Letters
Medication use was verified by reviewing medications that participants brought to the visit. We analyzed the prevalence of indications for statin therapy according to ACC/AHA guidelines and ATP III guidelines (which were the most relevant guidelines at the time of ARIC visit 5) and the use of statins and other medications to lower lipid levels. Results | A considerable portion of the ARIC cohort used medication to lower lipid levels at visit 5, but uncontrolled hyperlipidemia was still common according to the ATP III guidelines then in place (Table 1). Individuals with a high absolute risk for coronary heart disease (>20% for 10 years) were the least likely to be at their goal for low-density lipoprotein cholesterol levels (49.2% not at goal), whereas participants with not more than 1 risk factor for coronary heart disease were most likely to be at goal (18.6% not at goal). Full implementation of the prior ATP III guidelines should have resulted in treatment of 72.8% of our sample. In contrast, according to ACC/AHA guidelines, 97.1% of ARIC participants 75 years or younger met 1 of the 4 major indications for statin therapy (clinical CVD, diabetes, lowdensity lipoprotein cholesterol level >190 mg/dL [to convert to millimoles per liter, multiply by 0.0259], or absolute 10-year CVD risk ≥7.5%) (Table 2). Of these individuals 75 years or younger, 49.8% were taking a statin but only 9.0% were taking a high-intensity statin (Table 2). Half the cohort studied was older than 75 years and 53.2% of these individuals were taking a statin. Individuals older than 75 years are not included in the ACC/AHA guidelines owing to lack of evidence in this age group. These findings confirm that implementation of the new guidelines should increase statin use significantly in individuals aged 65 to 75 years. Discussion | The increase in statin eligibility according to the new guidelines is largely a consequence of the 7.5% CVD risk threshold in primary prevention. Although substantial ev idence supports a risk-based approach for statin allocation,1 the 7.5% CVD risk threshold is aggressive, creating a nearly universal recommendation for statin use in individuals aged 65 to 75 years. The recently updated lipid guidelines in the United Kingdom6 have chosen a 10% risk threshold for CVD to allocate statin use. The ideal risk threshold for CVD, the optimal role for statin therapy in the elderly, and the overall utility of statin therapy in primary prevention remain highly controversial topics that require further research. Michael D. Miedema, MD, MPH Faye L. Lopez, MS, MPH Michael J. Blaha, MD, MPH Salim S. Virani, MD, PhD Josef Coresh, MD, PhD Christie M. Ballantyne, MD Aaron R. Folsom, MD, MPH
Corresponding Author: Michael D. Miedema, MD, MPH, Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, 800 E 28th St, Minneapolis, MN 55414 ([email protected]). Published Online: November 17, 2014. doi:10.1001/jamainternmed.2014.6288. Author Contributions: Dr Miedema and Ms Lopez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Miedema, Lopez, Blaha, Virani, Folsom. Drafting of the manuscript: Miedema. Critical revision of the manuscript for important intellectual content: Lopez, Blaha, Virani, Coresh, Ballantyne, Folsom. Statistical analysis: Miedema, Lopez. Obtained funding: Coresh, Folsom. Administrative, technical, or material support: Virani. Study supervision: Folsom. Conflict of Interest Disclosures: Dr Ballantyne has received institutional grant support from Abbott Diagnostics, Amarin, Amgen, Eli Lilly, Esperion, GlaxoSmithKline, Genentech, Merck, Novartis, Pfizer, Regeneron, Roche, Roche Diagnostic, Sanofi-Synthelabo, the National Institutes of Health, and the American Heart Association and has served as a consultant to Abbott Diagnostics, Aegerion, Amarin, Amgen, Arena, Cerenis, Esperion, Genentech, Genzyme, Kowa, Merck, Novartis, Pfizer, Resverlogix, Regeneron, Roche, and Sanofi-Synthelabo. No other disclosures were reported. 1. Stone NJ, Robinson J, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;6(25, part B):2889-2934. 2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25): 3143-3421. 3. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med. 2014;370 (15):1422-1431. 4. Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C; American College of Cardiology; American Heart Association; National Heart, Lung and Blood Institute. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. Circulation. 2002;106(8):1024-1028. 5. ARIC Investigators. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. Am J Epidemiol. 1989;129(4):687-702. 6. National Collaborating Centre for Primary Care (UK). Lipid modification: cardiovascular risk assessment of blood lipids for the primary and secondary prevention of cardiovascular disease [Internet]. London, England: Royal College of General Practiioners (UK): July 2014. http://www.nice.org.uk/guidance/cg181 /resources/guidance-lipid-modification-cardiovascular-risk-assessment-and -the-modification-of-blood-lipids-for-the-primary-and-secondary-prevention -of-cardiovascular-disease-pdf. Accessed May 15, 2014.
COMMENT & RESPONSE
Do Not Throw Out the Resveratrol With the Bath Water
Author Affiliations: Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota (Miedema); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota,
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Minneapolis (Lopez, Folsom); Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, Maryland (Blaha); Center for Innovations, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas (Virani); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Coresh); Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas (Ballantyne); Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas (Ballantyne).
To the Editor Potential disease-preventive effects of the red grape constituent resveratrol are a subject of intense biomedical research and attract a lot of media interest. Recently, Semba et al1
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poured cold water over the idea that resveratrol as a dietary constituent prevents heart disease or cancer or prolongs life. The study suggests that the intake of red wine by elderly persons, as judged by urinary levels of resveratrol metabolites, did not affect overall mortality, incidence of cardiovascular disease or cancer, or biomarkers of incipient inflammation. This publication elicited considerable negative resonances in the international lay press (eg, “Red wine health benefits ‘overhyped’”).2 We submit that several aspects render the study unsuitable to warrant such negative resonance. Participants were classified into quartiles based on their urinary resveratrol metabolite levels measured once at the start of the study. We seriously doubt that this single value can accurately reflect lifetime exposure because the impact of resveratrol on health is likely to have been heavily influenced by consumption patterns prior to the investigation. The dose-response relationships that govern the efficacy of resveratrol are unclear and may display hormetic properties with opposing effects observed at small and large doses.3 In the study by Semba et al,1 the first quartile of urine levels contained values from participants who refrained from resveratrol consumption and those whose resveratrol intake was low, militating against the ability to tease out potential differences between resveratrol-naive participants and those with a low intake. Nutritional status of study participants is one of the many variables that affect disease prevention outcomes. Resveratrol is likely to engage its effects via subtle disturbances of abnormal cell metabolic processes associated with high fat intake typical of the Western diet.4 This means that resveratrol may cause its preventive efficacy only in individuals who have consistently ingested high amounts of fat and/or have the metabolic syndrome, but not in healthy ones.5 The article by Semba et al1 does not give any indication as to the amount of fat consumption by the participants. A quarter to a third of them were prediabetic or diabetic; assessment of study end points vs resveratrol consumption in this subgroup vis à vis the metabolically uncompromised participants might have been revealing. We believe that many more trials focusing on individuals characterized by a particular biochemical or pathological constitution or nutritional intake need to be performed before resveratrol can confidently be thrown out with the proverbial bath water. Karen Brown, PhD Alessandro Rufini, PhD Andreas Gescher, DSc Author Affiliations: Cancer Biomarkers and Prevention Group, Department of Cancer Studies, University of Leicester, Leicester, England. Corresponding Author: Andreas Gescher, DSc, Cancer Biomarkers and Prevention Group, Department of Cancer Studies, University of Leicester, RKCSB Leicester LE2 7LX, England ([email protected]).
(University of Wisconsin), Joseph Baur, PhD (University of Pennsylvania), Anait S. Levenson, MD, PhD (University of Mississippi), John Pezzuto, PhD (University of Hawaii at Hilo), and Ole Vang, PhD (Roskilde University, Denmark). 1. Semba RD, Ferrucci L, Bartali B, et al. Resveratrol levels and all-cause mortality in older community-dwelling adults. JAMA Intern Med. 2014;174(7): 1077-1084. 2. Roberts M. Red wine health benefits 'overhyped.' BBC News. May 12, 2014. http://www.bbc.co.uk/news/health-27371546. Accessed August 2014. 3. Calabrese EJ, Mattson MP, Calabrese V. Resveratrol commonly displays hormesis: occurrence and biomedical significance. Hum Exp Toxicol. 2010;29 (12):980-1015. 4. Baur JA, Pearson KJ, Price NL, et al. Resveratrol improves health and survival of mice on a high-calorie diet. Nature. 2006;444(7117):337-342. 5. Yoshino J, Conte C, Fontana L, et al. Resveratrol supplementation does not improve metabolic function in nonobese women with normal glucose tolerance. Cell Metab. 2012;16(5):658-664.
Left Ventricular Noncompaction and Athletes: Looking for Stratification Criteria To the Editor We read with great interest the case report by Peritz et al1 about the distinction between hypertrabeculation and left ventricle noncompaction (LVNC) cardiomyopathy, especially in participants in competitive sports. In our opinion, and after reviewing literature, there are 2 matters of concern. First, as reported in a recently published series of 1146 athletes by Gati et al,2 athletes exhibit a higher prevalence of left ventricular trabeculation compared with controls. Therefore, for the diagnosis of LVNC in this population, we think that perhaps it would be necessary to take into account other factors such as familiar disease previously known, left ventricle dilatation and/or dysfunction, ventricular arrhythmias in Holter monitoring or during exercise testing, and the presence of late gadolinium hyperenhancement in cardiac magnetic resonance imaging as a marker of fibrosis. As Stöllberger et al3 mentioned, this is an important diagnostic dilemma, and given the further implications that diagnosis of LVNC implies, especially in athletes, standardization of diagnostic criteria is mandatory. Otherwise, as it happens in hypertrophic cardiomyopathy, several risk stratification criteria of sudden death should be considered for LVNC. Once the diagnosis is established following the classic criteria, different clinical scenarios of LVNC can be present, probably with different prognosis. Ventricular dysfunction, nonsustained ventricular tachycardia in Holter monitoring, and the presence of fibrosis should be considered as high-risk criteria.4 In conclusion, we think that to establish clear diagnosis criteria of hypertrabeculation vs LVNC is mandatory, and once LVNC is diagnosed, stratification criteria and follow-up is fundamental. Sandra Secades, MD Maria Martín, MD, PhD Cesar Morís, MD, PhD
Conflict of Interest Disclosures: None reported. Funding/Support: The authors’ research is supported by Cancer Research United Kingdom. Role of the Funder/Sponsor: Cancer Research United Kingdom had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication. Additional Contributions: We gratefully acknowledge suggestions and feedback during the preparation of this letter from Nihal Ahmad, PhD jamainternalmedicine.com
Author Affiliations: Department of Cardiology, Hospital Universitario Central de Asturias, Oviedo, Spain. Corresponding Author: María Martín, MD, PhD, Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu 27, 4L Oviedo Asturias, Spain ([email protected]). Conflict of Interest Disclosures: None reported. JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
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141
Medication use was verified by reviewing medications that participants brought to the visit. We analyzed the prevalence of indications for statin therapy according to ACC/AHA guidelines and ATP III guidelines (which were the most relevant guidelines at the time of ARIC visit 5) and the use of statins and other medications to lower lipid levels. Results | A considerable portion of the ARIC cohort used medication to lower lipid levels at visit 5, but uncontrolled hyperlipidemia was still common according to the ATP III guidelines then in place (Table 1). Individuals with a high absolute risk for coronary heart disease (>20% for 10 years) were the least likely to be at their goal for low-density lipoprotein cholesterol levels (49.2% not at goal), whereas participants with not more than 1 risk factor for coronary heart disease were most likely to be at goal (18.6% not at goal). Full implementation of the prior ATP III guidelines should have resulted in treatment of 72.8% of our sample. In contrast, according to ACC/AHA guidelines, 97.1% of ARIC participants 75 years or younger met 1 of the 4 major indications for statin therapy (clinical CVD, diabetes, lowdensity lipoprotein cholesterol level >190 mg/dL [to convert to millimoles per liter, multiply by 0.0259], or absolute 10-year CVD risk ≥7.5%) (Table 2). Of these individuals 75 years or younger, 49.8% were taking a statin but only 9.0% were taking a high-intensity statin (Table 2). Half the cohort studied was older than 75 years and 53.2% of these individuals were taking a statin. Individuals older than 75 years are not included in the ACC/AHA guidelines owing to lack of evidence in this age group. These findings confirm that implementation of the new guidelines should increase statin use significantly in individuals aged 65 to 75 years. Discussion | The increase in statin eligibility according to the new guidelines is largely a consequence of the 7.5% CVD risk threshold in primary prevention. Although substantial ev idence supports a risk-based approach for statin allocation,1 the 7.5% CVD risk threshold is aggressive, creating a nearly universal recommendation for statin use in individuals aged 65 to 75 years. The recently updated lipid guidelines in the United Kingdom6 have chosen a 10% risk threshold for CVD to allocate statin use. The ideal risk threshold for CVD, the optimal role for statin therapy in the elderly, and the overall utility of statin therapy in primary prevention remain highly controversial topics that require further research. Michael D. Miedema, MD, MPH Faye L. Lopez, MS, MPH Michael J. Blaha, MD, MPH Salim S. Virani, MD, PhD Josef Coresh, MD, PhD Christie M. Ballantyne, MD Aaron R. Folsom, MD, MPH
Corresponding Author: Michael D. Miedema, MD, MPH, Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, 800 E 28th St, Minneapolis, MN 55414 ([email protected]). Published Online: November 17, 2014. doi:10.1001/jamainternmed.2014.6288. Author Contributions: Dr Miedema and Ms Lopez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Miedema, Lopez, Blaha, Virani, Folsom. Drafting of the manuscript: Miedema. Critical revision of the manuscript for important intellectual content: Lopez, Blaha, Virani, Coresh, Ballantyne, Folsom. Statistical analysis: Miedema, Lopez. Obtained funding: Coresh, Folsom. Administrative, technical, or material support: Virani. Study supervision: Folsom. Conflict of Interest Disclosures: Dr Ballantyne has received institutional grant support from Abbott Diagnostics, Amarin, Amgen, Eli Lilly, Esperion, GlaxoSmithKline, Genentech, Merck, Novartis, Pfizer, Regeneron, Roche, Roche Diagnostic, Sanofi-Synthelabo, the National Institutes of Health, and the American Heart Association and has served as a consultant to Abbott Diagnostics, Aegerion, Amarin, Amgen, Arena, Cerenis, Esperion, Genentech, Genzyme, Kowa, Merck, Novartis, Pfizer, Resverlogix, Regeneron, Roche, and Sanofi-Synthelabo. No other disclosures were reported. 1. Stone NJ, Robinson J, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;6(25, part B):2889-2934. 2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25): 3143-3421. 3. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med. 2014;370 (15):1422-1431. 4. Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C; American College of Cardiology; American Heart Association; National Heart, Lung and Blood Institute. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. Circulation. 2002;106(8):1024-1028. 5. ARIC Investigators. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. Am J Epidemiol. 1989;129(4):687-702. 6. National Collaborating Centre for Primary Care (UK). Lipid modification: cardiovascular risk assessment of blood lipids for the primary and secondary prevention of cardiovascular disease [Internet]. London, England: Royal College of General Practiioners (UK): July 2014. http://www.nice.org.uk/guidance/cg181 /resources/guidance-lipid-modification-cardiovascular-risk-assessment-and -the-modification-of-blood-lipids-for-the-primary-and-secondary-prevention -of-cardiovascular-disease-pdf. Accessed May 15, 2014.
COMMENT & RESPONSE
Do Not Throw Out the Resveratrol With the Bath Water
Author Affiliations: Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota (Miedema); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota,
140
Minneapolis (Lopez, Folsom); Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, Maryland (Blaha); Center for Innovations, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas (Virani); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Coresh); Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas (Ballantyne); Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas (Ballantyne).
To the Editor Potential disease-preventive effects of the red grape constituent resveratrol are a subject of intense biomedical research and attract a lot of media interest. Recently, Semba et al1
JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
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Letters
poured cold water over the idea that resveratrol as a dietary constituent prevents heart disease or cancer or prolongs life. The study suggests that the intake of red wine by elderly persons, as judged by urinary levels of resveratrol metabolites, did not affect overall mortality, incidence of cardiovascular disease or cancer, or biomarkers of incipient inflammation. This publication elicited considerable negative resonances in the international lay press (eg, “Red wine health benefits ‘overhyped’”).2 We submit that several aspects render the study unsuitable to warrant such negative resonance. Participants were classified into quartiles based on their urinary resveratrol metabolite levels measured once at the start of the study. We seriously doubt that this single value can accurately reflect lifetime exposure because the impact of resveratrol on health is likely to have been heavily influenced by consumption patterns prior to the investigation. The dose-response relationships that govern the efficacy of resveratrol are unclear and may display hormetic properties with opposing effects observed at small and large doses.3 In the study by Semba et al,1 the first quartile of urine levels contained values from participants who refrained from resveratrol consumption and those whose resveratrol intake was low, militating against the ability to tease out potential differences between resveratrol-naive participants and those with a low intake. Nutritional status of study participants is one of the many variables that affect disease prevention outcomes. Resveratrol is likely to engage its effects via subtle disturbances of abnormal cell metabolic processes associated with high fat intake typical of the Western diet.4 This means that resveratrol may cause its preventive efficacy only in individuals who have consistently ingested high amounts of fat and/or have the metabolic syndrome, but not in healthy ones.5 The article by Semba et al1 does not give any indication as to the amount of fat consumption by the participants. A quarter to a third of them were prediabetic or diabetic; assessment of study end points vs resveratrol consumption in this subgroup vis à vis the metabolically uncompromised participants might have been revealing. We believe that many more trials focusing on individuals characterized by a particular biochemical or pathological constitution or nutritional intake need to be performed before resveratrol can confidently be thrown out with the proverbial bath water. Karen Brown, PhD Alessandro Rufini, PhD Andreas Gescher, DSc Author Affiliations: Cancer Biomarkers and Prevention Group, Department of Cancer Studies, University of Leicester, Leicester, England. Corresponding Author: Andreas Gescher, DSc, Cancer Biomarkers and Prevention Group, Department of Cancer Studies, University of Leicester, RKCSB Leicester LE2 7LX, England ([email protected]).
(University of Wisconsin), Joseph Baur, PhD (University of Pennsylvania), Anait S. Levenson, MD, PhD (University of Mississippi), John Pezzuto, PhD (University of Hawaii at Hilo), and Ole Vang, PhD (Roskilde University, Denmark). 1. Semba RD, Ferrucci L, Bartali B, et al. Resveratrol levels and all-cause mortality in older community-dwelling adults. JAMA Intern Med. 2014;174(7): 1077-1084. 2. Roberts M. Red wine health benefits 'overhyped.' BBC News. May 12, 2014. http://www.bbc.co.uk/news/health-27371546. Accessed August 2014. 3. Calabrese EJ, Mattson MP, Calabrese V. Resveratrol commonly displays hormesis: occurrence and biomedical significance. Hum Exp Toxicol. 2010;29 (12):980-1015. 4. Baur JA, Pearson KJ, Price NL, et al. Resveratrol improves health and survival of mice on a high-calorie diet. Nature. 2006;444(7117):337-342. 5. Yoshino J, Conte C, Fontana L, et al. Resveratrol supplementation does not improve metabolic function in nonobese women with normal glucose tolerance. Cell Metab. 2012;16(5):658-664.
Left Ventricular Noncompaction and Athletes: Looking for Stratification Criteria To the Editor We read with great interest the case report by Peritz et al1 about the distinction between hypertrabeculation and left ventricle noncompaction (LVNC) cardiomyopathy, especially in participants in competitive sports. In our opinion, and after reviewing literature, there are 2 matters of concern. First, as reported in a recently published series of 1146 athletes by Gati et al,2 athletes exhibit a higher prevalence of left ventricular trabeculation compared with controls. Therefore, for the diagnosis of LVNC in this population, we think that perhaps it would be necessary to take into account other factors such as familiar disease previously known, left ventricle dilatation and/or dysfunction, ventricular arrhythmias in Holter monitoring or during exercise testing, and the presence of late gadolinium hyperenhancement in cardiac magnetic resonance imaging as a marker of fibrosis. As Stöllberger et al3 mentioned, this is an important diagnostic dilemma, and given the further implications that diagnosis of LVNC implies, especially in athletes, standardization of diagnostic criteria is mandatory. Otherwise, as it happens in hypertrophic cardiomyopathy, several risk stratification criteria of sudden death should be considered for LVNC. Once the diagnosis is established following the classic criteria, different clinical scenarios of LVNC can be present, probably with different prognosis. Ventricular dysfunction, nonsustained ventricular tachycardia in Holter monitoring, and the presence of fibrosis should be considered as high-risk criteria.4 In conclusion, we think that to establish clear diagnosis criteria of hypertrabeculation vs LVNC is mandatory, and once LVNC is diagnosed, stratification criteria and follow-up is fundamental. Sandra Secades, MD Maria Martín, MD, PhD Cesar Morís, MD, PhD
Conflict of Interest Disclosures: None reported. Funding/Support: The authors’ research is supported by Cancer Research United Kingdom. Role of the Funder/Sponsor: Cancer Research United Kingdom had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication. Additional Contributions: We gratefully acknowledge suggestions and feedback during the preparation of this letter from Nihal Ahmad, PhD jamainternalmedicine.com
Author Affiliations: Department of Cardiology, Hospital Universitario Central de Asturias, Oviedo, Spain. Corresponding Author: María Martín, MD, PhD, Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu 27, 4L Oviedo Asturias, Spain ([email protected]). Conflict of Interest Disclosures: None reported. JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 06/01/2015
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