Author + information
- Antonio Abbate, MD* (, )
- Giuseppe Biondi-Zoccai, MD,
- Pierfrancesco Agostoni, MD,
- Luigi M. Biasucci, MD, FACC, FESC,
- Alfonso Baldi, MD and
- Filippo Crea, MD, FACC, FESC
- ↵*Virginia Commonwealth University, Department of Medicine, 10025 Bellona Court, Richmond, VA 23238
We read with extreme interest the recent report by Elsasser et al. (1). Their study reliably shows that both apoptotic and autophagic cell death occur in hibernating myocardium and may be responsible for progressive clinical deterioration and lack of functional recovery.
However, we are afraid the investigators may have made an inaccurate estimate of apoptotic cell death rate. The researchers indeed report an incidence of apoptosis of 0.002% (i.e., 1 of 50,000 cells). These data would suggest that at least 50,000 cells were counted per patient in order to ascertain whether at least one was apoptotic. But the investigators fail to clarify this issue thoroughly.
This point is particularly relevant when considering the electron microscopy data. Considering the specific limitations of electron microscopy we would imagine that the investigators evaluated not more than 100 cells at electron microscopy per case. Yet assuming 100 cells examined per case and an apoptotic rate of 1 in 50,000, the chance of randomly finding an apoptotic cell at the electron microscope level in a single case would be 1 in 500. Accordingly, the probabilty of 3 positive cases at electron microscopy would be only 1 in 125 million.
In conclusion, we find the message given by Elsasser et al. (1) extremely attractive and clinically relevant. However, we believe that they might have underestimated the incidence of apoptotic myocytes at confocal microscopy. We would greatly appreciate it if the investigators could clarify these apparent inconsistencies.
- American College of Cardiology Foundation