Letters To The Editor

To the Editor: We would like to raise the following points about the paper by Dr. Aggarwal et al¹ interpreting the Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial.²

The patients enrolled in the FREEDOM trial do not in our opinion completely reflect the real patients that we meet in our daily “real-world” practice.² The patients in the FREEDOM trial did not have a high-risk profile. Rather, the mean European System for Cardiac Operative Risk Evaluation score (EuroSCORE) was 2.7 ± 2.4 in the percutaneous coronary intervention (PCI) group and 2.8 ± 2.5 in the coronary artery bypass grafting group—whereas a score of 5 or more on the EuroSCORE is associated with decreased rates of survival.²

Furthermore, patients with left main coronary artery stenosis were completely excluded from the FREEDOM trial,² but this type of stenosis, with different grades, is found in about 30% of diabetic patients with multivessel coronary artery disease, a fact that may significantly influence the decision regarding the revascularization strategy (bypass grafting or PCI), especially in a clinical setting such as acute coronary syndrome.^3–5

In addition, the authors did not clearly highlight that diabetes mellitus is an independent risk factor for coronary lesion progression, coronary bypass graft occlusion, and cardiac mortality after bypass grafting surgery.^6–8 Clinical outcomes after bypass grafting in diabetic patients are worse than in nondiabetic patients; diabetic patients have higher rates of morbidity (deep sternal instability, wound infection, stroke, renal dysfunction, and respiratory problems), longer intensive care unit and hospital stays, and poorer postoperative physical functioning and quality of life.^6–8

The authors correctly explain the reasons for the superiority of coronary artery bypass grafting vs PCI in diabetic patients, either by the ability to achieve complete revascularization or by using more arterial grafts, and especially the left internal thoracic artery.¹ However, clarifying details on the strategy of revascularization in the FREEDOM trial are scarcely provided.² All we know from the provided details in this regard is that “for CABG surgery, arterial revascularization was encouraged” and 94.4% of the patients undergoing bypass grafting received left internal thoracic artery grafts.²

In addition, whereas off-pump coronary artery bypass grafting surgery is superior to conventional bypass grafting in terms of lower rates of death and major adverse cardiac and cerebrovascular events in diabetic patients with multivessel coronary artery disease,³ only 165 (18.5%) of the 893 patients who underwent bypass grafting in the FREEDOM trial underwent an off-pump procedure.^2,3

Therefore, all these considerations should be taken into account as the physician team discusses the therapeutic options (PCI and bypass grafting surgery) with diabetic patients who have multivessel coronary artery disease.

To the Editor: We would like to raise the following points about the paper by Dr. Aggarwal et al¹ interpreting the Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial.²

The patients enrolled in the FREEDOM trial do not in our opinion completely reflect the real patients that we meet in our daily “real-world” practice.² The patients in the FREEDOM trial did not have a high-risk profile. Rather, the mean European System for Cardiac Operative Risk Evaluation score (EuroSCORE) was 2.7 ± 2.4 in the percutaneous coronary intervention (PCI) group and 2.8 ± 2.5 in the coronary artery bypass grafting group—whereas a score of 5 or more on the EuroSCORE is associated with decreased rates of survival.²

Furthermore, patients with left main coronary artery stenosis were completely excluded from the FREEDOM trial,² but this type of stenosis, with different grades, is found in about 30% of diabetic patients with multivessel coronary artery disease, a fact that may significantly influence the decision regarding the revascularization strategy (bypass grafting or PCI), especially in a clinical setting such as acute coronary syndrome.^3–5

In addition, the authors did not clearly highlight that diabetes mellitus is an independent risk factor for coronary lesion progression, coronary bypass graft occlusion, and cardiac mortality after bypass grafting surgery.^6–8 Clinical outcomes after bypass grafting in diabetic patients are worse than in nondiabetic patients; diabetic patients have higher rates of morbidity (deep sternal instability, wound infection, stroke, renal dysfunction, and respiratory problems), longer intensive care unit and hospital stays, and poorer postoperative physical functioning and quality of life.^6–8

The authors correctly explain the reasons for the superiority of coronary artery bypass grafting vs PCI in diabetic patients, either by the ability to achieve complete revascularization or by using more arterial grafts, and especially the left internal thoracic artery.¹ However, clarifying details on the strategy of revascularization in the FREEDOM trial are scarcely provided.² All we know from the provided details in this regard is that “for CABG surgery, arterial revascularization was encouraged” and 94.4% of the patients undergoing bypass grafting received left internal thoracic artery grafts.²

In addition, whereas off-pump coronary artery bypass grafting surgery is superior to conventional bypass grafting in terms of lower rates of death and major adverse cardiac and cerebrovascular events in diabetic patients with multivessel coronary artery disease,³ only 165 (18.5%) of the 893 patients who underwent bypass grafting in the FREEDOM trial underwent an off-pump procedure.^2,3

Therefore, all these considerations should be taken into account as the physician team discusses the therapeutic options (PCI and bypass grafting surgery) with diabetic patients who have multivessel coronary artery disease.

To the Editor: We would like to raise the following points about the paper by Dr. Aggarwal et al¹ interpreting the Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial.²

The patients enrolled in the FREEDOM trial do not in our opinion completely reflect the real patients that we meet in our daily “real-world” practice.² The patients in the FREEDOM trial did not have a high-risk profile. Rather, the mean European System for Cardiac Operative Risk Evaluation score (EuroSCORE) was 2.7 ± 2.4 in the percutaneous coronary intervention (PCI) group and 2.8 ± 2.5 in the coronary artery bypass grafting group—whereas a score of 5 or more on the EuroSCORE is associated with decreased rates of survival.²

Furthermore, patients with left main coronary artery stenosis were completely excluded from the FREEDOM trial,² but this type of stenosis, with different grades, is found in about 30% of diabetic patients with multivessel coronary artery disease, a fact that may significantly influence the decision regarding the revascularization strategy (bypass grafting or PCI), especially in a clinical setting such as acute coronary syndrome.^3–5

In addition, the authors did not clearly highlight that diabetes mellitus is an independent risk factor for coronary lesion progression, coronary bypass graft occlusion, and cardiac mortality after bypass grafting surgery.^6–8 Clinical outcomes after bypass grafting in diabetic patients are worse than in nondiabetic patients; diabetic patients have higher rates of morbidity (deep sternal instability, wound infection, stroke, renal dysfunction, and respiratory problems), longer intensive care unit and hospital stays, and poorer postoperative physical functioning and quality of life.^6–8

The authors correctly explain the reasons for the superiority of coronary artery bypass grafting vs PCI in diabetic patients, either by the ability to achieve complete revascularization or by using more arterial grafts, and especially the left internal thoracic artery.¹ However, clarifying details on the strategy of revascularization in the FREEDOM trial are scarcely provided.² All we know from the provided details in this regard is that “for CABG surgery, arterial revascularization was encouraged” and 94.4% of the patients undergoing bypass grafting received left internal thoracic artery grafts.²

In addition, whereas off-pump coronary artery bypass grafting surgery is superior to conventional bypass grafting in terms of lower rates of death and major adverse cardiac and cerebrovascular events in diabetic patients with multivessel coronary artery disease,³ only 165 (18.5%) of the 893 patients who underwent bypass grafting in the FREEDOM trial underwent an off-pump procedure.^2,3

Therefore, all these considerations should be taken into account as the physician team discusses the therapeutic options (PCI and bypass grafting surgery) with diabetic patients who have multivessel coronary artery disease.

In Reply: We appreciate the comments of Dr. Saeed and colleagues. As stated in our article, given that the patients included in the FREEDOM trial represent a select group with diabetes and multivessel coronary artery disease, they may not represent all patients encountered in a real-world setting. We highlighted that only 10% of the patients screened were included for randomization, which limits the generalizability of the results. Also, the overall patient population may not be at high risk, as evidenced by low mean EuroSCORE and SYNTAX scores and by the low proportion of patients with ejection fractions less than 40%. However, patients with left main coronary artery disease (even without diabetes) have been shown to have better outcomes with coronary artery bypass grafting than with PCI, although a head-to-head trial in a diabetic subgroup is currently not available.^1,2 In addition, it is important to realize that the FREEDOM trial deals with stable angina; therefore, the results may not extend to patients with acute coronary syndrome wherein primary PCI remains the most feasible option in most cases.

Diabetes mellitus is independently associated with complex, accelerated, and multifocal coronary artery disease. Therefore, outcomes after revascularization (with bypass grafting or PCI) are worse in diabetic patients than in those without diabetes. However, this association does not prove the superiority of PCI over bypass grafting.

As we stated in our paper, the FREEDOM trial did not clearly define the strategy for arterial grafts in patients undergoing bypass grafting. The mean number of coronary lesions in the bypass grafting group was high (mean = 5.74), but the average number of grafts used was only 2.9, and data were not provided on the use of sequential grafting and multiple arterial conduits. Lastly, it is true that the FREEDOM trial had relatively fewer patients (18.5%) that underwent off-pump bypass grafting surgery; however, this approach has never been shown to be superior in large randomized trials.^3,4

In conclusion, no randomized trial should replace clinical judgment to define the targeted revascularization strategy for an individual patient. Rather, results from the FREEDOM trial should help support clinical decision-making in the context of the patient and the institution.

In Reply: We appreciate the comments of Dr. Saeed and colleagues. As stated in our article, given that the patients included in the FREEDOM trial represent a select group with diabetes and multivessel coronary artery disease, they may not represent all patients encountered in a real-world setting. We highlighted that only 10% of the patients screened were included for randomization, which limits the generalizability of the results. Also, the overall patient population may not be at high risk, as evidenced by low mean EuroSCORE and SYNTAX scores and by the low proportion of patients with ejection fractions less than 40%. However, patients with left main coronary artery disease (even without diabetes) have been shown to have better outcomes with coronary artery bypass grafting than with PCI, although a head-to-head trial in a diabetic subgroup is currently not available.^1,2 In addition, it is important to realize that the FREEDOM trial deals with stable angina; therefore, the results may not extend to patients with acute coronary syndrome wherein primary PCI remains the most feasible option in most cases.

Diabetes mellitus is independently associated with complex, accelerated, and multifocal coronary artery disease. Therefore, outcomes after revascularization (with bypass grafting or PCI) are worse in diabetic patients than in those without diabetes. However, this association does not prove the superiority of PCI over bypass grafting.

As we stated in our paper, the FREEDOM trial did not clearly define the strategy for arterial grafts in patients undergoing bypass grafting. The mean number of coronary lesions in the bypass grafting group was high (mean = 5.74), but the average number of grafts used was only 2.9, and data were not provided on the use of sequential grafting and multiple arterial conduits. Lastly, it is true that the FREEDOM trial had relatively fewer patients (18.5%) that underwent off-pump bypass grafting surgery; however, this approach has never been shown to be superior in large randomized trials.^3,4

In conclusion, no randomized trial should replace clinical judgment to define the targeted revascularization strategy for an individual patient. Rather, results from the FREEDOM trial should help support clinical decision-making in the context of the patient and the institution.

In Reply: We appreciate the comments of Dr. Saeed and colleagues. As stated in our article, given that the patients included in the FREEDOM trial represent a select group with diabetes and multivessel coronary artery disease, they may not represent all patients encountered in a real-world setting. We highlighted that only 10% of the patients screened were included for randomization, which limits the generalizability of the results. Also, the overall patient population may not be at high risk, as evidenced by low mean EuroSCORE and SYNTAX scores and by the low proportion of patients with ejection fractions less than 40%. However, patients with left main coronary artery disease (even without diabetes) have been shown to have better outcomes with coronary artery bypass grafting than with PCI, although a head-to-head trial in a diabetic subgroup is currently not available.^1,2 In addition, it is important to realize that the FREEDOM trial deals with stable angina; therefore, the results may not extend to patients with acute coronary syndrome wherein primary PCI remains the most feasible option in most cases.

Diabetes mellitus is independently associated with complex, accelerated, and multifocal coronary artery disease. Therefore, outcomes after revascularization (with bypass grafting or PCI) are worse in diabetic patients than in those without diabetes. However, this association does not prove the superiority of PCI over bypass grafting.

As we stated in our paper, the FREEDOM trial did not clearly define the strategy for arterial grafts in patients undergoing bypass grafting. The mean number of coronary lesions in the bypass grafting group was high (mean = 5.74), but the average number of grafts used was only 2.9, and data were not provided on the use of sequential grafting and multiple arterial conduits. Lastly, it is true that the FREEDOM trial had relatively fewer patients (18.5%) that underwent off-pump bypass grafting surgery; however, this approach has never been shown to be superior in large randomized trials.^3,4

In conclusion, no randomized trial should replace clinical judgment to define the targeted revascularization strategy for an individual patient. Rather, results from the FREEDOM trial should help support clinical decision-making in the context of the patient and the institution.

To the Editor: The July 2013 Cleveland Clinic Journal of Medicine includes timely articles addressing the problems of electronic health records (EHRs). At least to this reader, there is little that is surprising in the observations.

A common inside joke among programmers, sometimes displayed at one’s cubicle, is: “Fast, good, or cheap (pick two).” In other words, there is always a compromise to be had between a good product and one that is punched out on a given timetable and inexpensive. Economists call this the “second best.”

Any truly great software product accomplishes three goals. First, it allows the user to do everything previously doable at least as well or as easily as before. Second, it eliminates drudgery. And third, ideally, it provides new functionality, which previously was difficult or impossible to accomplish or to afford.

The reality is that much software is sold on the basis of the third goal, whereas goal number 1 and sometimes goal number 2 get short shrift. And for EHRs in particular, it is a fallacy for physicians to think that EHRs were brought out primarily for their benefit rather than for the benefit of the front office. This was all the more true a decade ago, when very few physicians were employed by hospitals. Thus, if the physician’s workload was increased because of the hospital’s choice of EHR, the hospital felt no financial pain. With greater reliance on an employment model, we can hope that hospitals will recognize that physicians should not be turned into very expensive secretaries.

To the Editor: The July 2013 Cleveland Clinic Journal of Medicine includes timely articles addressing the problems of electronic health records (EHRs). At least to this reader, there is little that is surprising in the observations.

A common inside joke among programmers, sometimes displayed at one’s cubicle, is: “Fast, good, or cheap (pick two).” In other words, there is always a compromise to be had between a good product and one that is punched out on a given timetable and inexpensive. Economists call this the “second best.”

Any truly great software product accomplishes three goals. First, it allows the user to do everything previously doable at least as well or as easily as before. Second, it eliminates drudgery. And third, ideally, it provides new functionality, which previously was difficult or impossible to accomplish or to afford.

The reality is that much software is sold on the basis of the third goal, whereas goal number 1 and sometimes goal number 2 get short shrift. And for EHRs in particular, it is a fallacy for physicians to think that EHRs were brought out primarily for their benefit rather than for the benefit of the front office. This was all the more true a decade ago, when very few physicians were employed by hospitals. Thus, if the physician’s workload was increased because of the hospital’s choice of EHR, the hospital felt no financial pain. With greater reliance on an employment model, we can hope that hospitals will recognize that physicians should not be turned into very expensive secretaries.

To the Editor: The July 2013 Cleveland Clinic Journal of Medicine includes timely articles addressing the problems of electronic health records (EHRs). At least to this reader, there is little that is surprising in the observations.

A common inside joke among programmers, sometimes displayed at one’s cubicle, is: “Fast, good, or cheap (pick two).” In other words, there is always a compromise to be had between a good product and one that is punched out on a given timetable and inexpensive. Economists call this the “second best.”

Any truly great software product accomplishes three goals. First, it allows the user to do everything previously doable at least as well or as easily as before. Second, it eliminates drudgery. And third, ideally, it provides new functionality, which previously was difficult or impossible to accomplish or to afford.

The reality is that much software is sold on the basis of the third goal, whereas goal number 1 and sometimes goal number 2 get short shrift. And for EHRs in particular, it is a fallacy for physicians to think that EHRs were brought out primarily for their benefit rather than for the benefit of the front office. This was all the more true a decade ago, when very few physicians were employed by hospitals. Thus, if the physician’s workload was increased because of the hospital’s choice of EHR, the hospital felt no financial pain. With greater reliance on an employment model, we can hope that hospitals will recognize that physicians should not be turned into very expensive secretaries.

To the Editor: I read with interest the review of the new oral anticoagulants by Fawole et al¹ and agree with their comments on the prevention of bleeding and the importance of monitoring renal function in managing patients on the new classes of oral anticoagulants. However, no specifics were given on how to proceed. Thus, I recommend that renal risk stratification be done before and 1 week after starting these new drugs.

Originally, the US Food and Drug Administration approved dabigatran (Pradaxa) at a dose of 150 mg orally twice daily in patients with a creatinine clearance of 15 to 30 mL/min/1.73 m². This dosing corresponded to the estimated glomerular filtration rate (eGFR) in patients with stage 4 chronic kidney disease, but this dosing is contraindicated in other guidelines worldwide (Canada, Europe, the United Kingdom, Japan, Australia, and New Zealand).² Not unexpectedly, 3,781 serious adverse effects were noted in the 2011 US postmarketing experience with dabigatran. These included death (542 cases), hemorrhage (2,367 cases), acute renal failure (291 cases), stroke (644 cases), and suspected liver failure (15 cases).³ Thirteen months after dabigatran’s approval in the United States, Boehringer Ingelheim changed the dosage and product guidelines.^2–4 The new dosage⁴ is 75 mg twice daily for patients with a creatinine clearance of 15 to 30 mL/min/1.73 m².

Therefore, I suggest a nephrologic “way out”⁵ when using the new oral anticoagulants to avoid the problems with dabigatran noted above.

First, if these drugs are to be used in nonvalvular atrial fibrillation, risk factors should be determined using the CHADS2 or the CHADS2-VASc score. Special attention should be given to patients age 75 and older, women, and patients with a history of stroke, transient ischemic attack, or systemic embolism. All of these have been noted to be major risk factors.^6,7

Second, renal risk stratification⁸ should be done using a comprehensive metabolic panel before and 1 week after starting new oral anticoagulants, or if there is a change in the patient’s clinical condition. Most US laboratories now provide an eGFR and the stage of chronic kidney disease.^3,5 For example (Table 1), if dabigatran is used, one should follow current dosing guidelines for chronic kidney disease stages 1 through 3, ie, 150 mg twice daily. If stage 4 chronic kidney disease is detected (creatinine clearance 15–29 mL/min/1.73 m²), the updated recommended dosage is 75 mg twice daily. If stage 5 is noted (eGFR ≤ 15 mL/min/1.73 m²), dabigatran is not indicated. Similar steps can be done using current guidelines for the other new oral anticoagulants.

This simple renal risk stratification guideline should help avoid some of the problems noted in the dabigatran postmarketing experience, which were aggravated by the lack of approval of a 110-mg dose and by misleading advertising, claiming that no blood monitoring was required.^2–5 Thus, the new oral anticoagulants should be a welcome addition to our armamentarium in patients who need them, and we hope to avoid the risks, morbidity, mortality, and expense of trying to reverse adverse effects.

To the Editor: I read with interest the review of the new oral anticoagulants by Fawole et al¹ and agree with their comments on the prevention of bleeding and the importance of monitoring renal function in managing patients on the new classes of oral anticoagulants. However, no specifics were given on how to proceed. Thus, I recommend that renal risk stratification be done before and 1 week after starting these new drugs.

Originally, the US Food and Drug Administration approved dabigatran (Pradaxa) at a dose of 150 mg orally twice daily in patients with a creatinine clearance of 15 to 30 mL/min/1.73 m². This dosing corresponded to the estimated glomerular filtration rate (eGFR) in patients with stage 4 chronic kidney disease, but this dosing is contraindicated in other guidelines worldwide (Canada, Europe, the United Kingdom, Japan, Australia, and New Zealand).² Not unexpectedly, 3,781 serious adverse effects were noted in the 2011 US postmarketing experience with dabigatran. These included death (542 cases), hemorrhage (2,367 cases), acute renal failure (291 cases), stroke (644 cases), and suspected liver failure (15 cases).³ Thirteen months after dabigatran’s approval in the United States, Boehringer Ingelheim changed the dosage and product guidelines.^2–4 The new dosage⁴ is 75 mg twice daily for patients with a creatinine clearance of 15 to 30 mL/min/1.73 m².

Therefore, I suggest a nephrologic “way out”⁵ when using the new oral anticoagulants to avoid the problems with dabigatran noted above.

First, if these drugs are to be used in nonvalvular atrial fibrillation, risk factors should be determined using the CHADS2 or the CHADS2-VASc score. Special attention should be given to patients age 75 and older, women, and patients with a history of stroke, transient ischemic attack, or systemic embolism. All of these have been noted to be major risk factors.^6,7

Second, renal risk stratification⁸ should be done using a comprehensive metabolic panel before and 1 week after starting new oral anticoagulants, or if there is a change in the patient’s clinical condition. Most US laboratories now provide an eGFR and the stage of chronic kidney disease.^3,5 For example (Table 1), if dabigatran is used, one should follow current dosing guidelines for chronic kidney disease stages 1 through 3, ie, 150 mg twice daily. If stage 4 chronic kidney disease is detected (creatinine clearance 15–29 mL/min/1.73 m²), the updated recommended dosage is 75 mg twice daily. If stage 5 is noted (eGFR ≤ 15 mL/min/1.73 m²), dabigatran is not indicated. Similar steps can be done using current guidelines for the other new oral anticoagulants.

This simple renal risk stratification guideline should help avoid some of the problems noted in the dabigatran postmarketing experience, which were aggravated by the lack of approval of a 110-mg dose and by misleading advertising, claiming that no blood monitoring was required.^2–5 Thus, the new oral anticoagulants should be a welcome addition to our armamentarium in patients who need them, and we hope to avoid the risks, morbidity, mortality, and expense of trying to reverse adverse effects.

To the Editor: I read with interest the review of the new oral anticoagulants by Fawole et al¹ and agree with their comments on the prevention of bleeding and the importance of monitoring renal function in managing patients on the new classes of oral anticoagulants. However, no specifics were given on how to proceed. Thus, I recommend that renal risk stratification be done before and 1 week after starting these new drugs.

Originally, the US Food and Drug Administration approved dabigatran (Pradaxa) at a dose of 150 mg orally twice daily in patients with a creatinine clearance of 15 to 30 mL/min/1.73 m². This dosing corresponded to the estimated glomerular filtration rate (eGFR) in patients with stage 4 chronic kidney disease, but this dosing is contraindicated in other guidelines worldwide (Canada, Europe, the United Kingdom, Japan, Australia, and New Zealand).² Not unexpectedly, 3,781 serious adverse effects were noted in the 2011 US postmarketing experience with dabigatran. These included death (542 cases), hemorrhage (2,367 cases), acute renal failure (291 cases), stroke (644 cases), and suspected liver failure (15 cases).³ Thirteen months after dabigatran’s approval in the United States, Boehringer Ingelheim changed the dosage and product guidelines.^2–4 The new dosage⁴ is 75 mg twice daily for patients with a creatinine clearance of 15 to 30 mL/min/1.73 m².

Therefore, I suggest a nephrologic “way out”⁵ when using the new oral anticoagulants to avoid the problems with dabigatran noted above.

First, if these drugs are to be used in nonvalvular atrial fibrillation, risk factors should be determined using the CHADS2 or the CHADS2-VASc score. Special attention should be given to patients age 75 and older, women, and patients with a history of stroke, transient ischemic attack, or systemic embolism. All of these have been noted to be major risk factors.^6,7

Second, renal risk stratification⁸ should be done using a comprehensive metabolic panel before and 1 week after starting new oral anticoagulants, or if there is a change in the patient’s clinical condition. Most US laboratories now provide an eGFR and the stage of chronic kidney disease.^3,5 For example (Table 1), if dabigatran is used, one should follow current dosing guidelines for chronic kidney disease stages 1 through 3, ie, 150 mg twice daily. If stage 4 chronic kidney disease is detected (creatinine clearance 15–29 mL/min/1.73 m²), the updated recommended dosage is 75 mg twice daily. If stage 5 is noted (eGFR ≤ 15 mL/min/1.73 m²), dabigatran is not indicated. Similar steps can be done using current guidelines for the other new oral anticoagulants.

This simple renal risk stratification guideline should help avoid some of the problems noted in the dabigatran postmarketing experience, which were aggravated by the lack of approval of a 110-mg dose and by misleading advertising, claiming that no blood monitoring was required.^2–5 Thus, the new oral anticoagulants should be a welcome addition to our armamentarium in patients who need them, and we hope to avoid the risks, morbidity, mortality, and expense of trying to reverse adverse effects.

In Reply: We agree with the comments of Dr. Pazmiño regarding specifics of renal risk stratification in patients taking the new oral anticoagulants. In order to reduce the bleeding risks associated with these agents, they should be prescribed on the basis of the individual patient’s clinical characteristics. We did not discuss this since the focus of our article was management of bleeding that resulted from use of these drugs. We appreciate the recommendations of Dr. Pazmiño.

In Reply: We agree with the comments of Dr. Pazmiño regarding specifics of renal risk stratification in patients taking the new oral anticoagulants. In order to reduce the bleeding risks associated with these agents, they should be prescribed on the basis of the individual patient’s clinical characteristics. We did not discuss this since the focus of our article was management of bleeding that resulted from use of these drugs. We appreciate the recommendations of Dr. Pazmiño.

In Reply: We agree with the comments of Dr. Pazmiño regarding specifics of renal risk stratification in patients taking the new oral anticoagulants. In order to reduce the bleeding risks associated with these agents, they should be prescribed on the basis of the individual patient’s clinical characteristics. We did not discuss this since the focus of our article was management of bleeding that resulted from use of these drugs. We appreciate the recommendations of Dr. Pazmiño.

To the Editor: I was somewhat confused by the Clinical Picture case in the May 2013 issue.¹ The caption for Figure 1 stated that the MRI showed erosions and marrow edema, which were “asymmetrical compared with the other wrist, a finding highly suggestive of rheumatoid arthritis.” However, rheumatoid arthritis is generally considered to be symmetrical.² Was this a typographical error, or did I miss a crucial concept somewhere?

To the Editor: I was somewhat confused by the Clinical Picture case in the May 2013 issue.¹ The caption for Figure 1 stated that the MRI showed erosions and marrow edema, which were “asymmetrical compared with the other wrist, a finding highly suggestive of rheumatoid arthritis.” However, rheumatoid arthritis is generally considered to be symmetrical.² Was this a typographical error, or did I miss a crucial concept somewhere?

To the Editor: I was somewhat confused by the Clinical Picture case in the May 2013 issue.¹ The caption for Figure 1 stated that the MRI showed erosions and marrow edema, which were “asymmetrical compared with the other wrist, a finding highly suggestive of rheumatoid arthritis.” However, rheumatoid arthritis is generally considered to be symmetrical.² Was this a typographical error, or did I miss a crucial concept somewhere?

In Reply: We apologize for the confusion. We wanted to convey that, in that patient at that time, synovitis with erosions and edema indicating inflammation (greater on the right than on the left left) was suggestive of rheumatoid arthritis despite the asymmetry seen (findings greater in the right wrist than in the left). Given the patient’s clinical findings at that time and the above imaging findings, the initial diagnosis of rheumatoid arthritis was correct. But since the patient was not responding to therapy and since the abdominal pain was worsening, we probed further. Subsequently, the patient was diagnosed with Whipple disease. The fact that inflammatory arthritis can occur in other conditions that are not rheumatologic is a primary reason we found this case worth sharing.

In Reply: We apologize for the confusion. We wanted to convey that, in that patient at that time, synovitis with erosions and edema indicating inflammation (greater on the right than on the left left) was suggestive of rheumatoid arthritis despite the asymmetry seen (findings greater in the right wrist than in the left). Given the patient’s clinical findings at that time and the above imaging findings, the initial diagnosis of rheumatoid arthritis was correct. But since the patient was not responding to therapy and since the abdominal pain was worsening, we probed further. Subsequently, the patient was diagnosed with Whipple disease. The fact that inflammatory arthritis can occur in other conditions that are not rheumatologic is a primary reason we found this case worth sharing.

In Reply: We apologize for the confusion. We wanted to convey that, in that patient at that time, synovitis with erosions and edema indicating inflammation (greater on the right than on the left left) was suggestive of rheumatoid arthritis despite the asymmetry seen (findings greater in the right wrist than in the left). Given the patient’s clinical findings at that time and the above imaging findings, the initial diagnosis of rheumatoid arthritis was correct. But since the patient was not responding to therapy and since the abdominal pain was worsening, we probed further. Subsequently, the patient was diagnosed with Whipple disease. The fact that inflammatory arthritis can occur in other conditions that are not rheumatologic is a primary reason we found this case worth sharing.

To the Editor: We recently read the article by Dr. Emmanuel Bravo.¹ In his comprehensive paper, he defined a road map for the workup of resistant hypertension. Resistant hypertension is a challenging problem in everyday practice, with multiple pitfalls at each step from diagnosis to treatment.

Although not mentioned in the paper, obstructive sleep apnea is strongly associated with hypertension, and its prevalence in patients with resistant hypertension can be as high as 83%.² The upper airway resistance syndrome is another form of sleep-disordered breathing in which transient increases in upper airway resistance result in repetitive electroencephalographic arousals. Unlike obstructive sleep apnea, upper airway resistance syndrome is not associated with apnea or diminished airflow, although snoring and excessive daytime somnolence are common. Repeated arousals, desaturations, or both during sleep lead to recurrent sympathetic surges with resultant nocturnal hypertension. There are a number of reports in the literature of large blood-pressure reductions after continuous positive airway pressure treatment.³

In conclusion, sleep-disordered breathing syndromes should be sought vigorously in cases of resistant hypertension, and every effort should be taken for proper management.

To the Editor: We recently read the article by Dr. Emmanuel Bravo.¹ In his comprehensive paper, he defined a road map for the workup of resistant hypertension. Resistant hypertension is a challenging problem in everyday practice, with multiple pitfalls at each step from diagnosis to treatment.

Although not mentioned in the paper, obstructive sleep apnea is strongly associated with hypertension, and its prevalence in patients with resistant hypertension can be as high as 83%.² The upper airway resistance syndrome is another form of sleep-disordered breathing in which transient increases in upper airway resistance result in repetitive electroencephalographic arousals. Unlike obstructive sleep apnea, upper airway resistance syndrome is not associated with apnea or diminished airflow, although snoring and excessive daytime somnolence are common. Repeated arousals, desaturations, or both during sleep lead to recurrent sympathetic surges with resultant nocturnal hypertension. There are a number of reports in the literature of large blood-pressure reductions after continuous positive airway pressure treatment.³

In conclusion, sleep-disordered breathing syndromes should be sought vigorously in cases of resistant hypertension, and every effort should be taken for proper management.

To the Editor: We recently read the article by Dr. Emmanuel Bravo.¹ In his comprehensive paper, he defined a road map for the workup of resistant hypertension. Resistant hypertension is a challenging problem in everyday practice, with multiple pitfalls at each step from diagnosis to treatment.

Although not mentioned in the paper, obstructive sleep apnea is strongly associated with hypertension, and its prevalence in patients with resistant hypertension can be as high as 83%.² The upper airway resistance syndrome is another form of sleep-disordered breathing in which transient increases in upper airway resistance result in repetitive electroencephalographic arousals. Unlike obstructive sleep apnea, upper airway resistance syndrome is not associated with apnea or diminished airflow, although snoring and excessive daytime somnolence are common. Repeated arousals, desaturations, or both during sleep lead to recurrent sympathetic surges with resultant nocturnal hypertension. There are a number of reports in the literature of large blood-pressure reductions after continuous positive airway pressure treatment.³

In conclusion, sleep-disordered breathing syndromes should be sought vigorously in cases of resistant hypertension, and every effort should be taken for proper management.