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n–3 Fatty Acids in Cardiovascular Disease

n–3 Fatty Acids in Cardiovascular Disease correspondence To the Editor: In his review article concerning Sopravvivenza nell’Insufficienza Cardiaca Heart 1 1 n–3 fatty acids (June 23 issue), De Caterina Failure trial (GISSI-HF, NCT00336336), tested states that a beneficial effect on mortality had ivabradine on top of optimal medical therapy ver- not been shown in contemporary drug trials in sus placebo in patients with heart failure. Its pri- chronic heart failure. Actually, two recent trials mary outcome was the composite of cardiovascu- reported that two pharmacologic agents have lar death or hospital admission for worsening shown such benefit. In the Eplerenone in Mild Pa- heart failure. I would point out that the SHIFT tients Hospitalization and Survival Study in Heart trial did not actually show a reduction in total Failure (EMPHASIS-HF; ClinicalTrials.gov number, mortality or in cardiovascular mortality, since NCT00232180), Zannad and coworkers found the decrease was driven by hospital admissions that the addition of eplerenone reduced all-cause for worsening heart failure. I agree with the state- mortality (hazard ratio [HR], 0.63; 95% confidence ment that the recent EMPHASIS-HF study, which interval [CI], 0.54 to 0.74; P<0.001) in patients with used eplerenone, has also shown a reduction in systolic dysfunction who were in New York Heart total mortality, albeit in a population that was Association (NYHA) functional class II. In the Sys- not receiving n–3 fatty acids and, according to tolic Heart Failure Treatment with the If Inhibitor the inclusion criteria, was not receiving other Ivabradine trial (SHIFT; Current Controlled Trials potassium-sparing diuretics. Of note, the GISSI-HF number, ISRCTN70429960), we found that adding study, reporting a beneficial effect of n–3 fatty ivabradine to lower the heart rate in patients with acids on total mortality, allowed the use of po- systolic dysfunction and in NYHA class II, III, or tassium-sparing diuretics and reported the use of IV reduced the number of deaths due to heart fail- spironolactone in over 39% of the patients. There- ure (HR, 0.74; 95% CI, 0.58 to 0.94; P = 0.014). fore, by acting on pathways that lead to death from heart failure unaffected by other pharmaco- Karl Swedberg, M.D., Ph.D. logic treatments, n–3 fatty acids added to the University of Gothenburg Gothenburg, Sweden treatment appear to have effects that are truly [email protected] additive to those of any class of drugs previous ly Dr. Swedberg reports having received honoraria and research reported to affect mortality in patients with grants from Pfizer and Servier. No other potential conf lict of chronic heart failure. interest relevant to this letter was reported. 1. De Caterina R. n–3 Fatty acids in cardiovascular disease. Raffaele De Caterina, M.D., Ph.D. N Engl J Med 2011;364:2439-50. Gabriele d’Annunzio University 2. Zannad F, McMurray JJ, Krum H, et al. Eplerenone in pa- Chieti, Italy tients with systolic heart failure and mild symptoms. N Engl J [email protected] Med 2011;364:11-21. 3. Swedberg K, Komajda M, Bohm M, et al. Ivabradine and Since publication of his article, the author reports no further outcomes in chronic heart failure (SHIFT): a randomised placebo- potential conf lict of interest. controlled study. Lancet 2010;376:875-85. 1. Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n–3 polyunsaturated fatty acids in patients with chronic heart failure The author replies: The SHIFT trial, subse- (the GISSI-HF trial): a randomised, double-blind, placebo-con- quent to the Gruppo Italiano per lo Studio della trolled trial. Lancet 2008;372:1223-30. Conscious Sedation for Minor Procedures in Adults To the Editor: In their online video, Jones and conscious sedation from minimal and deep seda- colleagues (June 23 issue) describe conscious tion on the basis of the response to verbal com- sedation in adults. According to the recommen- mands or painful stimulation. The crucial prob- dations of the American Society of Anesthesi- lem with conscious sedation is to ensure sedation ologists, the authors propose to discriminate without respiratory depression. In real-life expe- n engl j med 365;12 nejm.org september 22, 2011 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The New England Journal of Medicine The New England Journal of Medicine

n–3 Fatty Acids in Cardiovascular Disease

The New England Journal of Medicine , Volume 365 (12): 1 – Sep 22, 2011
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References (4)

Publisher
The New England Journal of Medicine
Copyright
Copyright © 2011 Massachusetts Medical Society. All rights reserved.
ISSN
0028-4793
eISSN
1533-4406
DOI
10.1056/NEJMc1108375
pmid
21992140
Publisher site
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Abstract

correspondence To the Editor: In his review article concerning Sopravvivenza nell’Insufficienza Cardiaca Heart 1 1 n–3 fatty acids (June 23 issue), De Caterina Failure trial (GISSI-HF, NCT00336336), tested states that a beneficial effect on mortality had ivabradine on top of optimal medical therapy ver- not been shown in contemporary drug trials in sus placebo in patients with heart failure. Its pri- chronic heart failure. Actually, two recent trials mary outcome was the composite of cardiovascu- reported that two pharmacologic agents have lar death or hospital admission for worsening shown such benefit. In the Eplerenone in Mild Pa- heart failure. I would point out that the SHIFT tients Hospitalization and Survival Study in Heart trial did not actually show a reduction in total Failure (EMPHASIS-HF; ClinicalTrials.gov number, mortality or in cardiovascular mortality, since NCT00232180), Zannad and coworkers found the decrease was driven by hospital admissions that the addition of eplerenone reduced all-cause for worsening heart failure. I agree with the state- mortality (hazard ratio [HR], 0.63; 95% confidence ment that the recent EMPHASIS-HF study, which interval [CI], 0.54 to 0.74; P<0.001) in patients with used eplerenone, has also shown a reduction in systolic dysfunction who were in New York Heart total mortality, albeit in a population that was Association (NYHA) functional class II. In the Sys- not receiving n–3 fatty acids and, according to tolic Heart Failure Treatment with the If Inhibitor the inclusion criteria, was not receiving other Ivabradine trial (SHIFT; Current Controlled Trials potassium-sparing diuretics. Of note, the GISSI-HF number, ISRCTN70429960), we found that adding study, reporting a beneficial effect of n–3 fatty ivabradine to lower the heart rate in patients with acids on total mortality, allowed the use of po- systolic dysfunction and in NYHA class II, III, or tassium-sparing diuretics and reported the use of IV reduced the number of deaths due to heart fail- spironolactone in over 39% of the patients. There- ure (HR, 0.74; 95% CI, 0.58 to 0.94; P = 0.014). fore, by acting on pathways that lead to death from heart failure unaffected by other pharmaco- Karl Swedberg, M.D., Ph.D. logic treatments, n–3 fatty acids added to the University of Gothenburg Gothenburg, Sweden treatment appear to have effects that are truly [email protected] additive to those of any class of drugs previous ly Dr. Swedberg reports having received honoraria and research reported to affect mortality in patients with grants from Pfizer and Servier. No other potential conf lict of chronic heart failure. interest relevant to this letter was reported. 1. De Caterina R. n–3 Fatty acids in cardiovascular disease. Raffaele De Caterina, M.D., Ph.D. N Engl J Med 2011;364:2439-50. Gabriele d’Annunzio University 2. Zannad F, McMurray JJ, Krum H, et al. Eplerenone in pa- Chieti, Italy tients with systolic heart failure and mild symptoms. N Engl J [email protected] Med 2011;364:11-21. 3. Swedberg K, Komajda M, Bohm M, et al. Ivabradine and Since publication of his article, the author reports no further outcomes in chronic heart failure (SHIFT): a randomised placebo- potential conf lict of interest. controlled study. Lancet 2010;376:875-85. 1. Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n–3 polyunsaturated fatty acids in patients with chronic heart failure The author replies: The SHIFT trial, subse- (the GISSI-HF trial): a randomised, double-blind, placebo-con- quent to the Gruppo Italiano per lo Studio della trolled trial. Lancet 2008;372:1223-30. Conscious Sedation for Minor Procedures in Adults To the Editor: In their online video, Jones and conscious sedation from minimal and deep seda- colleagues (June 23 issue) describe conscious tion on the basis of the response to verbal com- sedation in adults. According to the recommen- mands or painful stimulation. The crucial prob- dations of the American Society of Anesthesi- lem with conscious sedation is to ensure sedation ologists, the authors propose to discriminate without respiratory depression. In real-life expe- n engl j med 365;12 nejm.org september 22, 2011

Journal

The New England Journal of Medicine – The New England Journal of Medicine

Published: Sep 22, 2011

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