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To the Editor, In the recent issue of your journal, we were pleased to read an interesting article by Sahin et al. (1) evaluating p-wave dispersion (PWd) in 58 patients with lichen planus (LP) compared to 37 age- and gender-matched healthy controls. The authors showed that PWd was higher in LP patients compared to healthy controls (39.9±12.9 msec vs. 32.4±11.8 msec, p = 0.005). Additionally, high-sensitivity C-reactive protein (hsCRP), low-density lipoprotein (LDL)-cholesterol and triglyceride levels were significantly higher in the LP group compared to the healthy controls. Furthermore, hsCRP levels were positively correlated with PWd. Atrial fibrillation (AF) is the most common clinical arrhythmia and presents as heterogeneous and discontinuous intra- and/or inter-atrial conduction due to several insults (e.g., inflammatory status) that promote atrial structural remodeling and provide a substrate for AF (2). In previous studies, Dilaveris et al. (3) described a new ECG index (PWd) and demonstrated that a p maximum >110 msec and a PWd >40 msec were simple and noninvasive parameters for the prediction of paroxysmal lone AF; Aytemir et al. (4) reported similar findings at a p maximum >106 msec and a PWd >36 msec. Thereafter, p-wave indices have been applied in a wide range of clinical contexts (5-9). The study by Sahin et al. (1) was the first in the literature to evaluate this marker in LP patients. However, mean p-wave indices in the study by Sahin et al. (1) were lower than described by Dilaveris et al. (3) and Aytemir et al. (4) in the prediction of paroxysmal lone AF. This result may be due to several differences among those studies, including different patient populations and risk factors and relatively short disease durations for the LP patients. Additionally, the study results should be interpreted in the context of the effects of LP on serum lipid levels (i.e., higher LDL-cholesterol and triglyceride levels), which are known as significant risk factors for chronic inflammation and AF development (10,11). Moreover, despite the volume of studies on this topic, p-wave index reference values and measurement techniques have not been standardized. Therefore, echocardiographic and clinical follow-up data could assist with determining the impact of both cardiac and non-cardiac diseases on p-wave indices. Other studies have suggested that intra- and/or inter-atrial electromechanical delays measured by tissue-Doppler imaging could be useful markers for the prediction of paroxysmal AF along with PWd (12-14). In addition to the non-invasive measurements, clinical follow-up data are essential to predict several parameters of AF development accurately. In conclusion, Sahin et al. highlighted LP as a chronic inflammatory condition and described the impact of this condition on atrial conduction using p-wave indices. However, tissue-Doppler imaging with echocardiography and the collection of clinical follow-up data related to AF development should be considered in future studies in addition to electrocardiographic evaluation.

Dear Editor, In a recent issue of your journal, we were grateful to read the enjoyable article by Caram et al. (1), which evaluated the prevalence of electrocardiographic and echocardiographic abnormalities in patients with chronic obstructive pulmonary disease (COPD) according to disease severity (25 mild/moderate and 25 severe/very severe COPD patients). The study showed that COPD patients have a high prevalence of left ventricular diastolic dysfunction (LVDD) and that this dysfunction is associated with disease severity. The authors also concluded that because of this close association, it is important to exclude decompensated heart failure (HF) during the evaluation of COPD exacerbation. Heart failure and COPD are the most common causes of mortality worldwide (2). The two diseases have significant overlap with regard to risk factors and pathophysiological mechanisms (including systemic inflammation), resulting in diagnostic and therapeutic challenges for both emergency department and outpatient physicians (3,4). Approximately 10–40% of patients with HF have reported concomitant COPD (3). Additionally, the prevalence of unrecognized HF was 20.9% in patients with COPD or asthma presenting to the emergency department (5), and this prevalence was reported as 20.5 and 17% in community patients with stable COPD (6,7). In addition to the similarity in mechanism, both conditions may present with highly similar symptoms, including dyspnea, orthopnea, coughing, exercise intolerance, fatigue, muscle weakness, disturbed sleep, anorexia, and anxiety (8). Caram et al. (1) noted that patients with COPD have significant echocardiographic abnormalities, independent of disease severity (98%). The most frequently noted echocardiographic abnormality was mild LVDD (88%). Of the several studied risk factors, COPD severity was the only significant predictor of LVDD, which might explain the common pathophysiological pathways in both conditions. However, this association should be coupled with follow-up data demonstrating that the concurrent presence of HF and COPD can increase morbidity and mortality. The findings of Caram et al. (1) demonstrated that HF and COPD are common and frequently concomitant conditions in patients with COPD that can be screened for using transthoracic echocardiography, an acceptable, safe, valid, and reliable imaging modality applicable to the COPD population. In addition to imaging techniques, concurrent HF and COPD exacerbations can be differentiated by biochemical tests, including natriuretic peptides (such as brain natriuretic peptide). Natriuretic peptides provide additional diagnostic accuracy and might be the most effective tool in refining the diagnosis for this patient population, given the high negative predictive value of a normal result. However, through the effects on pulmonary artery pressure and right-ventricular overload, COPD can also cause elevated circulating levels of natriuretic peptides (9,10). Despite this potential confounding factor, the negative predictive accuracy of natriuretic peptides for ruling out acute decompensated HF appears to be preserved, even in cohorts of patients with both HF and COPD diagnoses (5,11). In conclusion, this study demonstrated that patients with COPD have significant electrocardiographic and echocardiographic abnormalities, independent of disease severity. Among all of the pathological findings, LVDD is of great importance because of the prognostic role it plays in patients with COPD. As diagnosing cardio-pulmonary interaction is a complex process, LVDD in COPD patients can be best addressed through simple clinical measures, including natriuretic peptides and objective measurements of ventricular dysfunction by echocardiography.