gal T, Nombela-Franco L, García Del Blanco B, Kerner A, Bergeron S, Del Trigo M, Pibarot P, Shkurovich S, Eigler N, Abraham WT. Interatrial shunting for heart failure: early and late results from the first-in-human experience with the v-wave system. JACC Cardiovasc Interv. 2018 Nov 26;11(22):2300–10.
3 Del Trigo M, Bergeron S, Bernier M, Amat-Santos IJ, Puri R, Campelo-Parada F, Altisent OA, Regueiro A, Eigler N, Rozenfeld E, Pibarot P, Abraham WT, Rodés-Cabau J. Unidirectional left-to-right interatrial shunting for treatment of patients with heart failure with reduced ejection fraction: a safety and proof-of-principle cohort study. Lancet. 2016 Mar 26;387(10025):1290–7.
4 Schueler R, Öztürk C, Wedekind JA, Werner N, Stöckigt F, Mellert F, Nickenig G, Hammerstingl C. Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution. JACC Cardiovasc Interv. 2015 Mar;8(3):450–9.
One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
Severe AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).
Refer...
One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
Severe AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).
References
(1) Rispler S., Rinkevich D., Markiewicz ., Reisner SA
Missed diagnosis of severe symptomatic aortic stenosis
Am J Cardiol 1995;76:728-730
(2) Varat MA., Adolph RJ., Fowler NO
Cardiovascular effects of anemia
Am Heart J 1972;83:415-426
(3)Saad RA., Lwaleed BA., Kazmi RS
Gastrointestinal bleeding and aortic stenosis(Heyde's syndrome): The role of aortic valve replacement
J Card Surg 2013;28:414-416
(4) Zezulka A., MacKinnon J., Beevers DG
Hypertension in aortic valve disease and its response to valve replacement
Postgrad Med J 1992;68:180-185
(5) Barlow J., Kincaid-Smith P
The auscultatory findings in hypertension
Brit Heart J 1960;22:505-514
(6) Ramcharan T., Taylor A., Chikemane A
Hypertension and murmur with a "normal echo" An uncommon late presentation of coarctation of the aorta
Heart 2016;102(Suppl 1):P33
Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
(i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
(ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
References
(1) Stout KK., Verrier ED
Acute valvular regurgitation
Circulation 2009;119:3232-3241
(2) Hamirani YS., Dietl CA., Voyles V et al
Acute aortic regurgitation
Circulation 2012;126:1121-1126
(3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
Clinical characteristics and thrombolytic outc...
Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
(i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
(ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
References
(1) Stout KK., Verrier ED
Acute valvular regurgitation
Circulation 2009;119:3232-3241
(2) Hamirani YS., Dietl CA., Voyles V et al
Acute aortic regurgitation
Circulation 2012;126:1121-1126
(3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
Clinical characteristics and thrombolytic outcomes of infective endocarditis-associated stroke
Neurohospitalist 2012;2;87-91
(4)Liang JJ., Bishu KG., Anavekar NS
Infective endocarditis complicated by acute ischemic stroke from septic embolus: successful solitaire FR thrombectomy
Cardiol Res 2012;3:277-280
Martínez –Milla el al, report an interesting case of cardiac lymphoma, presenting as complete AV block.
A close look at the electrocardiogram, reveals a P wave with a normal frontal axis, broad (duration > 120 ms), and bimodal ( notched). These are the diagnostic hallmarks of partial interatrial block (IAB).
In this patient, the lymphoma probably infiltrates the Bachmann’s bundle, interrupting the preferential pathway of left atrial activation, causing partial IAB.
Although often overlooked, IAB is frequent in the elderly, and it is associated with atrial arrhythmias and stroke.
Because the diagnosis of IAB relies on the morphology and duration of the P wave, a meticulous analysis of the electrocardiogram is mandatory.
The recommendation that combined antiplatelet and new oral anticoagulant(NOAC) therapy should rely on the lowest approved NOAC dose effective for stroke prevention(1) is one which favours low-dose edoxaban instead of either dabigatran, rivaroxaban, or apixaban, when reduction of risk of gastrointestinal(GIT) bleeding is taken into account. In a review of clinical experience of bleeding associated with NOACs(dabigatran, rivaroxaban, apixaban, and edoxaban) versus warfarin in nonvalvular atrial fibrillation(NVAF), edoxaban 30 mg/day was the only antithrombotic agent associated with significantly(p < 0.001) lower risk of GIT bleeding than warfarin(Hazard Ratio: 0.67;95% Confidence Interval 0.53 to 0.83). For apixaban and for dabigatran 110 mg BID, the risk of GIT bleeding was comparable with the risk associated with warfarin use. For rivaroxaban and for dabigatran 150 mg BID the risk of GIT haemorrhage was significantly higher(P < 0.0001, and p < 0.001, respectively) than the GIT bleeding risk associated with warfarin(2).
In a study where 92.2% of 5301 NVAF users of antiplatelet agents were prescribed a NOAC in combination with only one antiplatelet agent vs 86.3% of 9106 NVAF users of antiplatelet agents who were prescribed warfarin with only one antiplatelet agent , concomitant antiplatelet and NOAC use was associated with significantly lower risk of intracranial bleeding than concomitant antiplatelet and warfarin use(HR 0.68, 95% CI, 0.51 to 0.91). Ne...
The recommendation that combined antiplatelet and new oral anticoagulant(NOAC) therapy should rely on the lowest approved NOAC dose effective for stroke prevention(1) is one which favours low-dose edoxaban instead of either dabigatran, rivaroxaban, or apixaban, when reduction of risk of gastrointestinal(GIT) bleeding is taken into account. In a review of clinical experience of bleeding associated with NOACs(dabigatran, rivaroxaban, apixaban, and edoxaban) versus warfarin in nonvalvular atrial fibrillation(NVAF), edoxaban 30 mg/day was the only antithrombotic agent associated with significantly(p < 0.001) lower risk of GIT bleeding than warfarin(Hazard Ratio: 0.67;95% Confidence Interval 0.53 to 0.83). For apixaban and for dabigatran 110 mg BID, the risk of GIT bleeding was comparable with the risk associated with warfarin use. For rivaroxaban and for dabigatran 150 mg BID the risk of GIT haemorrhage was significantly higher(P < 0.0001, and p < 0.001, respectively) than the GIT bleeding risk associated with warfarin(2).
In a study where 92.2% of 5301 NVAF users of antiplatelet agents were prescribed a NOAC in combination with only one antiplatelet agent vs 86.3% of 9106 NVAF users of antiplatelet agents who were prescribed warfarin with only one antiplatelet agent , concomitant antiplatelet and NOAC use was associated with significantly lower risk of intracranial bleeding than concomitant antiplatelet and warfarin use(HR 0.68, 95% CI, 0.51 to 0.91). Nevertheless, risk of GIT bleeding was comparable(HR 1,08, 95% CI, 0.81 to 1.45)(3).
Given the fact that VKA therapy is associated with greater risk of intracranial bleeding than NOAC therapy, not only in the absence of concomitant antiplatelet drug use(2), but also in the context of combined anticoagulant and only one antiplatelet agent (3), the safest use of triple antithrombotic therapy(TAT) appears to be one which involves either low-dose edoxaban, low-dose dabigatran or apixaban so as to optimise mitigation of the risk of gastrointestinal bleeding..
Although PIONEER AF-PCI was a TAT study which documented significantly(p < 0.001) lower rates of clinically significant bleeding in recipients of TAT involving low dose rivaroxaban than in recipients of TA involving warfarin that study was not powered to evaluate non inferiority of the low-dose rivaroxaban regime to the warfarin regime for thromboprophylaxis against NVAF-related stroke(4). Future trials should now optimise the advantage that the sole use of low-dose edoxaban enjoys over sole use of other NOACs in mitigating the risk of both intracranial and GIT bleeding, by exploring the possibility that the universal inclusion of the 30 mg/day edoxaban dose (irrespective of renal function and body weight), in a TAT regime might be non inferior to a TAT regime that involves warfarin, with regard to thromboprophylaxis against NVAF-related stroke. .
I have no funding and no conflict of interest
References
(1) Capodano D
Triple antithrombotic therapy after ACS and PCI in patients on chronic oral anticoagulation Update
Heart 2018;104:1976-1983
(2) Eikelboom J., Meril G
Bleeding with direct oral anticoagulants vs warfarin: Clinical experience
Am J Med 2016;129:S33-S40
(3)Douros A., Renoux X., Yin H et al
Concomitant use of direct oral anticoagulants with antiplatelet agents and the risk of major bleeding in patients with nonvalvular atrial fibrillation
Am J Med 2018;DOI.org/10.1016/amjmed 2018.10.008
(4) Gibson CM., Mehran R., Bode C et al
Prevention of bleeding in patients with atrial fibrillation undergoing PCI
N Engl J Med 2016;375:2423-2434
Given the fact that constrictive pericarditis is an eminently reversible cause of congestive heart failure(CHF) its timely clinical recognition deserved special mention in the recent review of epidemiology of pericardial diseases in Africa(1). Timely recognition and treatment might, arguably, mitigate the risk of perioperative mortality which is currently of the order of 12.5% to 14%, given the fact that this adverse statistic is principally generated by patients who come to operation in New York Heart Association functional class III and IV(2)(3). Accordingly, what needs to be done is to educate doctors and medical students to identify stigmata which differentiate CP from "run of the mill" CHF so as to expedite early referral of suspected CP to tertiary centres for definitive diagnosis and, hence, timely pericardiectomy.
According to Little and Freeman, in the typical case of CP, "there will be marked jugular venous distension, hepatic congestion, ascites, and peripheral oedema, while the lungs remain clear"(3). Consequently, on the basis of their series of 30 patients, Evans and Jackson observed that "the presence of distended neck veins in a patient who is able to lie comfortably in the recumbent posture is characteristic of the disease"(4). The jugular venous pressure(JVP) response to a diagnostic trial of diuretic therapy may also be of diagnostic significance(5)(6). In CP, the typical response is that the JVP remains persisten...
Given the fact that constrictive pericarditis is an eminently reversible cause of congestive heart failure(CHF) its timely clinical recognition deserved special mention in the recent review of epidemiology of pericardial diseases in Africa(1). Timely recognition and treatment might, arguably, mitigate the risk of perioperative mortality which is currently of the order of 12.5% to 14%, given the fact that this adverse statistic is principally generated by patients who come to operation in New York Heart Association functional class III and IV(2)(3). Accordingly, what needs to be done is to educate doctors and medical students to identify stigmata which differentiate CP from "run of the mill" CHF so as to expedite early referral of suspected CP to tertiary centres for definitive diagnosis and, hence, timely pericardiectomy.
According to Little and Freeman, in the typical case of CP, "there will be marked jugular venous distension, hepatic congestion, ascites, and peripheral oedema, while the lungs remain clear"(3). Consequently, on the basis of their series of 30 patients, Evans and Jackson observed that "the presence of distended neck veins in a patient who is able to lie comfortably in the recumbent posture is characteristic of the disease"(4). The jugular venous pressure(JVP) response to a diagnostic trial of diuretic therapy may also be of diagnostic significance(5)(6). In CP, the typical response is that the JVP remains persistently in spite of resolution of peripheral oedema(5)(6), even when this is accompanied by weight loss(5). At the very least, patients who exhibit those stigmata should have chest x-ray to detect pericardial calcification. If the index of suspicion for CP still persists, the next step should be computed tomography of the thorax to detect pericardial thickening.
In developed countries delay in the clinical recognition of CP is common(7), but this diagnostic lapse can be excused on the basis of the rarity of CP in those societies. In the African context, however, where CP is more prevalent, preventable diagnostic delay is inexcusable.
I have no conflict of interest and no funding
References
(1) Noubiap JJ., Agbor VN., Ndoadoumgue AL et al
Epidemiology of pericardial disease in Africa: A sytematic review
Heart 10th November 2018;Doi 10.1136/heartjnl2018-313922
(2) Yangni-Angate K., Tanauh Y., Meneas C et al
Surgical experience on chronic constricitve pericarditis in African setting: review of 35 years experience in Cote d'Ivorie
Cardiovasc Diagn Ther 2016,6(Suppl 1):S13-S19
(3)Mutyaba AK., Balkaran S., Cloete R et al
Constrictive pericarditis requiring pericardiectomy at Groote Schuur Hospital Capetown, South Africa: Cuases and perioperative outcomes in the HIV era(1990-2012)
The Journal of Thoracic and Cardiovascular surgery 2014;148:3058-3065
(3)Little WC., Freeman GL
Pericardial disease
Circulation 2006;113:1622-1632
(4) Evans W., Jackson F
Constrictive pericarditis
British Heart Journal 1952:14:53-69
(5)Conti CR., Friesinger GC
Chronic constrictive pericarditis; clinical and laboratory findings in 11 case
Johns Hopkins Med J 1967;120:262-274
(6) Chambliss JR., Jaruszewski EJ., Brofman BL., Martin JF., Feil H
Chronic cardiac compression(Chronic constrictive pericarditis)
A critical study of sixty one operated cases with follow up
Circulation 1951;4:816-835
(7) Marshall A., Ring N., Lewis T
Constrictive pericarditis: lessons from the past five years experience in the South West Cardiothoracic centre
Clinical Medicine 2006;6:592-597
Editor, We agree with Lavie et al that the current standard model of delivering cardiac rehabilitation (CR) predominantly in hospital or centre based facilities has reached saturation and we should be looking at offering alternatives which could improve the global suboptimal rates of participation in CR. [1] Uptake of CR in heart failure remains particularly poor with rates of less than 20% in Europe. [2].
Show MoreClinicians and commissioners should consider implementing the findings of a UK based multicentre trial on home-based CR [3] which responds to the updated 2018 NICE guidance recommendation that adults with heart failure are offered a “..personalised, exercise-based CR programme – in a format and setting (at home, in the community or in the hospital) that is easily accessible” [https://www.nice.org.uk/guidance/ng106/chapter/Recommendations#cardiac-r... ]
We believe REACH HF to be the largest randomised trial of home based CR (co-developed by clinicians, academics, caregivers and patients) in heart failure with reduced ejection fraction and it provides important new evidence for a novel home-based CR programme in terms of benefit to patients and their caregivers. [3]
The results of the REACH HF trial show that it is possible to significantly improve patients’ health related quality of life and that the intervention has a cost of £418 per patient, within th...
Given the fact that the entire purpose of blood pressure measurement is to identify the cut-off level of blood pressure that increases the risk for cerebral, cardiac, and renal events, and that "brachial blood pressure can be an imperfect surrogate for central aortic pressure"(1), the latter being independently correlated with incident cardiovascular disease and cardiovascular risk(2), the ultimate test of the utility of the novel cuffless device is the degree to which it deviates from central blood pressure. Only 33% of conventional brachial blood pressure values have been found to lie within 5 mm Hg below or above intra-arterial values(3). The other challenge is the validity of cuffless blood pressure measurements obtained from patients with atrial fibrillation
References
(1)Messerli F., Williams B., Ritz E
Essential hypertension
Lancet 2007;370:591-603
(2) Agabiti-Rosei E., Mancia G., O'Rourke MF et al
Cntral blood pressure measurements and antihypertensive therapy: A consensus statement
Hypertension 2007;50:154-160
(3)Manios E., Vemmos K., Tsivgoulis G et al
Comparison of noninvasive oscillometric and intraarterial blood pressure measurements in hyperacute stroke
Blood Press Monit 2007;12:149-156
Gardezi and colleagues (1) report on the limited accuracy for detection of valvular heart disease (VHD) by cardiac auscultation in asymptomatic patients in primary care. VHD was categorized as either mild or significant and cardiac auscultation was dichotomized in either a present or absent murmur. The authors propose a low sensitivity and modest specificity of cardiac auscultation by general practitioners and by cardiologists to assess VHD.
However, the authors underestimated the specificity and positive predictive value of cardiac auscultation for the assessment of VHD. Patients with a cardiac murmur in whom, by transthoracic echocardiography, mild VHD was detected were included in the ‘negative’ group for assessing significant VHD and more importantly, vice versa. By doing so, many murmurs are classified as false-positive although VHD was present, either mild or significant. We believe that the “true negative” group only includes those patients without any VHD on echocardiography. This would increase the specificity of cardiac auscultation by general practitioners from 67% to 76% and from 81% to 93% for cardiologists, which results in much higher positive predictive values for significant VHD. While it does not change the reported low sensitivity of cardiac auscultation, which remains rather unsatisfactory, this perspective would make the conclusions of this paper at least a little less detrimental to the good old stethoscope.
References
Show More1. Gardezi S...
An imprtant caveat to reliance on brain natriuretic peptide(BNP) levels > 100 pg/ml to trigger referral to secondary care(1) is that there exists a clinical phenotype of congestive heart failure(CHF) characterised by BNP equal to or less than 100 pg/ml(2).. In the latter study 46 out of 1159 subjects with CHF and left ventricular ejection fraction(LVEF) > 50%, 46 subjects were characterised by BNP equal to or less than 100 pg/ml. Heart failure symptoms such as effort dyspnoea were equally prevalent(93% vs 90%) in subject with BNP equal to or less than 100 pg/ml vs counterparts with BNP > 100 pg/ml(2). The same was true of orthopnoea(48% vs 48%) and paroxysmal nocturanal dyspnoea(28% vs 29%)(2).
Show MoreThe other caveat is that constrictive pericarditis(CP), an entity characterised by symptoms such as effort dyspnoea and pedal oedema, similar to those in CHF, may be characterised by BNP as low as 50 pg/ml and 88 pg/ml, respectively, in spite of coexistence of New York Heart Association functional class III and IV symptoms(3), and natriuretic propeptide tyype B 147 pg/ml in spite of worsening dyspnoea(4). An overriding consideration is the "diagnostic value of physical examination....in primary care"(5) which includes evaluation of jugular venous pressure(JVP)(5). In the latter study elevation of JVP contributed 12 points towards a score of >54 needed to generate a >70% probability of CHF(5). In CP marked elevation of JVP is almost universal(6)....
To the Editor,
Show MoreWe read with interest the paper by Ikenaga et al. (1), who must be commended for their detailed report on the determinants of persistent iatrogenic atrial septal defect (iASD) following percutaneous mitral valve clip (MV clip) placement. The authors found that elevated left atrial (LA) pressure after the MV clip procedure was the main determinant of persistent iASD during follow-up. Remarkably, in spite of their poorer clinical condition, patients with and without persistent iASD had similar outcomes during follow-up. This suggested that interatrial shunt has a benefit in some MV clip patients. Previous studies that evaluated the usefulness of an interatrial shunt device for treating heart failure patients without valve disease also showed a significant benefit of the shunt in patients with high LA pressure (2, 3).
However, these findings disagree with other findings of the persistence of iASD after MV clip placement with negative outcomes, mainly due to right ventricle (RV) claudication (4). Indeed, previous studies of the interatrial shunt device suggest that the size of the shunt plays a key role in outcomes. Indeed, the ideal shunt size should allow the reduction of LA pressure without hampering right heart function. The maximum interatrial shunt devices are 5 mm2 (3); too large iASDs may increase the Qp/Qs enough to cause RV failure, while too small iASDs may be have negligible hemodynamical and clinical results. No MV clip studies reported...
One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
Show MoreSevere AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).
Refer...
Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
Show More(i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
(ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
References
(1) Stout KK., Verrier ED
Acute valvular regurgitation
Circulation 2009;119:3232-3241
(2) Hamirani YS., Dietl CA., Voyles V et al
Acute aortic regurgitation
Circulation 2012;126:1121-1126
(3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
Clinical characteristics and thrombolytic outc...
Martínez –Milla el al, report an interesting case of cardiac lymphoma, presenting as complete AV block.
A close look at the electrocardiogram, reveals a P wave with a normal frontal axis, broad (duration > 120 ms), and bimodal ( notched). These are the diagnostic hallmarks of partial interatrial block (IAB).
In this patient, the lymphoma probably infiltrates the Bachmann’s bundle, interrupting the preferential pathway of left atrial activation, causing partial IAB.
Although often overlooked, IAB is frequent in the elderly, and it is associated with atrial arrhythmias and stroke.
Because the diagnosis of IAB relies on the morphology and duration of the P wave, a meticulous analysis of the electrocardiogram is mandatory.
The recommendation that combined antiplatelet and new oral anticoagulant(NOAC) therapy should rely on the lowest approved NOAC dose effective for stroke prevention(1) is one which favours low-dose edoxaban instead of either dabigatran, rivaroxaban, or apixaban, when reduction of risk of gastrointestinal(GIT) bleeding is taken into account. In a review of clinical experience of bleeding associated with NOACs(dabigatran, rivaroxaban, apixaban, and edoxaban) versus warfarin in nonvalvular atrial fibrillation(NVAF), edoxaban 30 mg/day was the only antithrombotic agent associated with significantly(p < 0.001) lower risk of GIT bleeding than warfarin(Hazard Ratio: 0.67;95% Confidence Interval 0.53 to 0.83). For apixaban and for dabigatran 110 mg BID, the risk of GIT bleeding was comparable with the risk associated with warfarin use. For rivaroxaban and for dabigatran 150 mg BID the risk of GIT haemorrhage was significantly higher(P < 0.0001, and p < 0.001, respectively) than the GIT bleeding risk associated with warfarin(2).
Show MoreIn a study where 92.2% of 5301 NVAF users of antiplatelet agents were prescribed a NOAC in combination with only one antiplatelet agent vs 86.3% of 9106 NVAF users of antiplatelet agents who were prescribed warfarin with only one antiplatelet agent , concomitant antiplatelet and NOAC use was associated with significantly lower risk of intracranial bleeding than concomitant antiplatelet and warfarin use(HR 0.68, 95% CI, 0.51 to 0.91). Ne...
Given the fact that constrictive pericarditis is an eminently reversible cause of congestive heart failure(CHF) its timely clinical recognition deserved special mention in the recent review of epidemiology of pericardial diseases in Africa(1). Timely recognition and treatment might, arguably, mitigate the risk of perioperative mortality which is currently of the order of 12.5% to 14%, given the fact that this adverse statistic is principally generated by patients who come to operation in New York Heart Association functional class III and IV(2)(3). Accordingly, what needs to be done is to educate doctors and medical students to identify stigmata which differentiate CP from "run of the mill" CHF so as to expedite early referral of suspected CP to tertiary centres for definitive diagnosis and, hence, timely pericardiectomy.
Show MoreAccording to Little and Freeman, in the typical case of CP, "there will be marked jugular venous distension, hepatic congestion, ascites, and peripheral oedema, while the lungs remain clear"(3). Consequently, on the basis of their series of 30 patients, Evans and Jackson observed that "the presence of distended neck veins in a patient who is able to lie comfortably in the recumbent posture is characteristic of the disease"(4). The jugular venous pressure(JVP) response to a diagnostic trial of diuretic therapy may also be of diagnostic significance(5)(6). In CP, the typical response is that the JVP remains persisten...
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