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Introduction: Advanced age is an important risk factor for acute coronary syndrome (ACS). Our purpose was to evaluate the particularities of ACS in octogenarians in comparison with the younger group. Methods: We studied a sample of 3009 cases of ACS from 10 Portuguese public hospitals, consecutively discharged within each hospital in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors according to a standard protocol. We divided patients into two categories (

This study examined possible selective impairment of endothelial dysfunction in the peripheral vascular bed in patients with chronic heart failure in the absence of confounding factors influencing endothelial function (i.e. hypertension, hypercholesterolaemia and diabetes mellitus). Several recent studies have suggested that endothelium-dependent peripheral vasodilation is impaired but endothelium-independent vasodilation is preserved in patients with chronic heart failure. However, a classical paper has demonstrated that sodium nitrite-mediated calf blood flow is clearly depressed in patients with valvular heart disease and cardiomyopathy. We examined forearm blood flow changes mediated by acetylcholine and nitroprusside in patients with valvular heart disease (n = 55) or congenital heart disease (n = 13), and a comparison was made with healthy volunteers (n = 21). The blood flow changes mediated by acetylcholine and nitroprusside were significantly impaired in both patient groups (P < 0.01). When blood flow responses were collected from all patients, two types of vasodilatory capacity were found to have decreased significantly with increasing clinical severity of heart failure (New York Heart Association functional class; P < 0.01). This suggests that the peripheral vasodilatory responses mediated by endothelium-dependent and endothelium-independent vasodilators are significantly impaired in patients with symptomatic chronic heart failure due to non-ischaemic heart disease.

In this review paper on the pathophysiology of myocardial ischaemia, the recent concepts of the ischaemic cascade, as well as the concepts of stunning and hibernating myocardium, are discussed. It is clear that painful ischaemia is the final phenomenon in the ischaemic cascade and that it is preceded by biochemical disturbances, diastolic and systolic dysfunction and electrocardiographic abnormalities. Silent ischaemia remains a difficult research field.

This paper reviews the evidence regarding the cardioprotective effects of oestrogen replacement therapy in postmenopausal women. Oestrogens have been shown to improve serum lipid profiles, carbohydrate metabolism, and insulin sensitivity; prevent the formation and development of atherosclerotic plaque; reduce blood pressure and plasma fibrinogen levels; and favourably affect overall cardiac function. Thus, oestrogen replacement therapy may prevent or inhibit the progression of existing coronary disease, and may also have a protective effect against acute cardiovascular and cerebrovascular ischaemic events.

Valeur et al. report findings from a substudy of the DANAMI-2 trial. The paper describes the prognostic importance of a pre-discharge maximal exercise test following acute myocardial infarction in the era of aggressive reperfusion treatment of ST-elevation myocardial infarction (STEMI). Exercise testing has been validated and adopted for risk stratification before discharge in patients with acute coronary syndromes for several years. In addition to providing important prognostic information, exercise testing has also been used to select high-risk patients with provocable myocardial ischaemia (MI) suitable for revascularization. A pre-discharge exercise test also has significant impact on the patient’s rehabilitation; information on exercise capacity may facilitate tailored physical activity at a safe level, to be continued when the patient is at home. Since its first introduction in the 1930s, stressing the heart by exercise testing has been an important routine investigation in known or suspected coronary artery disease. However, in the modern era of very aggressive interventional reperfusion strategies, exercise testing is somewhat out of fashion, and today only a minority of patients go through a pre-discharge exercise test after an episode of acute coronary disease. In addition, the emphasis has progressively shifted from the exercise capacity obtained during the test, towards signs of ischaemia (ST-segment changes). Thus, when an exercise test is performed the information obtained on the individual exercise capacity may be overlooked because of the emphasis on ischaemia. This may be unfortunate since the exercise capacity is a strong independent risk factor for both cardiovascular and other mortality. Initially demonstrated in healthy subjects, a recent study by Myers showed that also in a clinical patient population referred for exercise testing with and without coronary artery disease, the peak exercise capacity was the strongest predictor for death. In fact, exercise capacity seems to be the best single exercise variable for identifying patients with low risk for cardiac death post-MI, either pre-discharge or post-discharge. In a meta-analysis of pre-discharge risk stratification, post-MI markers of left ventricular dysfunction (such as exercise duration) were better predictors of adverse outcome than markers of ischaemia. The rehabilitation aspect of testing is often neglected and the angiogram is substituted as a marker of increased risk, with the perception that once the stenosis is fixed, the risk is gone. However, the prognostic importance of angiographic findings is often overestimated.

This editorial refers to "The prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe: The Euro Heart Surgery on diabetes and the heart" † by M. Bartnik et al. on page 1884 Coronary artery disease (CAD) accounts for over 60% of deaths in people with diabetes, which is at least twice that of the non-diabetic population. In addition, impaired glucose metabolism (IGM), comprising impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG), is also associated with an increased risk of CAD. The paper by Bartnik et al. [1] in this issue of the Journal reports the findings of the Euro Heart Survey on Diabetes and the Heart. In a cohort of 4961 people from 110 countries throughout Europe presenting with CAD, only 29% of people with acute CAD and 34% of people with stable CAD were normoglycaemic. In other words, in people presenting to hospital with CAD, it was abnormal to have normal glucose tolerance. Abnormal glucose tolerance is common in the general population. In Australian men and women aged 65 years, similar to the mean age of the Euro Heart Survey population, approximately 8% had undiagnosed diabetes and 25% had IGM [2]. Therefore, although both undiagnosed diabetes and IGM are common, they are even more common in people presenting with CAD. Although there are some uncertainties with respect … *Correspondence to: Stephen Colagiuri, Professor and Director, Department of Endocrinology and Diabetes, Diabetes and Metabolism Faculty, Prince of Wales Hospital, Avoca St, Randwick 2031 NSW, Australia. Tel.: +61 2 9382 4602; fax: +61 2 9382 4688 (E-mail: colagiuris{at}sesahs.nsw.gov.au).

This editorial refers to “Differences between patients with a preserved and a depressed left ventricular function: a report from the EuroHeart Failure Survey”1 by M.J. Lenzen et al. on page 1214 The enigma faces us every day and we still do not know how to define or manage it. Patients develop the typical signs and symptoms of heart failure although they apparently have “normal” left ventricular systolic function. The syndrome occurs both acutely and chronically and is responsible for approximately half of the heart failure epidemic.1 The terminology is the subject of debate. There is consensus that patients with “diastolic heart failure” or “heart failure with preserved left ventricular function” tend to be older and more frequently female with a history of hypertension. The rates of other common co-morbidities appear to be similar. Prognosis is generally as poor as in patients with systolic dysfunction. Given the paucity of studies assessing the incidence and prevalence of this common condition, the paper “Differences between patients with a preserved and a depressed left ventricular function: a report from the EuroHeart Failure Survey” by Lenzen et al.,2 published in this issue, is a welcome contribution. The report compares the demographic differences between patients with reduced ejection fractions and patients with preserved left ventricular function based on data from the EuroHeart Failure survey.3 The reported data helps us to understand some of the similarities and differences between the patient characteristics of these two groups. The red herring may be our traditional dependence on … *Correspondence to: Kenneth Dickstein, Division of Cardiology, University of Bergen, Central Hospital in Rogaland 4011 Stavanger, Norway. Tel.: +47-51-51-80-00; fax: +47-51-51-99-21 E-mail address: trout{at}online.no

Sir, I read with interest the recent paper by Pugh et al. on the acute haemodynamic effects of testosterone in patients with cardiac failure, with the greatest benefit seen in those with the lowest androgen levels.1I note that a larger study assessing the safety and efficacy of testosterone therapy for …

To the Editor We read with great interest the paper by de Simone and colleagues1showing that the addition of verapamil to class IC or III antiarrhythmic drugs significantly reduced the atrial fibrillation (AF) recurrences. Recurrences of AF were assessed mainly on the basis of patients’ symptoms. Such a strategy may result in a failure to detect brief, symptom-free episodes of AF. Moreover, …

We read with great interest the paper by Baldasseroni et al. who report increased mortality in patients with congestive heart failure (CHF) complicated by atrial fibrillation (AF), left bundle-branch block (LBBB) or both.1This observation is interesting, but probably not surprising, as AF and LBBB are associated with a number of factors which may affect mortality and morbidity in CHF patients. Many cardiovascular (and cerebrovascular) events associated with CHF and AF have thrombosis as the underlying pathophysiological process. AF is associated with a hypercoagulable state, and an increased risk of thromboembolism compared to sinus rhythm.2CHF fulfils the components of Virchow’s triad for thrombogenesis, and epidemiological data support an association between CHF and thromboembolism3 …

Pressure and flow velocity can be measured distal to coronary stenoses by means of miniaturized sensors with guidewire technology. This is an alternative non-invasive method of assessing functional coronary vessel stenosis severity, applicable for the intermediate stenoses and for the results of coronary interventions. The complexity of the coronary circulation, however, limits the possibility of establishing simple cut-off criteria to identify flow-limiting stenoses. In this paper, we review advantages and limitations of the different pressure and velocity indices and their application in different clinical settings.

See doi:10.1016/S1095-668X(03)00282-3for the article to which this editorial refers Humans have always tried to push back the limits imposed by their physical characteristics. Competitive sports are in themselves a continuous struggle tosurpass these established limits. As physicians, we are frequently asked not only to identify and treat diseases, but to define what is and what is not healthy behaviour. The paper by Heidbuchel and co-workers poses a fundamental question to medical practitioners: what are the reasonable limits for the practice of sport? The general population has the perception that athletes are the healthiest members of society, since they are capable of such impressive physical performance. However, the cardiological community has been interested in the inherent risk of sport for many years. Although …

This paper was guest edited by Brahmajee Nallamothu, University of Michigan, Ann Arbor, MI, USA. Emergency invasive coronary angiography for non-ST-elevation myocardial infarction revealed an occluded ( Panel A ) left anterior descending artery (LAD) and apical akinesia with reduced global ejection fraction (EF = 35%) in an 83-year-old female patient and a conservative treatment strategy was amended. Coronary …

This paper was guest edited by Prof. Frank E. Rademakers, University Hospital Gasthuisberg, Leuven, Belgium A 65-year-old male patient with typical chest pain underwent low-dose coronary computed tomographic (CT) angiography (CCTA) with 1.4 mSv for evaluation of coronary artery disease (CAD). Panel A shows a curved multiplanar reformation of the left circumflex artery with a high-grade …

It is only in the last few years that the broad-spectrum antiarrhythmic properties of sotalol have become increasingly recognized. Racemic sotalol has potent beta-blocking and class III antiarrhythmic properties, and it has been reported that this drug is able to control supraventricular and ventricular arrhythmias. Recently, several studies performed with the d-sotalol isomer, which is almost devoid of the beta-blocking effects compared to the racemate, suggest significant antiarrhythmic efficacy and good tolerance of the dextro-isomer. In this paper we review and discuss the effects of sotalol and d-sotalol in patients with ventricular tachycardia (VT), ventricular fibrillation (VF) or cardiac arrest in whom VT or VF was induced by programmed electrical stimulation (PES).

This paper describes and discusses interventions that may lead to prolongation of the action potential. Special emphasis is given to regulation by drugs. The results of studies focusing on the modulation of inward and outward currents are presented in detail. Specific attention is given to Na+, Ca2+, K+ and Cl- channel currents and their components.

As a consequence of persistently raised blood pressure, left ventricular hypertrophy (LVH) develops as a compensatory mechanism for wall stress induced by the increase in afterload. Recent advances in the fields of molecular biology and genetics are now clarifying the mechanisms involved in the development of LVH. It has been reported that messenger RNA of oncogenes, such as c-fos and c-myc, increases by stretching; these oncogenes contribute to the progression of LVH, the messenger RNA expression of myosin and contractile protein synthesis in the cardiomyocytes. Vasoactive hormones and vascular contracting factors are also reported to have a progressive effect on LVH. In contrast, some antihypertensive agents have been shown to have pharmacological effects on regression of LVH in animals and man. The mechanisms responsible for LVH progression have been extensively studied. In contrast, the mechanisms of LVH regression have not been defined and require elucidation. This paper outlines the basic recognition of the mechanisms of LVH progression and discusses the varied pharmacological actions of calcium antagonists and angiotensin converting enzyme inhibitors on the regression of LVH in man and rats. Although the role of antihypertensive therapy in regression of LVH remains controversial, the calcium antagonist nicardipine appears to have an important role to play in the treatment of LVH in hypertension and in congestive heart failure.

The ECAT Angina Pectoris Study is a European multicentre study investigating the pathogenetic and possibly predictive role of the haemostatic system in the progress of coronary heart disease. In this paper we report the cross-sectional analysis of haemostatic factors in 3043 patients, who underwent coronary angiography due to angina pectoris. Fibrinogen levels were higher in patients with one or more coronary stenoses of at least 50% than in patients without, by an average of 0.16 g.l-1 (P0.0001). Depressed fibrinolytic activity due to higher levels of PAI was also associated with the presence of coronary stenoses. There was no association with the extent of coronary arteriosclerosis, as assessed by the number of involved arteries, except that patients who had more vessels with total occlusions had higher fibrinogen levels. Depressed fibrinolytic activity was also clearly associated with diabetes, obesity, higher triglyceride levels, smoking and impaired cardiac pump function as assessed by ejection fraction. Cholesterol levels were particularly correlated with protein C and plasminogen.

We have read with great interest the paper by Schulz et al. 1 recently published in the European Heart Journal . In this study, discontinuation of clopidogrel therapy was significantly associated with drug-eluting stents (DES) thrombosis (ST) only in the first 6 months after the procedure, with no …

Innovations in pacing technology, which include the addition of rate-responsive features to programmable pacemakers, can improve the quality of life of patients suffering from sick sinus syndrome. Among the strategies providing rate-adaptive cardiac pacing, the most attractive is the physiological restoration of closed-loop chronotropic control. This paper describes how autonomic nervous system (ANS) control information is extracted from dynamic measures of myocardial contractile performance obtained from unipolar conductance measurements using the stimulation electrode in the right ventricular cavity. The pacemaker uses the ANS information to modulate pacing rate and restore normal physiological control of heart rate. A new algorithm, regional effective slope quantity (RQ), for isolating the ANS signal was developed. The resulting signal, ventricular inotropic parameter (VIP), is a normalized parameter proportional to the strength of the ANS inotropic signals to the myocardium. The efficacy of the ANS control concept was evaluated in multi-centre studies. Patients with AV block and VIP-controlled pulse generators performed defined exercise protocols. The ANS-controlled pacing rate and the spontaneous sinus rate were closely correlated. Blood pressure and subjective patient reports further indicated that good control of the cardiovascular circulation was achieved.

An east-west regional gradient in cardiovascular mortality was found within seven counties in mid-Sweden during the years 1969-1983. The mortality differences were of considerable magnitude for ischaemic heart disease (IHD) as well as for stroke. In previous reports, in which the distribution of risk factors among middle-aged men was presented, the moderate variation among the communities could not explain the mortality variation. Water hardness has previously been reported to be inversely related to cardiovascular mortality in several countries. In this paper, water samples from all 76 communities in seven counties were analysed in relation to mortality rates from IHD and stroke for men and women. Water hardness (Ca+Mg and other minor constituents), and the sulphate and bicarbonate concentrations of the drinking water were inversely related to IHD as well as stroke mortality. The water factors were also inversely related to non-fatal IHD even when account was taken of the age variation and the traditional risk factors as measured by a postal questionnaire. Variation of the water factors accounted for 41% of the variation in IHD mortality rate and 14% of the variation in stroke mortality rate over the 76 communities.

Despite numerous publications, mostly with small patient populations, the management of post-infarct septal rupture is still not well defined. Although urgent surgery appears to be the therapy of choice it is still unclear whether surgery very early after septal rupture in patients with severe haemodynamic compromise salvages a significant number of patients. In this paper we present the data from a large population of consecutive patients with post-infarct septal rupture from one cardiac centre. From 1980 through 1989, 108 patients with post-infarct septal rupture were seen at this Regional centre of whom 81 had operative repair; 43 (53%) of these survived the early postoperative period. Of 32 patients with cardiogenic shock who had surgery, early operative mortality in those operated on within 48 h of rupture was 90% (18/20) compared with 33% (4/12) in those operated on later (P less than 0.001). All survivors with pre-operative shock had intra-aortic balloon counter-pulsation before operation. Concomitant coronary artery bypass grafting was not associated with improved survival in our patients. Three patients survived long-term without operation. Analysis of population statistics suggest that approximately 270 patients with post-infarction septal rupture were not transferred from peripheral hospitals to the Regional Cardiothoracic Centre for assessment during this decade. Eur Heart J

We read with interest the results of the study by Nef et al. ,1 and would like to present a few comments to the paper. The Tako-Tsubo cardiomyopathy (TTC) is a circumferential epicardial damage manifested by very dynamic electrophysiologic and functional changes.2 The TTC occurs mainly in postmenopausal female after strong emotional stress, seldom in fertile …

We refer to the orginal paper by Jansson et al. 1 to which we would like to address some comments. Chromogranin A (CgA) has been accepted as a marker for the neuroendocrine tumours (NET), with some limits concerning its value for diagnostic purposes, and greater strength for monitoring their treatment. Chromogranin …

I read with interest the summary of the hotline sessions of this year's ESC Congress provided by Bergman et al. 1 The paper discusses the results of the F.I.R.E. study, which investigated the effect of a new drug, FX06 (fibrin-derived peptide Bβ15-42), for the prevention of ischaemia/reperfusion injury in the setting of acute STEMI, which we presented at hotline III. We think that the conclusion given in the EHJ that FX06 failed to significantly reduce reperfusion injury parameters in this STEMI population does not provide a fair judgement to the interesting results obtained in this trial. There is ample evidence from the literature that even small reductions in permanently damaged myocardium measured acutely after STEMI have the potential to provide sustained benefit for patients.2 This has been specifically demonstrated for microvascular obstruction by several groups, who …

We read with interest the paper by Turnbull et al. 1 about whether men and women respond differently to blood pressure-lowering treatment. For this purpose, a total of 31 randomized trials that included 103 268 men and 87 349 women were analysed. Interestingly, achieved blood pressure reductions were comparable for men and women in every trial. For the primary outcome of total major cardiovascular …

The Queen's Gambit is an opening move in chess that provides a variety of aggressive options to the player electing it. This report represents a similar gambit (the 'Sicilian Gambit') on the part of a group of basic and clinical investigators who met in Taormina, Sicily, to consider the classification of antiarrhythmic drugs. Paramount to their considerations were (1) dissatisfaction with the options offered by existing classification systems for inspiring and directing research, development and therapy, (2) the disarray in the field of antiarrhythmic drug development and testing in this post-CAST era, and (3) the desire to provide an operational framework for consideration of antiarrhythmic drugs that will both encourage advancement and have the plasticity to grow as a result of the advances that occur. The multifaceted approach suggested is, like the title of the manuscript, a gambit. It is an opening rather than a compendium, and is intended to challenge thought and investigation rather than to resolve issues. The manuscript incorporates first, a discussion of the shortcomings of the present system for drug classification; second, a review of the molecular targets on which drugs act (including channels and receptors); third, a consideration of the mechanisms responsible for arrhythmias, including the identification of 'vulnerable parameters' that might be most accessible to drug effect; and finally, clinical considerations with respect to antiarrhythmic drugs. Information relating to the various levels of information is correlated across categories (i.e., clinical arrhythmias, cellular mechanisms and molecular targets), and a 'spread sheet' approach to antiarrhythmic action is presented that considers each drug as a unit, with similarities to and dissimilarities from other drugs being highlighted. A complete reference list for this work would require as many pages as the text itself. For this reason, referencing is selective and incomplete. It is designed, in fact, to provide sufficient background information to give the interested reader a starting frame of reference, rather than to recognize the complete body of literature that is the basis for this paper.

We have read with interest the study by Brasselet et al. ,1 which evaluates the operator radiation exposure during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral approaches. We have some concerns about the paper. First, according to the authors' statement, the special feature of this study was that the operators were blinded to the data collection and study purpose; we would like to …

We read with great interest the investigative paper by Missel et al. 1 We would like to thank the authors for furthering our knowledge in this field with their continued production of high-quality research. Our one reservation is with the creation of a necrotic core (NC) to dense calcium (DC) ratio from VH–IVUS data. We are proponents of this excellent tool, but we also have …

We thank Dr Bonello and colleagues and Jeong and colleagues for their interest in our paper.1 We agree with Dr Bonello and colleagues that the clopidogrel regimen around the time of platelet function measurement is crucial, since this impacts both the level of platelet reactivity and possibly acute clinical outcomes. As we note in the methods section of our paper, patients on chronic clopidogrel therapy in our study were not re-loaded, and those who were clopidogrel-naive received a 600 mg loading dose. There was no significant difference in ADP-induced platelet reactivity between these two groups (mean 183 + 94 PRU vs. 186 + 73 PRU), nor was there a difference between these groups in the rate of patients having high platelet …

This paper updates the current view on clinical significance of systolic time intervals (STI) in estimating the cardiac changes associated with hypertension. The following three intervals were measured as STI: (1) electromechanical systole (QS2 interval); (2) left ventricular ejection time (LVET) and (3) pre-ejection period (PEP). Firstly, the influences of changes in heart rate, preload, afterload and myocardial contractility upon each interval were reviewed; secondly, clinical applications of STI in various types of hypertension such as essential hypertension, hypertension with angina pectoris and pheochromocytoma were studied. In patients with essential hypertension, there was a good positive correlation between PEP and left ventricular mass, and a shortening of LVET was observed only at the decompensated stage. The changes in STI in angina pectoris with or without hypertension were similar and were different from those in essential hypertensives. STI in patients with pheochromocytoma were characterized by a marked shortening of QS2 and LVET with normal PEP. These findings indicate the usefulness of STI in detecting cardiac changes in various types of hypertension.

In this paper, a few aspects of the dye dilution method for measuring cardiac output are described. Data obtained with this technique show good reproducibility, although any first determination tends to be higher than subsequent ones. The method has been found to be useful in the assessment of cardiac function in, for instance, hypertensive patients. An additional advantage is that it can be used also in exercising subjects. As the dye dilution technique still is considered to be the standard method, other methods, such as thermodilution, should always be validated in comparison with the dye dilution technique.

In this paper, we report a case of dilated cardiomyopathy with right atrial thrombi and pulmonary artery thromboemboli, in which regression of thromboemboli followed fibrinolytic therapy, and normalization of left ventricular dimensions and function were documented at echocardiographic follow-up. The important role of transoesophageal echocardiography in diagnosis and follow-up of right intracavitary masses and thromboemboli in the main pulmonary arteries is discussed, as is the role of echocardiography in follow-up of cardiomyopathy.

Each method used for the extraction and isolation of intimal lipoproteins has advantages and disadvantages. Gentle extraction methods are needed to characterize subtle modifications in the structure and biologic properties of the lipoproteins, whereas more aggressive methods are needed if the goal is to maximize the yield of lipoproteins from atherosclerotic arteries. The present paper evaluates different methods used for the isolation of intima1 lipoproteins. Normal intima contains remnant-like and low density lipoprotein (LDL)-like particles that more strongly stimulate cholesterol esterification in macrophages than do control plasma LDL. Both fractions contain apolipoprotein (apo) E but neither shows clear signs of oxidative modification. LDL-like particles from atherosclerotic lesions, on the other hand, contain malondialdehyde- and 4- hydroxynonenal-lysine adducts in apo B, are chemotactic for monocytes and show increased degradation in macrophages, a process that oxidized LDL prepared in vitro can compete with. The findings support the conclusion that at least a portion of the LDL isolated from atherosclerotic lesions is similar, if not identical, to oxidatively modified LDL.

This paper reviews the haemodynamic effects of angiotensin-converting enzyme (ACE) inhibitors in hypertension, focusing on their ability to cause a fall in systemic vascular resistance, with no change in cardiac output and no reduction and even an increase in blood flow to vital organs such as the brain, the kidney and the heart. The haemodynamic efects of ACE inhibitors are qualitatively similar in congestive heart failure, except that, in the presence of impaired cardiac function, the fall in resistance is accompanied by a pronounced increase in cardiac output and tissue perfusion. In both conditions ACE inhibition opposes sympathetic influences and enhances vagal influences and, in hypertension, this intervention is followed by a regression of left ventricular hypertrophy providing a multifold background for a cardioprotective action. The new ACE inhibitor quinaprill appears to share the haemodynamic effects of other ACE inhibitors with an improvement of cardiovascular function in congestive heart failure.

We appreciated the paper by Pelliccia et al. 1 emphasizing the efficacy of the Italian preparticipation screening program for identifying hypertrophic cardiomyopathy (HCM) in athletes. Their findings may indeed explain the lower rate of athletic field deaths due to HCM reported in Italy compared to the USA, where standard 12-lead electrocardiography (ECG) is not routinely performed. Indeed, comparable findings have been obtained by other screening programs. …

We read with interest the review paper on aspirin and clopidogrel resistance by Wang et al .1 We agree that it is an emerging entity with important clinical implications. Nevertheless, we were surprised that very little emphasis was put on the antiplatelet agent resistance of diabetic patients. Only one short sentence mentioned that hyperglycaemia may decrease the effectiveness of antiplatelet therapy by increasing reactive oxidant species. Still the specific case of diabetic patients is of major interest as diabetes mellitus, especially type 2 diabetes, is an increasing cause of cardiovascular disease worldwide. Antiplatelet therapy is a cornerstone in the prevention and …

We thank Maron et al . for their editorial on our paper.1,2 Hypertrophic cardiomyopathy (HCM) is a capricious disorder, characterized by heterogeneity at all levels. Together with its relative rarity, this has resulted in a dearth of evidence-based practice. The authors suggest that cardiologists rely on guidance from a few major centres and imply that our paper is out of step with expert consensus. Unfortunately, in their effort to prevent overenthusiastic interpretation of our study, the authors create the impression that there are widely divergent approaches to risk stratification even within the expert community. It is accepted that the annual sudden death …

We read with great interest the paper by Aujesky et al .,1 validating the prognostic model comprising 11 routinely available clinical parameters in patients with pulmonary embolism (PE). However, the presented model is of low cost but also complex. Moreover, some parameters like presence of cancer, altered mental status, severity of heart failure, and chronic lung disease, can be difficult to assess …

In our paper, ‘Comparative analysis of the activity and content of different streptokinase preparations,’1 we only mentioned the results of the chromogenic assay for the activity measurement of STPase. To confirm, we also tested the samples with a clot-lysis assay as second assay. We have not shown the data of this confirmational tests as they did not significantly differ from the results of the chromogenic assay. The results of both …

We read with great interest the paper by Ou et al. 1 who report a significant association between the so-called ‘gothic’ aortic arch morphology and resting hypertension in patients after successful surgical repair of aortic coarctation. The article, however, raises several questions. A large population of post-coarctectomy patients is followed in our tertiary referral centre and cardiac magnetic resonance (CMR) imaging is performed at regular intervals in every patient. We were not able to classify all patients based on CMR angiography …

We would like to add some comments to an interesting paper of Voci et al. 1 Apart from the anterior and posterior descending coronary artery, it is possible to visualize transthoracically proximal and middle segments of the circumflex coronary artery and all three segments of the right coronary artery.2–5 The images other than from the apical windows are obtainable.4 Reduction of coronary flow reserve (CFR) depends not only …

It was with great interest that I read the paper by Nollen et al. 1 on the predictive value of aortic stiffness on the occurrence of progressive aortic dilatation in patients with Marfan syndrome. Their major finding was that aortic distensibility is an independent predictor of progressive aortic dilatation. The early diagnosis of Marfan syndrome and the identification of patients at high risk of aortic complication are still …

This editorial refers to "Newly detected abnormal glucose tolerance: an important predictor of long term outcome after myocandial infarction" † by M. Bartnik on page 1990. Recently, a plethora of scientific papers have revealed the parallel impairment of carbohydrate metabolism in patients referred to hospitals along with acute ischaemic events.1 The most recent, the Euro Heart Survey, reports the finding that more than two thirds of those patients are affected.3 This shows that the physicians in charge, both emergency care cardiologists and diabetologists responsible for the long-term treatment of these patients have so far completely underestimated the disease condition. On the other hand, it has been clear for several years that more than 75% of … * Correspondence to: Dr. Diethelm Tschope, Heart and Diabetes Center, North-Rhine Wetsfalia, Ruhr University, Bochum, Germany (E-mail: diethelm.tschoepe{at}ruhr-uni-bochum.de).

Dear Editor, We read with great interest the paper by Cowie et al., on clinical applications of B-type natriuretic peptide (BNP) testing.1 Atrial (ANP) and B-type natriuretic peptide are peptide hormones released in response to myocyte stretch. Novel biomarkers have been evaluated for four clinical purposes: prognostic screening in asymptomatic individuals, risk stratification in patients with clinical disease, diagnosis of clinical disease in patients with symptoms of uncertain cause and guidance in the selection or titration of drugs in patients with known disease. A dramatic rise in the number …

We read with great interest the paper by Dernelis and Panaretou1 as well as the editorial by Abdelhadi and colleagues2 on the efficacy of steroids in the prevention of paroxysmal and permanent atrial fibrillation. We do concur with the conclusions of Abdelhadi et al., regarding the potential therapeutic value of anti-inflammatory medication in patients with AF and a high inflammation status as reflected by elevated C-reactive protein …

Our review1 summarises the evidence of the clinical role of plasma BNP measurements in the management of patients in a variety of clinical settings and situations. As is clearly stated in the paper, and as all experienced physicians will know, BNP should not be used as a `stand alone' test but should be interpreted in the clinical context. Nevertheless, the results of studies published to date (and further studies currently reporting at scientific meetings but not yet published in full) support the diagnostic utility of BNP measurement, particularly in …

We read with interest the paper by Silvestri et al.1 on the report of erectile dysfunction (ED) after therapy with beta-blockers. An acknowledged preliminary look at an important topic. The author found that the incidence of ED was 3% in the group not knowing which drug they were taking, 16% in the group knowing that they were receiving a beta-blocker and 31% in the group also knowing the …

We read the paper by Riesen et al .1with great interest. It provides important information on a new beneficial effect of the administration of atorvastatin. Their study concentrated on parameters of inflammation (C-reactive protein) as well as lipid profile in patients with hypercholesterolemia and with or at risk for coronary heart disease. Besides studying anti-inflammatory effect, another important aspect could be the measurement of haemorheological parameters, platelet aggregation and endotheliumdysfunction. …

Dear Sir In recent years, the practise of coronary heart disease prevention has seen a shift from a focus on single risk factors to an emphasis on the total burden of risk (global risk approach). We note the publication the Systematic Coronary Risk Evaluation (SCORE) project by Conroy et al. as an interesting contribution to this approach in Europe.1However, certain features of this paper are worthy ofcomment. First, the SCORE project calculated the total cardiovascular risk rather than the risk of coronary heart disease. This was done to give a better estimate of risk to the person, to provide a better reflection of the health service implications of cardiovascular risk factors, and because non-coronary cardiovascular disease represents a greater proportion of all cardiovascular risk in European regions with low rates of coronary heart disease. These reasons are understandable. However, this approach may cause difficulties in practise. The risk factor profiles for stroke and coronary heart …