The Author’s reply: We have read with interest the response letter to our paper ‘Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics’. The answers to the remarks of the author are perfectly summarised in the excellent editorial ‘Added value of heart valve clinics in the management of asymptomatic aortic stenosis’. The editorial underlines the gap between guidelinesrecommended intervention in valvular heart disease (VHD) and the realworld situation. This is certainly also the case for aortic valve stenosis (AS) and besides education, the organisation of ambulatory care of patients with AS in heart valve clinics (HVCs) offers a possibility for the optimisation of care. In our paper, we have shown for the first time how the approach in a dedicated HVC results in a better outcome compared with usual care. Improved followup with earlier recognition of symptoms and referral to surgery is the reason for these results. This was achieved by a higher number of consultations per year, longer average consultation time, more frequent use of exercise testing, biomarker use and CT. It is not surprising that the benefit was most important in the group with moderate AS. Besides the fact that we know that these patients are also at high risk of a bad outcome, the attention given to these patients (intended or not) in the usual care situation is less than when the treating cardiologist is alerted by aortic valve velocities >4 m/s, mean gradients >40 mm Hg and aortic valve areas <1 cm2. We agree that inequity in the management of patients with VHD/AS should be avoided and we should try to organise the care of these patients so that all patients are treated following the recommendations. The difficulty is the availability of material and human resources for a growing population of patients with AS. As for heart failure clinics, nurses specialised and trained for the followup of patients with AS could be part of the solution to this problem.
One of the challenges in prevention of stroke is identification of patients at risk of atrial fibrillation (AF) shortly before the onset of the arrhythmia so that prevention therapies can be promptly instituted. In this issue of Heart, Nadarajah and colleagues report the development and validation of an algorithm based on data from the UK Clinical Practice Research Datalink GOLD dataset that included 2 081 139 individuals of whom 7386 developed AF within 6 months. This new algorithm-Future Innovations in Novel Detection of Atrial Fibrillation (FINDAF) – identified a highrisk cohort with a 20fold higher 6 month incident of AF with a superior discrimination performance compared with other commonly used risk scores (figure 1). The 10 most important variables in the FINDAF score are age, ethnicity, heart failure, nonAF electrophysiology procedures, rhematic mitral stenosis, other mitral valve disease, chronic obstructive pulmonary disease, sex, gout and chronic ischaemic heart disease. In the accompanying editorial, Diederichsen and Swennbert comment that “The population studied was quite young and healthy at an average age of 50 years, and a low proportion developed AF (0.4%). Still, the model classified approximately 20% of individuals as high risk, with the risk of AF in those being 20fold higher compared with individuals classified as low risk.” The advantage of the FINDAF score is that is can be calculated automatically based on electronic health record data, not requiring biomarkers or imaging studies. Even so “screening and AF detection are not helpful themselves. Studies powered to investigate clinical outcomes downstream from screening are critically needed to reduce the risk of negative outcomes in undetected AF, but studies such as this help FIND a path forward.” Although opioids are though to reduce breathlessness in patients with heart failure (HF), a systemic review and metaanalysis of by Gaertner and colleagues of 7 randomised controlled trials with a total of 271 participants found no significant benefit of opioid therapy for symptom reduction (figure 2). Opioids also were associated with a higher risk of adverse effects including nausea, vomiting and constipation but not with more serious side effects such as respiratory depression or haemodynamic instability. Schlenker and Steiner put this study into a palliative care perspective. They comment that “we praise Gaertner and colleagues in their effort to clarify the role of opioids for dyspnoea management in heart failure. We agree that opioids may not be effective and may pose harm for some patients.” Even so, in endstage HF, “The experience of breathlessness can be terrifying for patients and is a major contributor to psychological distress in this population. Opioids are therefore a standard part of dyspnoea management at the end of life in an attempt to decrease the experience of air hunger.”
To the Editor No evaluation of cardiovascular disease and mortality sequelae of COVID19 would be complete without documentation of the increase in the prevalence of mechanical complications (MCs) of myocardial infarction (MI) attributable to delay in seeking or obtaining timely reperfusion treatment for ST elevation myocardial infarction (STEMI). This delay was associated with a resurgence of STEMIrelated MCs, namely, ventricularfree wall rupture, acute papillary muscle rupture with mitral regurgitation and ventricular septal rupture, which had hitherto undergone a significant decrease in prevalence. In Taiwan, Lin et al noted that among 1523 adult cardiac operations performed in two hospitals over a period of 5 years (January 2015 to December 2019), only 0.3% (95% CI 0.1% to 0.5%) of the patients were diagnosed with MCs of MI. However, within the first 5 months of 2020 (the COVID19 pandemic era), MIrelated MCs underwent an increase in prevalence amounting to 4.2% of 118 cardiac operations. In France, Bouisset et al studied the impact of delay in seeking medical attention (the socalled prehospital delay) on the prevalence of MCs of STEMI. Data on 6185 patients were evaluated in an analysis that covered two time periods, namely, 1 March 2019 to 31 May 2019 and 1 March 2020 to 31 May 2020. In that analysis, patients were allocated to four groups according to prehospital delay, as follows: 0–12 hours, 12–24 hours, 24–36 hours and 36–48 hours. In the four subgroups, global rates of MCs were 0.82%, 1.43%, 1.24% and 5.07%, respectively. The global rate of MC significantly (p<0.001) increased with prehospital delay. Lin et al attributed the prehospital delay to fear of contracting COVID19 infection. This was a fear also expressed by a number of patients in a narrative review of the association of COVID19 and STEMIrelated ventricular septal rupture.
