Letter to the Editor / Reply Published online: September 25, 2015
Med Princ Pract 2016;25:199 DOI: 10.1159/000437428
Methodological Contributions about Systolic Pulmonary Artery Pressure Omer Uz, Ugur Kucuk, Zafer Isılak, Mehmet Dogan Department of Cardiology, Gulhane Military Medical Academy, Haydarpasa Training Hospital Istanbul, Istanbul, Turkey
Dear Editor, We have read the article by Marouf et al. [1] entitled ‘Transthoracic echocardiography and 6-min walk test in Kuwaiti sickle cell disease patients’ with great interest. The authors had evaluated echocardiographic parameters and 6-min walk test results in patients with sickle cell disease (SCD) living in Kuwait. As a result of the study, when compared with healthy volunteers, a marked decrease in 6-min walk test distance was seen in SCD patients. Also, pulmonary artery systolic pressure (PASP) was over 30 mm Hg in only 8% of SCD patients. The study is noteworthy in terms of pointing out cardiac problems in SCD patients. Nevertheless, there are some aspects of the study that need further explanation. First, there should have been a table showing baseline characteristics, where patient and control groups were compared statistically. This table should have provided enough information on age, sex, body mass index and smoking status because it must be taken into consideration that physiologic range of PASP varies with age, sex and body mass index. Moreover, PASP can be considered normal until 40 mm Hg in the elderly and obese [2]. The effect of smoking on PASP is evident [3]. That is why it could have been more valuable to see those data in this trial.
Another point with regard to the PASP measurement of the patients in this study was made of tricuspid regurgitant jet. At the same time, the mean tricuspid regurgitant jet velocity was 1.7 ± 0.5 m/s in the patient population. When this value was analyzed, it gave the impression that sufficient flow was not obtained over the tricuspid valve. For this reason, since guidelines recommend to use contrast echocardiography with agitated saline in subjects where the measurement of tricuspid regurgitant jet velocity is difficult (insignificant/mild tricuspid regurgitant), we think this procedure would have enabled them to make a more appropriate evaluation by augmenting Doppler signals significantly [4], thus giving an opportunity to measure PASP in SCD patients more accurately. In conclusion, we congratulate the authors for this original trial and hope it could pioneer other studies like this.
References 1 Marouf R, Behbehani N, Zubaid M, et al: Transthoracic echocardiography and 6-minute walk test in Kuwaiti sickle cell disease patients. Med Princ Pract 2014;23:212–217. 2 McQuillan BM, Picard MH, Leavitt M, et al: Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circulation 2001;104:2797–2802. 3 Wright JL, Zhou S, Churg A: Pulmonary hypertension and vascular oxidative damage in cigarette smoke exposed eNOS(–/–) mice and human smokers. Inhal Toxicol 2012;24:732–740. 4 Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC); European Respiratory Society (ERS); International Society of Heart and Lung Transplantation (ISHLT), Galiè N, Hoeper MM, Humbert M, et al: Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2009;34:1219–1263.
Reply Rajaa Marouf a, Nasser Behbehanib, Mohammed Zubaidb, Hanan Al Wazzand, Hadeel El Muzainia, Rasha Abdullaa, Olusegun A. Mojiminiyia, Adekunle D. Adekilec Departments of aPathology, bMedicine and cPediatrics, Faculty of Medicine, Kuwait University, and dMinistry of Health – Kuwait, Safat, Kuwait
Dear Editor, We would like to thank Uz et al. for their interest and the comments on our paper [1]. They suggested that they would like to see the baseline characteristics, demographic and other data for the patients and controls in the study in a tabular form. There were no significant differences in these data (including age, body mass index and smoking prevalence) between the patients and the controls. There was, therefore, no need for extra tables and this was indicated in the text. However, the hematological and other laboratory data were significantly different in the two groups as mentioned in the text. The point about the use of agitated saline contrast echocardiography is well taken. However, this was not part of the design of our study, which was to gain an insight into potential cardiac complications in Kuwaiti sickle cell disease patients who have a generally milder phenotype than seen in North American or African patients
© 2015 S. Karger AG, Basel 1011–7571/15/0252–0199$39.50/0 E-Mail [email protected] www.karger.com/mpp
This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
[1]. Tricuspid regurgitant jet velocity is one parameter that has been used widely for this purpose, hence its use in our study. Contrast echocardiography may be incorporated into future studies, but the prevalence of cardiac abnormalities appears to be low in our patients. Reference 1
Marouf R, Behbehani N, Zubaid M, et al: Transthoracic echocardiography and 6-minute walk test in Kuwaiti sickle cell disease patients. Med Princ Pract 2014;23:212–217. Dr. Rajaa Marouf Kuwait University PO Box 24923 Safat 13110 (Kuwait) E-Mail r-marouf @ hsc.edu.kw
Ugur Kucuk Department of Cardiology, Gulhane Military Medical Academy Selimiye Mah., Tıbbiye Cad. Haydarpasa Training Hospital TR–34668 Istanbul (Turkey) E-Mail drugurkucuk @ gmail.com
Med Princ Pract 2016;25:199 DOI: 10.1159/000437428
Methodological Contributions about Systolic Pulmonary Artery Pressure Omer Uz, Ugur Kucuk, Zafer Isılak, Mehmet Dogan Department of Cardiology, Gulhane Military Medical Academy, Haydarpasa Training Hospital Istanbul, Istanbul, Turkey
Dear Editor, We have read the article by Marouf et al. [1] entitled ‘Transthoracic echocardiography and 6-min walk test in Kuwaiti sickle cell disease patients’ with great interest. The authors had evaluated echocardiographic parameters and 6-min walk test results in patients with sickle cell disease (SCD) living in Kuwait. As a result of the study, when compared with healthy volunteers, a marked decrease in 6-min walk test distance was seen in SCD patients. Also, pulmonary artery systolic pressure (PASP) was over 30 mm Hg in only 8% of SCD patients. The study is noteworthy in terms of pointing out cardiac problems in SCD patients. Nevertheless, there are some aspects of the study that need further explanation. First, there should have been a table showing baseline characteristics, where patient and control groups were compared statistically. This table should have provided enough information on age, sex, body mass index and smoking status because it must be taken into consideration that physiologic range of PASP varies with age, sex and body mass index. Moreover, PASP can be considered normal until 40 mm Hg in the elderly and obese [2]. The effect of smoking on PASP is evident [3]. That is why it could have been more valuable to see those data in this trial.
Another point with regard to the PASP measurement of the patients in this study was made of tricuspid regurgitant jet. At the same time, the mean tricuspid regurgitant jet velocity was 1.7 ± 0.5 m/s in the patient population. When this value was analyzed, it gave the impression that sufficient flow was not obtained over the tricuspid valve. For this reason, since guidelines recommend to use contrast echocardiography with agitated saline in subjects where the measurement of tricuspid regurgitant jet velocity is difficult (insignificant/mild tricuspid regurgitant), we think this procedure would have enabled them to make a more appropriate evaluation by augmenting Doppler signals significantly [4], thus giving an opportunity to measure PASP in SCD patients more accurately. In conclusion, we congratulate the authors for this original trial and hope it could pioneer other studies like this.
References 1 Marouf R, Behbehani N, Zubaid M, et al: Transthoracic echocardiography and 6-minute walk test in Kuwaiti sickle cell disease patients. Med Princ Pract 2014;23:212–217. 2 McQuillan BM, Picard MH, Leavitt M, et al: Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circulation 2001;104:2797–2802. 3 Wright JL, Zhou S, Churg A: Pulmonary hypertension and vascular oxidative damage in cigarette smoke exposed eNOS(–/–) mice and human smokers. Inhal Toxicol 2012;24:732–740. 4 Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC); European Respiratory Society (ERS); International Society of Heart and Lung Transplantation (ISHLT), Galiè N, Hoeper MM, Humbert M, et al: Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2009;34:1219–1263.
Reply Rajaa Marouf a, Nasser Behbehanib, Mohammed Zubaidb, Hanan Al Wazzand, Hadeel El Muzainia, Rasha Abdullaa, Olusegun A. Mojiminiyia, Adekunle D. Adekilec Departments of aPathology, bMedicine and cPediatrics, Faculty of Medicine, Kuwait University, and dMinistry of Health – Kuwait, Safat, Kuwait
Dear Editor, We would like to thank Uz et al. for their interest and the comments on our paper [1]. They suggested that they would like to see the baseline characteristics, demographic and other data for the patients and controls in the study in a tabular form. There were no significant differences in these data (including age, body mass index and smoking prevalence) between the patients and the controls. There was, therefore, no need for extra tables and this was indicated in the text. However, the hematological and other laboratory data were significantly different in the two groups as mentioned in the text. The point about the use of agitated saline contrast echocardiography is well taken. However, this was not part of the design of our study, which was to gain an insight into potential cardiac complications in Kuwaiti sickle cell disease patients who have a generally milder phenotype than seen in North American or African patients
© 2015 S. Karger AG, Basel 1011–7571/15/0252–0199$39.50/0 E-Mail [email protected] www.karger.com/mpp
This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
[1]. Tricuspid regurgitant jet velocity is one parameter that has been used widely for this purpose, hence its use in our study. Contrast echocardiography may be incorporated into future studies, but the prevalence of cardiac abnormalities appears to be low in our patients. Reference 1
Marouf R, Behbehani N, Zubaid M, et al: Transthoracic echocardiography and 6-minute walk test in Kuwaiti sickle cell disease patients. Med Princ Pract 2014;23:212–217. Dr. Rajaa Marouf Kuwait University PO Box 24923 Safat 13110 (Kuwait) E-Mail r-marouf @ hsc.edu.kw
Ugur Kucuk Department of Cardiology, Gulhane Military Medical Academy Selimiye Mah., Tıbbiye Cad. Haydarpasa Training Hospital TR–34668 Istanbul (Turkey) E-Mail drugurkucuk @ gmail.com
