eLetters

88 e-Letters

published between 2017 and 2020

  • The true value of the NICE guidance

    We read with interest the Editorial on the recently updated National Institute for Health and Care Excellence (NICE) guidance for the assessment of suspected stable angina (1). The authors raise some salient points regarding the importance of careful history taking, the vexed question of the exercise ECG and the relative merits of the myriad non-invasive tests for diagnosing coronary artery disease (CAD). However, we believe they have adopted an unnecessarily alarmist tone in their criticisms and feel obliged to respond to several issues.
    Although they suggest that the assessment of pretest probability (PTP) has been disregarded, this process has merely been made implicit rather than explicit. The guidelines emphasise the pivotal importance of the clinical history and, in the setting of suspected angina, the nature of the presenting symptoms is the dominant predictor of CAD. Existing risk tables (2) show that either typical or atypical angina essentially guarantees a PTP of CAD ≥ 10%, the threshold warranting further investigation in the earlier NICE guideline. The residual clinical risk seen in patients with non-anginal symptoms is best addressed through cardiovascular screening approaches with an emphasis of lifestyle modification and primary prevention.
    Second, in arguing against the cost-effectiveness of the new approach, the authors imply that NICE are recommending “universal CTCA” which is incorrect. Non-anginal chest pain occurs in 40-60% of patients pre...

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  • Liver injury with direct-acting anticoagulants: has the fog cleared?

    To the Editor,
    The timely retrospective US cohort study by Alonso et al.1 assessed the risk of hospitalisations for liver injury after initiation of oral anticoagulation in patients with non-valvular atrial fibrillation, an unresolved safety issue so far.
    This study has key merits. First, it demonstrates the importance of conducting analytical research following safety signals emerging from spontaneous reporting systems2, to confirm or refute the drug-related hypothesis; this allows actual risk assessment and avoids unnecessary alarm, sometimes generated by pharmacovigilance analyses which do not recognize the limits of detected signals.
    Second, it provides a significant contribution to the debate on targeted patients’ selection when prescribing DOACs. In fact, the authors found that hospitalization rates for liver injury were lower among DOAC initiators as compared to patients starting warfarin, with rivaroxaban and dabigatran associated with highest and lowest risk, respectively. They conclude that “dabigatran may be considered a safer option” in patients susceptible of liver complications. In this vulnerable population, our proposal when initiating DOAC administration is to early monitor hepatic enzymes (i.e., within the first month of therapy) and, subsequently, on a yearly basis, especially for rivaroxaban users.3
    Although this study contributes to allay concern on the hepatotoxicity potential of DOACs, a residual aspect deserves attention. The...

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  • Cautious anticoagulation strategy in patients with dialysis-requiring end-stage kidney disease.
    Jonathan M Behar

    We read with interest this manuscript which demonstrated in a large clinical registry that patients with chronic kidney disease with indications for anticoagulation were often treated sub-therapeutically (1). A more aggressive approach was therefore advocated.

    We would like to point out that, while this study should be commended for including a large number of patients, it did not show data on the key clinical...

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  • Presenting the results of a pharmacoeconomic study: incremental cost-effectiveness ratio vs net monetary benefit

    The article by Wouters and colleagues (1) presents an exhaustive overview on how QALYs can be used in cost-effectiveness analysis. In this framework, the authors also mention the incremental cost-effectiveness ratio (ICER), which is the parameter typically employed to express the results of a cost-effectiveness study. The article, however, does not discuss the net monetary benefit (NMB), which is another parameter employed to express the results of a cost-effectiveness study.

    The incremental cost (deltaC) and the incremental effectiveness (deltaE) are the two main parameters of pharmacoeconomics and cost-effectiveness analysis, along with the willingness-to-pay threshold (lambda). The decision rule (e.g. in the case of a favourable pharmacoeconomic result) is (deltaC/deltaE)<lambda (Equation 1), if based on the ICER, or (deltaE x lambda - deltaC) > 0 (Equation 2), if based on the NMB. Likewise, an unfavourable pharmacoeconomic result is when (deltaC/deltaE)>lambda or when (deltaE x lambda - deltaC) < 0; NMB is defined as deltaE x lambda - deltaC, while ICER is defined as deltaC/deltaE.

    Despite its apparent complexity, most part of pharmacoeconomic methodology is described by the two simple equations reported above (i.e. Equations 1 and 2), but whether the ICER or the NMB is the best parameter for the purposes of pharmacoeconomic decision-making remains on open question.

    The study by Cowper et al evaluating new versus old oral antic...

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  • RE: Tea consumption and risk of ischaemic heart disease
    Dr.Rajiv Kumar

    This is good to read a research article on "Tea consumption and risk of ischaemic heart disease" This is the largest prospective study (cohort of Chinese adults) published to assess the association between tea consumption and incidence of IHD and showed that daily tea consumption is beneficial in reducing risk of IHD. Study has more limitations (although the investigators rightly said this).The is observational study,ma...

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  • Time metrics for reperfusion therapy and failure to achieve Guideline mandated times with P-PCI

    We read with interest the article by Varcoe et al (Heart Jan 15 th 20917) “Impact of call-to-balloon time on 30-day mortality in contemporary practice” We were not surprised by the results which indicate yet again that patients with delays to reperfusion suffer worse mortality rates - the concept of timely reperfusion in STEMI has been previously very well documented, and its importance recognised for some time. Thus de Lucca (1), Cannon (2) and others (3) reported data >10 years ago which supported the concept that mortality rates increase when important time metrics are not achieved. Time dependent infarct size is considered the cause (4)
    When the National Infarct Angioplasty Project (NIAP) was established in 2008 with the explicit aim of rolling out P-PCI in the UK, everyone involved in care of STEMI patients thought it was a good idea to go with a policy of one STEMI management strategy, for simplicity. No-one doubted that P-PCI should become the standard of care. Some (including the authors of this letter - one of whom served on NIAP) voiced concerns however that, based on the published data, achieving guideline mandated times was essential, and that this might be difficult to achieve with P-PCI in patients transferred from more rural regions. There was assurance from Department of Health that >95% of patients were “within distance” of a P-PCI centre. We tried to point out that being “within distance”, and being within the mandated times were very differe...

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  • A Case for Palliative PCI
    Sarah R Blake

    Dear Editor

    On reading the review on coronary revascularisation in the elderly by Cockburn et al (1) I must agree that more trials are needed to focus on the benefit of PCI in elderly populations.

    When assessing these patients, clinicians should consider the impact of symptom relief versus procedural risk. If a patient is experiencing recurrent and debilitating chest pain requiring frequent hospital a...

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  • Re:A Case for Palliative PCI
    James Cockburn

    We would like to thank Sarah Blake et al, for their thoughtful and insightful comments.

    Firstly, we agree that "palliative PCI" can be a very useful treatment in this elderly patient population. Locally at our institution, via our heart team meeting, we can offer an elderly symptomatic patient with multiple co-morbidities percutaneous coronary intervention (PCI), which often fails to achieve complete re-vasculari...

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