Letter to the editor Herz 2013 DOI 10.1007/s00059-013-4001-1 © Urban & Vogel 2013
Comment on Ozcan F, Turak O, Canpolat U et al (2013) Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients. Herz. doi:10.1007/s00059-013-3914-z
To the Editor We read the article“Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients” by Ozcan et al. [1] with great interest. The authors aimed to investigate the association between TIMI risk score and epicardial fat thickness (EFT) in patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (USAP). They concluded that EFT is independently associated with TIMI risk score and may be an emerging risk factor for adverse events in NSTEMI/USAP patients. We thank the authors for their contribution of the present study, which is successfully designed and documented. EFT measurement with echocardiography has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. EFT has a three-dimensional distribution, and two-dimensional echocardiography cannot give an adequate window of all cardiac segments, especially in obese subjects, and is highly dependent on acoustic windows [2]. It is widely recognized that an accumulation of EFT is strongly related to coronary artery disease (CAD). EFT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition.
S. Balta · U. Canpolat
Association of epicardial fat thickness with TIMI risk score EFT measured by echocardiography has been known to be associated with metabolic syndrome [3]. Additionally, echocardiography-based EFT measurement was related to several metabolic abnormalities and independently associated with fatty liver disease [4]. Also, the duration of hormone therapy (HT) may be different in these patients. We think that the results of the study would be more robust if the authors had mentioned these factors including the duration of HT and liver function tests. EFT can also be affected by atherosclerotic risk factors such as alcohol consumption, hypothyroidism [5], and higher inflammatory status [3], for example, an inflammatory disease, cardiac syndrome X, and infection [6]. In the present study, the authors did not mention these possibly contributing factors. It would have been better if the authors had given information about these factors. Furthermore, the severity of CAD was evaluated by calculation of Gensini scores in the present study. However, the SYNTAX score (SS) may also be used for grading of coronary complexity based on angiographic visual assessment. The addition of clinical risk factors to the SS has been shown to potentially further augment its utility in the objective evaluation of the severity of CAD. The Logistic Clinical SXscore consisting of four continuous variables including SXscore, age, creatinine clearance, and left ventricular ejection fraction substantially enhances the risk stratification of CAD patients for the outcome of long-term all-cause death compared with the SXscore in isolation. The
Logistic Clinical SXscore was able to accurately distinguish patients with or without a clinical outcome and could accurately predict individual patient risk without under- or over-estimating risk [7]. Second, we strongly believe that it would be better to give interobserver and intraobserver variability for CAD severity in the current study. Finally, EFT itself without other inflammatory markers may not provide information to clinicians about systemic inflammation. Therefore, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will help evaluate the results of further studies on EFT and TIMI risk score in acute coronary syndrome patients.
Corresponding address S. Balta Department of Cardiology Gulhane School of Medicine Tevfik Saglam Street 06018 Etlik-Ankara Turkey [email protected]
Compliance with ethical guidelines Conflict of interest. S. Balta, S. Demirkol, M. Demir, U. Kucuk, and Z. Arslan state that there are no conflicts of interests.
Herz 2013
| 1
Letter to the editor
Reply We appreciate the interest and comments from Dr. Balta et al. on our study “Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients,” published in Herz [1]. Epicardial fat tissue (EFT) can be evaluated and measured by echocardiography, as first shown and validated by Iacobellis et al. [8]. Although radiologic techniques like computerized tomography[9, 10] and magnetic resonance imaging can provide a volumetric and more accurate measurement, echocardiographic assessment of EFT certainly has the advantages of being inexpensive, noninvasive, and readily available but still accurate and reproducible [8]. As noted by Balta et al. and also mentioned in the study limitations sections the article [1], our study would be stronger if these patients were evaluated with volumetric measurement techniques like computerized tomography or magnetic resonance imaging. However, because of the inclusion of patients with acute coronary syndrome, application of such techniques may delay patients for emergent catheterization. Also, additional radiation and contrast media exposure with computerized tomography before coronary angiography may harm patients much more. Thus, each technique may have both advantages and disadvantages, although their accuracies may differ from each other. It is known that EFT functions as an endocrine organ to secrete both pro-inflammatory and anti-inflammatory cytokines and mediators, which contributes to local and systemic inflammatory pathways. As an important risk factor that plays a role in acute coronary syndrome, metabolic syndrome is also associated with increased EFT in previous studies [10]. The association of increased EFT with TIMI risk score remained significant even after correction for traditional cardiovascular risk factors and metabolic syndrome components in our study. As we mentioned in our paper, we excluded patients with systemic inflammatory condition including infections, viral- and steato-hepatitis, abnormal renal and liver function tests, and hypo- or hyperthyroidism. However, we had no data about the duration of hyper-
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Herz 2013
tension and alcohol consumption in our study population, which may be associated with both coronary events and EFT. As noted by Balta et al., our study would be more powerful if we included SYNTAX and clinical SYNTAX scores besides the Gensini score. However, we know that the Gensini score is as effective as the SYNTAX score in prediction of cardiovascular outcomes [11]. Additionally, in our study, coronary angiograms were recorded in multiple projections for the left and right coronary arteries and reviewed for significant coronary artery obstructions (defined as >70% diameter stenosis in major coronary arteries) by two cardiologists who were unaware of the EFT data. Interobserver and intraobserver variability for CAD severity was 5.1 and 4.2%, respectively. Finally, Balta et al. suggest evaluating EFT with other inflammatory markers. However, because EFT is an endocrine organ that secretes pro- and anti-inflammatory mediators and the study population was composed of patients with acute coronary syndrome in whom inflammatory markers would increase, the correlation of EFT with other inflammatory markers might be more complex and may cause a dilemma. Thus, we did not opt to use such a biomarker (other than troponin and CK-MB) in our study.
Corresponding address U. Canpolat, MD Cardiology Clinic Türkiye Yüksek İhtisas Training and Research Hospital 06100 Ankara Turkey [email protected]
Compliance with ethical guidelines Conflict of interest. F. Ozcan, U. Canpolat, O. Turak, and S. Aydoğdu state that there are no conflicts of interest.
References 1. Ozcan F, Turak O, Canpolat U et al (2013) Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients. Herz 1–6 2. Balta S, Demirkol S, Kurt O et al (2013) Epicardial adipose tissue measurement: inexpensive, easy accessible and rapid practical method. Anadolu Kardiyol Derg 3. Balta S, Demirkol S, Arslan Z et al (2013) Epicardial fat thickness should be evaluated with other inflammatory markers and cardiovascular risk factors. Echocardiography 30(6):739 4. Lai Y-H, Yun C-H, Yang F-S et al (2012) Epicardial adipose tissue relating to anthropometrics, metabolic derangements and fatty liver disease independently contributes to serum high-sensitivity Creactive protein beyond body fat composition: a study validated with computed tomography. J Am Soc Echocardiogr 25(2):234–241 5. Balta S, Demırkol S, Kucuk U et al (2013) Epicardial adipose tissue should be evaluated with other inflammatory markers in patients with subclinical hypothyroidism. Med Princ Pract 6. Demirkol S, Balta S, Unlu M et al (2012) Evaluation of the mean platelet volume in patients with cardiac syndrome X. Clinics 67(9):1019–1022 7. Farooq V, Vergouwe Y, Räber L et al (2012) Combined anatomical and clinical factors for the longterm risk stratification of patients undergoing percutaneous coronary intervention: the Logistic Clinical SYNTAX score. Eur Heart J 33(24):3098–3104 8. Iacobellis G, Assael F, Ribaudo MC et al (2013) Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res 11:304–310 9. Yorgun H, Canpolat U, Hazirolan T et al (2012) Epicardial adipose tissue thickness predicts descending thoracic aorta atherosclerosis shown by multidetector computed tomography. Int J Cardiovasc Imaging 28:911–919 10. Yorgun H, Canpolat U, Hazirolan T et al (2013) Increased epicardial fat tissue is a marker of metabolic syndrome in adult patients. Int J Cardiol 165:308–313 11. Sinning C, Lillpopp L, Appelbaum S et al (2013) Angiographic score assessment improves cardiovascular risk prediction: the clinical value of SYNTAX and Gensini application. Clin Res Cardiol 102:495–503
Comment on Ozcan F, Turak O, Canpolat U et al (2013) Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients. Herz. doi:10.1007/s00059-013-3914-z
To the Editor We read the article“Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients” by Ozcan et al. [1] with great interest. The authors aimed to investigate the association between TIMI risk score and epicardial fat thickness (EFT) in patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (USAP). They concluded that EFT is independently associated with TIMI risk score and may be an emerging risk factor for adverse events in NSTEMI/USAP patients. We thank the authors for their contribution of the present study, which is successfully designed and documented. EFT measurement with echocardiography has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. EFT has a three-dimensional distribution, and two-dimensional echocardiography cannot give an adequate window of all cardiac segments, especially in obese subjects, and is highly dependent on acoustic windows [2]. It is widely recognized that an accumulation of EFT is strongly related to coronary artery disease (CAD). EFT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition.
S. Balta · U. Canpolat
Association of epicardial fat thickness with TIMI risk score EFT measured by echocardiography has been known to be associated with metabolic syndrome [3]. Additionally, echocardiography-based EFT measurement was related to several metabolic abnormalities and independently associated with fatty liver disease [4]. Also, the duration of hormone therapy (HT) may be different in these patients. We think that the results of the study would be more robust if the authors had mentioned these factors including the duration of HT and liver function tests. EFT can also be affected by atherosclerotic risk factors such as alcohol consumption, hypothyroidism [5], and higher inflammatory status [3], for example, an inflammatory disease, cardiac syndrome X, and infection [6]. In the present study, the authors did not mention these possibly contributing factors. It would have been better if the authors had given information about these factors. Furthermore, the severity of CAD was evaluated by calculation of Gensini scores in the present study. However, the SYNTAX score (SS) may also be used for grading of coronary complexity based on angiographic visual assessment. The addition of clinical risk factors to the SS has been shown to potentially further augment its utility in the objective evaluation of the severity of CAD. The Logistic Clinical SXscore consisting of four continuous variables including SXscore, age, creatinine clearance, and left ventricular ejection fraction substantially enhances the risk stratification of CAD patients for the outcome of long-term all-cause death compared with the SXscore in isolation. The
Logistic Clinical SXscore was able to accurately distinguish patients with or without a clinical outcome and could accurately predict individual patient risk without under- or over-estimating risk [7]. Second, we strongly believe that it would be better to give interobserver and intraobserver variability for CAD severity in the current study. Finally, EFT itself without other inflammatory markers may not provide information to clinicians about systemic inflammation. Therefore, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will help evaluate the results of further studies on EFT and TIMI risk score in acute coronary syndrome patients.
Corresponding address S. Balta Department of Cardiology Gulhane School of Medicine Tevfik Saglam Street 06018 Etlik-Ankara Turkey [email protected]
Compliance with ethical guidelines Conflict of interest. S. Balta, S. Demirkol, M. Demir, U. Kucuk, and Z. Arslan state that there are no conflicts of interests.
Herz 2013
| 1
Letter to the editor
Reply We appreciate the interest and comments from Dr. Balta et al. on our study “Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients,” published in Herz [1]. Epicardial fat tissue (EFT) can be evaluated and measured by echocardiography, as first shown and validated by Iacobellis et al. [8]. Although radiologic techniques like computerized tomography[9, 10] and magnetic resonance imaging can provide a volumetric and more accurate measurement, echocardiographic assessment of EFT certainly has the advantages of being inexpensive, noninvasive, and readily available but still accurate and reproducible [8]. As noted by Balta et al. and also mentioned in the study limitations sections the article [1], our study would be stronger if these patients were evaluated with volumetric measurement techniques like computerized tomography or magnetic resonance imaging. However, because of the inclusion of patients with acute coronary syndrome, application of such techniques may delay patients for emergent catheterization. Also, additional radiation and contrast media exposure with computerized tomography before coronary angiography may harm patients much more. Thus, each technique may have both advantages and disadvantages, although their accuracies may differ from each other. It is known that EFT functions as an endocrine organ to secrete both pro-inflammatory and anti-inflammatory cytokines and mediators, which contributes to local and systemic inflammatory pathways. As an important risk factor that plays a role in acute coronary syndrome, metabolic syndrome is also associated with increased EFT in previous studies [10]. The association of increased EFT with TIMI risk score remained significant even after correction for traditional cardiovascular risk factors and metabolic syndrome components in our study. As we mentioned in our paper, we excluded patients with systemic inflammatory condition including infections, viral- and steato-hepatitis, abnormal renal and liver function tests, and hypo- or hyperthyroidism. However, we had no data about the duration of hyper-
2 |
Herz 2013
tension and alcohol consumption in our study population, which may be associated with both coronary events and EFT. As noted by Balta et al., our study would be more powerful if we included SYNTAX and clinical SYNTAX scores besides the Gensini score. However, we know that the Gensini score is as effective as the SYNTAX score in prediction of cardiovascular outcomes [11]. Additionally, in our study, coronary angiograms were recorded in multiple projections for the left and right coronary arteries and reviewed for significant coronary artery obstructions (defined as >70% diameter stenosis in major coronary arteries) by two cardiologists who were unaware of the EFT data. Interobserver and intraobserver variability for CAD severity was 5.1 and 4.2%, respectively. Finally, Balta et al. suggest evaluating EFT with other inflammatory markers. However, because EFT is an endocrine organ that secretes pro- and anti-inflammatory mediators and the study population was composed of patients with acute coronary syndrome in whom inflammatory markers would increase, the correlation of EFT with other inflammatory markers might be more complex and may cause a dilemma. Thus, we did not opt to use such a biomarker (other than troponin and CK-MB) in our study.
Corresponding address U. Canpolat, MD Cardiology Clinic Türkiye Yüksek İhtisas Training and Research Hospital 06100 Ankara Turkey [email protected]
Compliance with ethical guidelines Conflict of interest. F. Ozcan, U. Canpolat, O. Turak, and S. Aydoğdu state that there are no conflicts of interest.
References 1. Ozcan F, Turak O, Canpolat U et al (2013) Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients. Herz 1–6 2. Balta S, Demirkol S, Kurt O et al (2013) Epicardial adipose tissue measurement: inexpensive, easy accessible and rapid practical method. Anadolu Kardiyol Derg 3. Balta S, Demirkol S, Arslan Z et al (2013) Epicardial fat thickness should be evaluated with other inflammatory markers and cardiovascular risk factors. Echocardiography 30(6):739 4. Lai Y-H, Yun C-H, Yang F-S et al (2012) Epicardial adipose tissue relating to anthropometrics, metabolic derangements and fatty liver disease independently contributes to serum high-sensitivity Creactive protein beyond body fat composition: a study validated with computed tomography. J Am Soc Echocardiogr 25(2):234–241 5. Balta S, Demırkol S, Kucuk U et al (2013) Epicardial adipose tissue should be evaluated with other inflammatory markers in patients with subclinical hypothyroidism. Med Princ Pract 6. Demirkol S, Balta S, Unlu M et al (2012) Evaluation of the mean platelet volume in patients with cardiac syndrome X. Clinics 67(9):1019–1022 7. Farooq V, Vergouwe Y, Räber L et al (2012) Combined anatomical and clinical factors for the longterm risk stratification of patients undergoing percutaneous coronary intervention: the Logistic Clinical SYNTAX score. Eur Heart J 33(24):3098–3104 8. Iacobellis G, Assael F, Ribaudo MC et al (2013) Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res 11:304–310 9. Yorgun H, Canpolat U, Hazirolan T et al (2012) Epicardial adipose tissue thickness predicts descending thoracic aorta atherosclerosis shown by multidetector computed tomography. Int J Cardiovasc Imaging 28:911–919 10. Yorgun H, Canpolat U, Hazirolan T et al (2013) Increased epicardial fat tissue is a marker of metabolic syndrome in adult patients. Int J Cardiol 165:308–313 11. Sinning C, Lillpopp L, Appelbaum S et al (2013) Angiographic score assessment improves cardiovascular risk prediction: the clinical value of SYNTAX and Gensini application. Clin Res Cardiol 102:495–503
