Inflamm Bowel Dis  Volume 21, Number 1, January 2015

Letters to the Editor

Conventional Risk Factors and Cardiovascular Outcomes of Patients with Inflammatory Bowel Disease with Confirmed Coronary Artery Disease Reply: We thank Dr. Thapa for his interest in our work and for his thoughtful comments.1 This is indeed an area that has generated lot of interest, although a lot is still unknown. To our knowledge, ours is the largest study characterizing coronary angiogram findings in patients with inflammatory bowel disease (IBD). We would like to take this opportunity to respond to some of the comments included in the letter. First, we agree that Framingham Risk scores were not very high in this group. However, we would have to disagree that this puts this patient population in a low-risk category for coronary artery disease (CAD), simply for the fact that all these patients actually had angiographically proven CAD. We believe that the finding of low Framingham risk scores in this study population actually provides further evidence that traditional risk factors may be inadequate to estimate the actual CAD risk and, as we have postulated, that ongoing inflammation may be contributory to disease pathogenesis. Second, regarding the comment of low rates of biologic use, our study includes patients who had coronary catheterization between 2004 and 2010, and use of biologics may not have been as common in the early years of this study. We did analyze the difference in angiogram findings stratified by the use of immunomodulators/biologics and found no difference in the 2 groups, other than higher prevalence of severe right coronary artery stenosis in patients who were not on immunomodulators, as shown

The authors have no conflicts of interest to disclose. Copyright © 2014 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/MIB.0000000000000275 Published online 4 December 2014.

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in Supplementary Table 3a. It would be certainly interesting to see if patients who are requiring biologics have more severe CAD and also to see if patients on biologics actually have better outcomes from percutaneous coronary intervention because of improved inflammation control. Third, there were no statistically significant differences in the prevalence of hypertension, hyperlipidemia, or diabetes between the patients with IBD and the nonIBD control groups. As mentioned in our Discussion section, we agree that some of these risk factors, such as lower rates of active smoking may contribute to less severe coronary involvement in the IBD group. We also postulate that medications like 5-ASA may also have a protective effect. Given the lack of significant difference in the prevalence of hypertension, diabetes, or hyperlipidemia between the 2 groups in our study population, we do not think that these were major determinant factors for differences in coronary angiogram findings, although this certainly remains open to individual interpretation. Fourth, the absolute difference in preexisting coronary artery bypass graft rates between the 2 groups was only 8% and was not statistically significant. We do not see this as a major limitation to our study as the control population was matched for gender, cardiac catheterization date, and race. Although there is a possibility for selection bias, we believe that there may be an actual protective effect seen in the patient with IBD. It would be interesting to see if our data can be externally validated in other patient populations as well.

Ashish Aggarwal, MD* Ashish Atreja, MD, MPH† Samir Kapadia, MD‡ Rocio Lopez, MS, MPH§ Jean-Paul Achkar, MD† *Department of Internal Medicine Medicine Institute Cleveland Clinic † Department of Gastroenterology & Hepatology, Digestive Disease Institute Cleveland Clinic



Department of Cardiology Heart and Vascular Institute Cleveland Clinic § Department of Quantitative Health Sciences Cleveland Clinic Cleveland, Ohio

REFERENCE 1. Thapa SD. IBD and Extent of Coronary Atherosclerosis. Inflamm Bowel Dis. 2014;21:E1.

Clinical Remission As Defined by the Mayo Score: Do We Deceive Ourselves? To the Editor: I have read with great interest the article by Samaan et al1 on the measurement of endoscopic healing in ulcerative colitis (UC) clinical trials. Recently, mucosal healing has emerged as a major therapeutic goal in UC. In this context, endoscopic scores are increasingly used in both clinical trials and clinical practice in UC. In this systematic review, the authors concluded that the sigmoidoscopic component of the Mayo Score and the UC endoscopic index of severity show the most promise as reliable evaluative instruments of endoscopic disease activity.1 In 1987, Schroeder et al assessed oral 5-aminosalicylic acid prepared with a pH-sensitive polymer coating in 87 patients with mildly to moderately active UC

L. Peyrin-Biroulet received consulting fees from Merck & Co., Abbott Laboratories, Janssen Pharmaceutica, Genentech, Mitsubishi Motors, Ferring Pharmaceuticals, Norgine, Tillotts Pharma AG, Vifor, Shire plc, Therakos, Pharmacosmos, Pilege, BMS, UCB Pharma, Hospira, Celltrion, Takeda Pharmaceutical Company, Boehringer Ingelheim, Lilly and also received lecture fees from Merck & Co., Abbott Laboratories, Janssen Pharmaceutica, Ferring Pharmaceuticals, Norgine, Tillotts Pharma AG, Vifor, Therakos, HAC Pharma. Copyright © 2014 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/MIB.0000000000000293 Published online 4 December 2014.

Conventional risk factors and cardiovascular outcomes of patients with inflammatory bowel disease with confirmed coronary artery disease.

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