Editor, we read with great interest the article "NICE evaluation of
transmyocardial laser revascularisation and percutaneous laser
revascularisation for refractory angina [1].
The authors described a variety of treatment options for patients
suffering from refractory angina pectoris (RAP). However, a very
important, evolving innovation is missing: coronary sinus intervention
(CSI).
Editor, we read with great interest the article "NICE evaluation of
transmyocardial laser revascularisation and percutaneous laser
revascularisation for refractory angina [1].
The authors described a variety of treatment options for patients
suffering from refractory angina pectoris (RAP). However, a very
important, evolving innovation is missing: coronary sinus intervention
(CSI).
Coronary venous intervention (CVI) and CSI for the treatment of
ischemic heart disease were introduced more than 60 years ago [2]. CVI and
CSI means ligation or narrowing of the coronary sinus or other components
of the coronary venous system. Sixty years ago CVI, CSI like
transmyocardial laser revascularisation (TMR) was a major chest surgery
requires general anesthesia and lateral thoracotomy. This raises the
question of whether a patient with a jeopardized myocardium can survive
such a major operation.
In the mid-1990s, we invented the first percutaneous intravenous
coronary sinus reducer stent (CSRS). The CSRS is the implementation of
what we've called the upside-down strategy. When impaired coronary blood
flow can't be restored with input improvement, restriction of coronary
output remains an option and instead of forcing pressure to enlarge a
coronary artery the CSRS restricts a coronary sinus.
The CSRS is a balloon-expandable stent, hourglass shaped, implanted
by percutaneous transvenous approach through the right internal jugular
vein. It reduces the coronary sinus diameter to 3 mm.
First human study with CSRS began in 2004 [3]. It is a prospective,
open-label, safety feasibility study. The stent was percutaneously
implanted in 15 patients suffering of RAP. All patients were discharged
from hospital one to two days afterward. Six months after implantation,
most of the patients had improved Canadian Cardiovascular Society Scores
(CCSS) compared with baseline (3.07 versus 1.64; P <0.0001).
Improvements were also seen for stress-induced ST-segment depression and
for the extent and severity of myocardial ischemia as shown by either
dobutamine echocardiography or thallium single-photon emission CT. All
these improvements were maintained at 3 years after CSRS implementation
[4].
Further evaluation of CSRS for the treatment of patients with RAP is
ahead but initial findings suggest it may be a safe, feasible,
comfortable, and additional effective option for RAP patients that has to
be mentioned when dealing with RAP.
1. Schofield P M, McNab D. NICE evaluation of transmyocardial laser
revascularisation and percutaneous laser revascularisation for refractory
angina. Heart 2010 Feb;96(4):312-3.
2. Fauteux M. Surgical treatment of angina pectoris: experiences with
ligation of the great cardiac vein and pericoronary neurectomy. Ann Surg.
1946;124:1041-4.
3. Banai S, Ben Muvhar S, Parikh KH et al. Coronary sinus reducer
stent for the treatment of chronic refractory angina pectoris: a
prospective, open-label,
multicenter, safety feasibility first-in-man study. J Am Coll Cardiol.
2007;49:1783-1799.
4. Banai S, Schwartz M, Sievert H et al. Long-term follow-up to
evaluate the safety of the Neovasc Reducer a device-based therapy for
chronic refractory angina. J Am Coll Cardiol. 2010;55;A98.E927.
Editor, I read the recent publication by Uno et al [1]. Uno et al concluded that adiponectin is an indicator of LV diastolic dysfunction in patients with HCM [1]. There are some points to be concerned before using this conclusion. First, only 26 cases were investigated in this work and this might be a weakness in statistical analysis. Second, there are several practical concerns on the measurement of adiponectin starting from samp...
Editor, I read the recent publication by Uno et al [1]. Uno et al concluded that adiponectin is an indicator of LV diastolic dysfunction in patients with HCM [1]. There are some points to be concerned before using this conclusion. First, only 26 cases were investigated in this work and this might be a weakness in statistical analysis. Second, there are several practical concerns on the measurement of adiponectin starting from sample collection to intralaboratory analysis [2 - 3]. Indeed, a more favorable method for determination of adiponectin seems to be a latex particle-enhanced turbidimetric immunoassay with an automated analyzer [3]. Whether the inferences are well controlled by Uno et al is still questionable.
References 1. Unno K, Shibata R, Izawa H, Hirashiki A, Murase Y, Yamada T, Kobayashi M, Noda A, Nagata K, Ouchi N, Murohara T. Adiponectin acts as a positive indicator of left ventricular diastolic dysfunction in patients with hypertrophic cardiomyopathy. Heart. 2010 Mar;96(5):357-61. 2. Tanita T, Miyakoshi H, Nakano Y. Performance of ELISA for specific measurement of high-molecular-weight (HMW) adiponectin. J Immunol Methods. 2008 Apr 20;333(1-2):139-46. 3. Nishimura A, Sawai T. Determination of adiponectin in serum using a latex particle-enhanced turbidimetric immunoassay with an automated analyzer. Clin Chim Acta. 2006 Sep;371(1-2):163-8.
Shaw D and Conway DI (1) correctly identify that a fact neither proved nor disproved lies at the heart of both Pascalââ¬â¢s wager and the National Institute of Clinical Excellence (NICE) guidance in relation to the use of antibiotic (abx) prophylaxis for infective endocarditis (IE) . The no lose argument is no match winner for NICE because cardiologists are all too keenly aware that antibiotics kill as sure...
Shaw D and Conway DI (1) correctly identify that a fact neither proved nor disproved lies at the heart of both Pascalâ₉„¢s wager and the National Institute of Clinical Excellence (NICE) guidance in relation to the use of antibiotic (abx) prophylaxis for infective endocarditis (IE) . The no lose argument is no match winner for NICE because cardiologists are all too keenly aware that antibiotics kill as surely as IE. In relation to Pascal's wager consider the following equation: [harm caused by IE with Abx prophylaxis harm caused by Abx] [harm caused by IE without Abx prophylaxis] The cardiologistâ₉„¢s wager is that this equation is false. Both positions are ultimately based upon belief rather than sufficient empirical evidence because of equipoise in relation to the core fact in play. For cardiologists offering antibiotics is as valid and as strongly based a belief in overall benefit as is the NICE position. Pragmatically the principle should be that NICE should not intervene to alter the status quo where the underlying empirical evidence base is in equipoise. No treatment can be determined to be cost-effective if it is neither proven nor disproven. (2) Indeed in its own guidance upon social value judgements (3) NICE declares its first principle to be that it should not recommend an intervention "if there is no evidence, or not enough evidence, on which to make a clear decision". The effect of the NICE guidance is to implement a de facto clinical trial under the cover of a cost-effectiveness judgement. By purporting to lack the intention to undertake a clinical trial NICE is side-stepping the legal framework for research. (4) The medical duty of care imposes an ethical obligation upon clinicians to pursue the data collection required to interpret the result of the de facto trial in the absence of any other agency being so obliged. (1) Shaw D, Conway DI. Pascalâ₉„¢s Wager, infective endocarditis and the Å“no- lose philosophy in medicine. Heart 2010;96:15- 18 doi:10.1136/hrt.2009.186056 (2) Mohindra RK. NICE, drug-eluting stents and the limits of trial data. Heart 2009;95(6):505-506 (3) National Institute For Health And Clinical Excellence. Social Value Judgements. Principles for the development of NICE guidance. 2nd Edition. Para 4.1 www.nice.org.uk/aboutnice/howwework/socialvaluejudgements/socialvaluejudgements.jsp (accessed 13/02/2010 (4) Reg 2 Medicines for Human Use (Clinical Trials) Regulations 2004 SI 2004/103
The statistics of propensity adjustment, that Harjai et al.(1) have
used with some modifications, is a recognised tool to increase the value
of non-experimental data(2,3).
However, these authors have used propensity statistics less
efficiently than other studies in this area have done(2,3). In fact,
propensity statistics has only been introduced by Harjai et al. in their
multivariate regression analysis, but...
The statistics of propensity adjustment, that Harjai et al.(1) have
used with some modifications, is a recognised tool to increase the value
of non-experimental data(2,3).
However, these authors have used propensity statistics less
efficiently than other studies in this area have done(2,3). In fact,
propensity statistics has only been introduced by Harjai et al. in their
multivariate regression analysis, but no 1:1 propensity matching has been
made to identify two patient subgroups of identical size (derived from the
cohorts who continued or discontinued the treatment, respectively) and
compare outcomes between these two matched-pair subgroups.
No specific rules have yet been devised to determine the size of the
cohorts to be included in propensity analyses. Nonetheless, since
propensity studies have less quality of evidence than randomized studies,
one can reasonably assume that the number of patients included in
propensity studies should not be smaller than the number of patients that
one would include in a randomized study aimed at the same question.
In patients receiving percutaneous coronary intervention, the
opportunity to continue clopidogrel at 6 or 12 months is presently matter
of debate. Using non-inferiority power calculations (power=0.80,
alpha=0.05, event frequency around 10%, clinically meaningful relative
risk reduction set at 20%), a total of at least 2,500 patients (1,250 per
arm) would be needed to adequately power a randomized study. Event
frequencies less than 10% would give even larger sample sizes.
Two propensity analyses have recently addressed this issue(1,4). The
study by Harjai et al.(1) analyzed 835 patients treated with bare metal
stents and 1024 treated with drug-eluting stents, while Shin's study(4)
examined fewer patients (N=844) treated with drug eluting stents (with an
advantage in that a matched-pair analysis was tried). Both studies suggest
that prolonging clopidogrel beyond 6 or 12 months confers no benefit.
Although these findings have been interpreted this way, it has not
been observed that these studies were largely underpowered to adequately
address this therapeutic problem. Hence, a large-scale randomized study is
still needed in this area. Alternatively, a propensity-score investigation
could be useful provided that at least 3,000 patients are included in the
matched-pair analysis.
References
1. Harjai KJ, Shenoy C, Orshaw P, Boura J. Dual antiplatelet therapy
for more than 12 months after percutaneous coronary intervention: insights
from the Guthrie PCI Registry. Heart. 2009;95(19):1579-86.
2. Mauri L, Silbaugh TS, Garg P, Wolf RE, Zelevinsky K, Lovett A,
Varma MR, Zhou Z, Normand SL. Drug-eluting or bare-metal stents for acute
myocardial infarction. N Engl J Med. 2008;359(13):1330-42.
3. Egorova N, Giacovelli J, Greco G, Gelijns A, Kent CK, McKinsey JF.
National outcomes for the treatment of ruptured abdominal aortic aneurysm:
comparison
of open versus endovascular repairs. J Vasc Surg. 2008;48(5):1092-100.
4. Shin DH, Chae IH, Youn TJ, Cho SI, Kwon DA, Suh JW, Chang HJ, Cho
YS, Chung WY, Choi YJ, Gwon HC, Han KR, Choi DJ. Reasonable duration of
Clopidogrel use after drug-eluting stent implantation in Korean patients.
Am J Cardiol. 2009;104(12):1668-73.
Our ischemic cardiopathy study group have read with interest the article written by Wurtz et al (1) related with the effect of proton pump inhibitor (PPI) on the antiplatelet effect of aspirin in patients with coronary artery disease. We agree that in view of the widespread use of PPIs, studies exploring the inhibitory effect of PPIs on aspirin are important.
First of all,there is evidence that atherosclerosis is an inflammatory...
Our ischemic cardiopathy study group have read with interest the article written by Wurtz et al (1) related with the effect of proton pump inhibitor (PPI) on the antiplatelet effect of aspirin in patients with coronary artery disease. We agree that in view of the widespread use of PPIs, studies exploring the inhibitory effect of PPIs on aspirin are important.
First of all,there is evidence that atherosclerosis is an inflammatory disease of the vasculature (2), and aspirin intake reduces the levels of inflammatory markers and the risk of vascular events (3,4). Therefore, we understand that aspirin acts by reducing the inflammatory component in the atherosclerotic plaques.
Regarding this, we would like to know the position of the authors on the following question judged relevant by our group: would the reduced effect of aspirin on the platelet aggregation (related with the PPI use) affect significantly the clinical benefits known with the use of aspirin?
REFERENCES
1. Wurtz M, Grove EL, Kristensen SD, Hvas AM. The antiplatelet effect of aspirin is reduced by proton pump inhibitors in patients with coronary artery disease. Heart 2010;96(5):368-71.
2. Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med 1999;340(2):115-26.
3. Kennon S, Price CP, Mills PG, Ranjadayalan K, Cooper J, Clarke H, et al. The effect of aspirin on C-reactive protein as a marker of risk in unstable angina. J Am Coll Cardiol 2001;37(5):1266-70.
4. Lindahl B, Toss H, Siegbahn A, Venge P, Wallentin L. Markers of myocardial damage and inflammation in relation to long-term mortality in unstable coronary artery disease. FRISC Study Group. Fragmin during Instability in Coronary Artery Disease. N Engl J Med 2000;343(16):1139-47.
Thank you for your letter with its very interesting comments about
inappropriate filter settings for electrocardiographs and monitors. This
has been a research interest of mine for many years and Professor
Chamberlain in Brighton has been aware of it since the early 1980's. You
obviously have put in a significant amount of work in tracing your 50
patients. The 0.05 to 100 Hz settings are fine f...
Thank you for your letter with its very interesting comments about
inappropriate filter settings for electrocardiographs and monitors. This
has been a research interest of mine for many years and Professor
Chamberlain in Brighton has been aware of it since the early 1980's. You
obviously have put in a significant amount of work in tracing your 50
patients. The 0.05 to 100 Hz settings are fine for ensuring that there is
no ST segment distortion but may allow significant baseline drift. If
linear phase filters of up to 0.5Hz are used the baseline drift can be
eliminated without causing any worse distortion than the old 0.05Hz first
order response.However it is essential to know that your machine has a
linear phase filter and meets the AHA or British standard before using it.
The situation is made more difficult because some machines may use a
linear phase filter in auto mode and a conventional one in manual mode.
Because many machines put the calibration pulses in after filtering the
ECG it is impossible to use the calibration pulse to assess how much
distortion the machine is producing. This is not as specified by the AHA.
As you state it is important to review the set up of all ECG equipment.
Further work and education is needed to prevent inappropriate
interventions and erroneous diagnoses.
We read with interest Dr Tayler et al's piece entitled 'Diagnosing an
MI: don't trust the monitor!'[1]. We have had a similar experience with
ECG filter-related artefactual ST segment change, resulting in patient
referral direct to the catheter lab for primary percutaneous coronary
intervention. As a consequence, we have audited the variation in ECG
filter settings utilised during the acute coronary syndrome 'patient
jou...
We read with interest Dr Tayler et al's piece entitled 'Diagnosing an
MI: don't trust the monitor!'[1]. We have had a similar experience with
ECG filter-related artefactual ST segment change, resulting in patient
referral direct to the catheter lab for primary percutaneous coronary
intervention. As a consequence, we have audited the variation in ECG
filter settings utilised during the acute coronary syndrome 'patient
journey'. We found that patients (n=50) had ECGs acquired using up-to 4
different (average 2.14 /-0.99) filter settings during their admission.
Across the hospital trust, 15 different filter settings were in operation
and only 10% of ECGs met the AHA standard of 0.05-100Hz[2]. Our audit
findings have increased awareness of the importance of ECG filter settings
in the fidelity of ECG recording and led to standardisation of all ECG
equipment in the trust, hopefully limiting the inappropriate diagnosis of
ST segment elevation. We congratulate the authors on raising awareness of
this problem and encourage others to review the set-up of their ECG
equipment
1. Tayler, D., J. Gunn, and D. Chamberlain, Diagnosing an MI: don't
trust the monitor! Heart. 96(5): p. 408-408.
2. Bailey, J., et al., Recommendations for standardization and
specifications in automated electrocardiography: bandwidth and digital
signal processing. A report for health professionals by an ad hoc writing
group of the Committee on Electrocardiography and Cardiac
Electrophysiology of the Council on Clinical Cardiology, American Heart
Association. Circulation, 1990. 81(2): p. 730-739.
We have read with interest the article written by Curzen et all related with the results of the COURAGE study2. We agree with the author that different interests and points of view drive us to different interpretations. However, independently of which position we defend one fact should not be underestimated: in addition to the important limitations pointed out by the author such as that only 6 % of the 35539 screened were finall...
We have read with interest the article written by Curzen et all related with the results of the COURAGE study2. We agree with the author that different interests and points of view drive us to different interpretations. However, independently of which position we defend one fact should not be underestimated: in addition to the important limitations pointed out by the author such as that only 6 % of the 35539 screened were finally randomised, only 3 % of the stents were drug eluting designs and the lack of inclusion as an end-point the 32.6 % revascularizations needed in the group of medical treatment, patient´s quality of life deserves also an especial attention. As is mentioned by Curzen, percutaneous intervention can be accomplished to improve survival, to relief symptoms or both. Patients with stable coronary disease unfortunately present comorbid conditions that require additional treatments and it conducts to a long list of pills needed at the end of the day. Quality of life in ischemic heart disease may be measured as anginal class, but also as patient´s well being. Multiple drug treatment is associated with a limitation in patient´s perception of comfort and may contribute to depression disorders3. Percutaneous revascularization permits a significant reduction in the number of pills needed and thus, any intervention that may reduce this dependence will add quality of life and this reduction should be considered in the decission making of this cohort of patients.
REFERENCES
1. Curzen NP. Is there evidence for prognostic benefit following PCI
in stable patients? COURAGE and its implications: an
interventionalist´s view. Heart 2010; 96: 103-5.
2. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al. Optimal medical therapy with or without PCI for stable coronary disease. N.Engl.J Med. 2007;356:1503-16.
3. Lichtman JH, Bigger JT, Jr., Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lesperance F et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation 2008;118:1768-75.
Conflict of Interest:
None declared
Trans-radial procedures - still two weights and two measures? (letter regarding article from SL Hetherington, Heart 2009;95:1612-1618)
Bernardo Cortese, MD
Cardiologia Interventistica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
We read with great interest the article from SL Hetherington et al. regarding the impact of trans-radial primary PCI on clinical outcome in a single-center experience.[1] Authors discovered lower (although not statistically significant) in-hospital mortality rates and lower major cardiac or cerebrovascular adverse events with this technique, compared to the standard trans-femoral route. Previous studies regarding this topic were small, single-centre experiences, therefore not powered enough to demonstrate a significant clinical impact of the trans-radial technique during urgent PCI. Today, this study covers a vacuum in the literature, and being us “radialists� since our very first PCI, we appreciate that.
Anyhow, despite the well-known lower hospital stay and costs, and now with the help of such clinical evidence, Authors and the community of interventional cardiologists should now investigate why this technique is still so underused in western countries. We wonder why if a single centre uncontrolled clinical trial is able to change the overall acute myocardial infarction management in the cath lab,[2] multi-centre, multi-national, old and recent [1, and Schufele TG, in http://directnews.americanheart.org/extras/sessions2009/slides/41_pslides.pdf, accessed 29 Nov 2009] clinical evidence-based and economical evidence-based medicine should not change current practice.
The extent of the problem of “radial resistance� may be easily understood given the following numbers. Until a few years ago, only 30% of European centres adopted a routine trans-radial approach for PCIs.[3] And has been recently disclosed that in only 1.32% of overall procedures performed in the US such approach is used.[4]
We believe that the interventional community should stop seeing at radialists as weird colleagues and start to change their mind. Now it is not time to call for a randomized trial. This is time to call for awareness.
[1] Hetherington SL, Adam Z, Morley R, et al. Acute coronary syndromes: Primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: changing patterns of vascular access, radial versus femoral artery. Heart 2009;95:1612-1618.
[2] Vlaar PJ, Svilaas T, van der Horst IC, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008 Jun 7;371(9628):1915-20.
[3] Lefevre T and Louvard Y. Description and management of difficult anatomy encountered during transradial intervention. In: M. Hamon and E. McFadden, Editors, Transradial approach for cardiovascular interventions, Europa Stethoscope Media, Carpiquet (2003),241-254.
[4] Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008 Aug;1(4):379-86.
Chen and Whitlock mention differences in risk for heart disease among
South Asians, Chinese and others, in seeking to unveil the causes of heart
disease in China, regionally and globally (1). Continuing disparities and
high rates of diabetes and premature heart disease continue among the 25
million South Asians abroad and the 1.3 billion in South Asia, with
initial low rates in China and the Chinese diaspora now increasing...
Chen and Whitlock mention differences in risk for heart disease among
South Asians, Chinese and others, in seeking to unveil the causes of heart
disease in China, regionally and globally (1). Continuing disparities and
high rates of diabetes and premature heart disease continue among the 25
million South Asians abroad and the 1.3 billion in South Asia, with
initial low rates in China and the Chinese diaspora now increasing.
The first research submitted showing differences in heart disease
between South Asians and Chinese was to this journal (then the British
Heart Journal) in February 1959 by Muir, published January 1960, exactly
fifty years ago (2). This necropsy study showed disproportionate early
mortality in South Asians in a study of seven racial groups in Singapore
from 1948 to 1957 (2). The first research published was by Danaraj and co-
authors, submitted April 1959 and published October 1959 in the American
Heart Journal, from similar necropsy studies in Singapore from 1950 to
1954, showing similar results, and reprinted January 2010 with an
accompanying editorial (3,4).
Credit for first publication and citations have gone to Danaraj, who
became an esteemed physician and leader in Malaya. Muir, with scant
reference to his publication in the extensive literature on this subject,
became an acclaimed leader in cancer research in Scotland and globally.
Time to publication was longer for Muir, likely since the British
Heart Journal was a quarterly then and the American Heart Journal,
monthly, explaining earlier submission and later publication. The lack of
credit and citations likely stems from the inadvertent omission of Muir's
publication from the 131 references in the 1989 definitive review, and a
typo in the text mentioning the first publication by Danaraj as 1957
rather than October 1959, making Muir's in January 1960, seem much later.
The 50th Anniversary of Muir's neglected landmark publication in this
journal is an opportunity to correct this, to recognize Muir's and
Danaraj's equally pioneering research on disparities in health, and an
opportunity to review and reduce continuing disparities (4). With the
causes of heart disease mostly unveiled, we now have a golden opportunity
to change the course of heart disease for South Asians and for all
communities globally (4).
1. Chen Z, Whitlock G. Unveiling the causes of heart disease in
China. Ed. Heart 2009;95:1818-9.
2. Muir CS. Coronary Heart Disease in seven racial groups in
Singapore. British Heart Journal 1960;22:45-53
3. Danaraj TJ, Acker MS, Danaraj W, et al. Ethnic Group Differences
in Coronary Heart Disease in Singapore: An Analysis of Necropsy Records.
American Heart Journal 1959;58:516-26.
4. Rambihar VS, Rambihar SP, Rambihar VS Jr. Race, Ethnicity and
Heart Disease: a challenge for cardiology for the 21st century. Ed. Am
Heart J 2010; 159:1-14.
Editor, we read with great interest the article "NICE evaluation of transmyocardial laser revascularisation and percutaneous laser revascularisation for refractory angina [1].
The authors described a variety of treatment options for patients suffering from refractory angina pectoris (RAP). However, a very important, evolving innovation is missing: coronary sinus intervention (CSI).
Coronary venous int...
The statistics of propensity adjustment, that Harjai et al.(1) have used with some modifications, is a recognised tool to increase the value of non-experimental data(2,3).
However, these authors have used propensity statistics less efficiently than other studies in this area have done(2,3). In fact, propensity statistics has only been introduced by Harjai et al. in their multivariate regression analysis, but...
Dear Dr Johnson,
Thank you for your letter with its very interesting comments about inappropriate filter settings for electrocardiographs and monitors. This has been a research interest of mine for many years and Professor Chamberlain in Brighton has been aware of it since the early 1980's. You obviously have put in a significant amount of work in tracing your 50 patients. The 0.05 to 100 Hz settings are fine f...
We read with interest Dr Tayler et al's piece entitled 'Diagnosing an MI: don't trust the monitor!'[1]. We have had a similar experience with ECG filter-related artefactual ST segment change, resulting in patient referral direct to the catheter lab for primary percutaneous coronary intervention. As a consequence, we have audited the variation in ECG filter settings utilised during the acute coronary syndrome 'patient jou...
Bernardo Cortese, MD Cardiologia Interventistica, Fondazione IRCCS Caââ¬â¢ Granda Ospedale Maggiore Policlinico, Milano, Italy
We read with great interest the article from SL Hetherington et al. regarding the impact of trans-radial primary PCI on clinical outcome in a sing...
Chen and Whitlock mention differences in risk for heart disease among South Asians, Chinese and others, in seeking to unveil the causes of heart disease in China, regionally and globally (1). Continuing disparities and high rates of diabetes and premature heart disease continue among the 25 million South Asians abroad and the 1.3 billion in South Asia, with initial low rates in China and the Chinese diaspora now increasing...
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