89 e-Letters

published between 2017 and 2020

  • misattribution of the source of an aortic systolic murmur

    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).

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  • a role for point of care scanning in the emergency context

    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).
    (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...

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  • Complete AV block…. but also partial interatrial block

    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.

  • A role for universal use of low-dose edoxaban in triple antithrombotic therapy

    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...

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  • How to mitigate diagnostic delay in constrictive pericarditis

    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...

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    We read with interest the article by Rusingiza et al (1)and report our experience from Northern Sri Lanka, a Low Middle Income Country (LMIC). Sri Lanka had invested heavily in free education and healthcare with demonstrably high literacy rates and positive health indices (2). However, the focus of the healthcare related investment has been in the secondary and tertiary care institutions, whilst primary care systems remain poorly developed. Northern Sri Lanka had been further impacted adversely by three decades of civil strife.
    We report our experience in the management of post-valvular surgery patients at the Jaffna Teaching Hospital, the only tertiary referral centre for the region. Improvements in socioeconomic conditions has resulted in a decline in the incidence of rheumatic heart disease in Sri Lanka which accounted for only 0.34% of all deaths in 2017 (3). Concurrently, established patients receiving prosthetic heart valves has increased mainly due to improving access to surgical facilities. Unfortunately, Northern Sri Lanka had been without facilities for cardiac surgery for three decades leaving patients to access facilities elsewhere in the country. Post-surgery follow-up occurred primarily in Jaffna and a few other secondary care hospitals in the region. Unlike in the Rwandan study, most of our patients received parenteral penicillin prophylaxis thereby enhancing compliance and were fitted with metallic rather than bioprosthetic valves, thereby necessitat...

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  • Hospitalization for Heart Failure as a Promising Risk Stratification Tool for Pulmonary Hypertension Related to Congenital Heart Disease

    To the Editor, we read with great interest the article by Ntiloudi et al[1], describing hospitalization for heart failure (HF) as a powerful predictor of mortality among adults with pulmonary hypertension related to congenital heart disease (PH-ACHD). Although pulmonary arterial hypertension (PAH) targeted therapy has improved their survival, long-term complications such as HF hospitalization commonly occurred, and dismal prognosis with a mortality rate of 18.5% deeply broke our heart, thus requiring earlier diagnosis, risk stratification and therapeutic intervention.
    Hospitalization for HF, a sign of clinical worsening, is associated with poor outcomes and generally used as one of composite endpoints in PAH[2], Ntiloudi et al stated nearly one-quarter of patients were hospitalized for HF, and they encountered a ninefold increased mortality risk compared to those not-hospitalized, since NYHA functional class III/IV raised a tenfold risk of death, its combination with HF hospitalization may better predict outcomes. A previous study[3] reported 29% patients with idiopathic and associated PAH were hospitalized for acute right heart failure at least once during a 39.1-month follow up, and those with hospitalizations had worse NYHA functional class, inferior right ventricle function, lower six minute walk test (6MWT) distance and worse outcomes defined by death/transplant (67% vs 33%). These two findings indicated a potential role of HF hospitalization for identifying...

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  • Hyponatramia may be drug side effect.

    There was significantly higher usage of both loop diuretics and aldosterone antagonist in the group with persistent hyponatraemia. Is it possible that one of the clinical manifestation of RV dysfunction, i.e peripheral oedema, led to an increased use of diuretic in this group and hence hyponatraemia as a complication of this treatment? Over diuresis in this scenario leads to activation of the RAAS which in turn worsens pulmonary hypertension and tricuspid regurgitation. The consequence of this is worsening peripheral oedema and the tendency to increase the diuretic dose.Hyponatraemia therefore may not be an independent predictor of outcome as stated.

  • We must continue to EXPLORE the benefits of CTO PCI

    We read with great interest the article by Elias et al (1) regarding the longer term clinical outcomes from the EXPLORE trial. The authors are to be congratulated for conducting this important study to address the optimal management of patients presenting with a concurrent CTO in a non-infarct related artery (non-IRA) during a STEMI. The results at 1 year are similar to those in the initial 4 month outcome (2), with no difference in the primary endpoints of cardiac MRI determined LVEF or LVEDV in either CTO-PCI and CTO-No PCI groups. At a median of 3.9 years, there was no difference in long term MACE, although an apparent increase in cardiovascular mortality (6% vs 1%, p=0.02).

    Whilst this important study adds to the much needed literature on randomised studies related to PCI of CTOs, the results should be interpreted with caution. Firstly, large scale contemporaneous studies in CTO PCI have had procedural success rates in the region of 90% (3), whilst in EXPLORE (2) this rate was considerably lower, at 73% by core laboratory. This suggests either a more anatomically complex subset of patients, or else attempts by non-dedicated CTO PCI operators, both of which affect the interpretation of the intention to treat population.

    Furthermore, the mortality data should be reviewed with care. At 12 months, there were 4 cardiovascular deaths (2.7%) in the CTO PCI group, with no deaths in the CTO-No PCI groups. These rates are significantly lower compared with other t...

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  • The prognostic role of collaterals should be explored.

    We thank dr. Katsouras for his response to our long-term EXPLORE manuscript (1). We agree that in the ST-segment elevation (STEMI) population the presence of collaterals to the concurrent chronic total occlusion (CTO) is of prognostic relevance. We previously reported in 413 consecutive STEMI patients with a CTO that the presence of well-developed collaterals to the CTO compared to poorly developed collaterals was associated with improved outcome. We also assessed the influence of the collateral origin on survival, as collaterals coming distally from the culprit lesion are (partially) blocked during the acute phase of STEMI. In 16% of the patients the collaterals originated directly or distal from the culprit lesion and these patients had a lower survival compared to the patients in whom the collaterals were not blocked during STEMI (2).

    In the EXPLORE trial patients with well-developed collaterals to the CTO had a significantly better left ventricular (LV) function at 4 months follow-up. Nonetheless, we did not find a significant treatment effect of CTO-PCI on global LV function nor on clinical outcome in patients with poorly developed nor with well-developed collaterals (3). On a regional level we found that the recovery of segmental wall thickening of the dysfunctional CTO myocardium was better in patients with well-developed collaterals. However, no significant interaction of collateral quality on the effect of CTO PCI was found (4). In EXPLORE there were 34 p...

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