AUCTORES
Globalize your Research
Chat with us
Review Article | DOI: https://doi.org/10.31579/2641-0419/017
1 Cardiology Department, Centro Hospitalar Universitário do Algarve - Faro, Portugal.
*Corresponding Author: Raquel Menezes Fernandes, Cardiology Department, Centro Hospitalar Universitário do Algarve - Faro, Portugal.
Citation: Raquel M Fernandes, Costa H, Mota T, Bispo J, Azevedo P. et al. (2019) Takotsubo Syndrome Versus Myocardial Infarction: what is the role of Echocardiography?, Clinical Cardiology and Cardiovascular Interventions, 2(2); DOI:10.31579/2641-0419 /017
Copyright: © 2019 Raquel M Fernandes, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 03 October 2019 | Accepted: 29 August 2019 | Published: 18 October 2019
Keywords: takotsubo syndrome; stress-induced cardiomyopathy; acute myocardial infarction; echocardiography; speckle tracking; global longitudinal strain
Reversible left ventricle dysfunction is a key feature of Takotsubo syndrome (TTS), but in the acute phase it can mimic an acute coronary syndrome, making this differentiation a significant challenge. Echocardiography is widely used in the early evaluation of these patients, and advanced imaging tools have highlighted the differences between both syndromes. The symmetrical pattern of left ventricular dysfunction, extending beyond the territory of a single coronary artery, associated with a less severe diastolic dysfunction, right ventricle involvement and a typical complete recovery of wall-motion abnormalities points towards the diagnosis of TTS. Despite all the imaging advances made so far, evaluation of coronary anatomy remains mandatory in these patients.
2D STE = Two-dimensional speckle tracking echocardiography
ACS = Acute coronary syndrome AMI = Acute myocardial infarction CFR = Coronary flow reserve
LAD = Left anterior descending LV = Left ventricle
LVEF = Left ventricle ejection fraction
LVOTO = Left ventricle outflow tract obstruction NSTEMI = Non-ST elevation myocardial infarction PSS = Post- systolic shortening; RV = Right ventricle SAM = Systolic anterior motion
TAPSE = Tricuspid annular plane systolic excursion TTS = Takotsubo syndrome
WMA = Wall motion abnormalities
Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, is an acute syndrome characterized by transient left ventricle (LV) dysfunction, in the absence of obstructive coronary artery disease [2,3]. It typically occurs in postmenopausal women and is often triggered by an emotional or physical stressful event. TTS may account for 1%–2% of all patients admitted with a presumed diagnosis of acute coronary syndrome (ACS) [2], but this rate increases to 6–7% if only females are considered [3].
Differentiating TTS from acute myocardial infarction (AMI) before coronariography proves to be a real challenge, since both share similar presentation, electrocardiographic,
echocardiographic and laboratory abnormalities [2,4,5]. TTS is a diagnosis of exclusion, so most patients are initially diagnosed as having an ACS, but do not have significant coronary artery lesions to explain the segmental abnormalities [6]. The greatest difficulty may be in distinguishing apical TTS (classical form) from non-ST-elevation myocardial infarction (NTSEMI) with left anterior descending (LAD) coronary artery disease [7,8], in which a coronariography is not emergent.
Conventional echocardiography
Due to its widespread availability, echocardiography is frequently the first non-invasive imaging modality used for early evaluation of LV systolic function in TTS patients [9]. It exhibits strong correlation with left ventriculography and detects potential complications such as mitral valve regurgitation, outflow tract obstruction, thrombus, LV free wall rupture and right ventricle (RV) involvement [9-12]. The main difficulty is the differentiation between classic TTS and anterior AMI, due to somewhat overlapping echocardiographic abnormalities.
LV dysfunction is a key feature in both TTS and AMI patients, but TTS is associated with worse LV systolic dysfunction and diffuse regional wall-motion abnormalities (WMA) at the acute phase, despite only a slight increase in troponin values[3,5,8]. TTS reveals a distinctive pattern of contractility characterized by symmetrical and circumferential WMA, irrespective of the epicardial vascular territory distribution (noncoronary pattern), suggestive of extensive myocardial stunning [2-4,9-13] . On the contrary, AMI primarily affects the territories supplied by the ‘‘culprit’’ coronary artery [9]. According to Citro el al, a wall motion score index (WMSI) of ≥1.75 has a high positive predictive value for the diagnosis of TTS, reinforcing the concept of diffuse injury [3]. WMSI values are higher in TTS patients with ST-segment elevation, indicating more severe myocardial dysfunction [3].
Classical TTS presents with mid- ventricular WMA (involving anterior, inferior, and lateral walls), apical akinesia, preserving or increasing the contractile function of the basal LV segments [9,14]
(Figure 1). Mid-cavity, basal segmental (reverse takotsubo), focal, biventricular and isolated RV variants have also been described, being less frequent [8,10,15]. However, Classical TTS presents with mid- ventricular WMA (involving anterior, inferior, and lateral walls), apical akinesia, preserving or increasing the contractile function of the basal LV segments [9,14] (Figure 1). Mid-cavity, basal segmental (reverse takotsubo), focal, biventricular and isolated RV variants have also been described, being less frequent [8, 10,15]. However, estimation of the LV ejection fraction (LVEF) using the modified Simpson’s rule does not yield the complexity of LV mechanics, since it only assesses the contractility in its radial direction [1,16].
Speckle Tracking Strain Echocardiography
Two-dimensional speckle tracking echocardiography (2D STE) is a tool for quantitative assessment of myocardial function [13,16-18]. Through measurement of myocardial strain, it has better reproducibility than tissue Doppler imaging strain and higher sensitivity in detecting subtle myocardial abnormalities [1,9], revealing myocardial dysfunction even before significant changes in LVEF and cardiac output [19]. Longitudinal strain has proven to be the most sensitive and reproducible of the various strain measurements performed with speckle tracking, and can provide important prognostic information [10,19].
In TTS patients, similar velocities are recorded among all basal LV segments, middle segments, and apical segments, translating in a circular LV dysfunction. In patients with anterior AMI, there are significant differences between those segments, affecting specifically the LAD coronary artery perfusion territory. These findings suggest that TTS is not the consequence of transient LAD occlusion [13].In parallel, Heggemann et al showed uniform reduction of radial strain along the entire mid LV circumference in TTS, comparing with significantly higher values in AMI posterior, lateral and inferior segments [4]. Similarly, longitudinal strain in some of the posterior, inferior and lateral segments is significantly lower in TTS compared to anterior AMI, adding to a greater involvement of the median and apical segments, resulting in a lower global longitudinal strain [4] (Figure 2).
LV twist parameters are preserved in basal segments, while apical twist during systole and diastole are significantly reduced in TTS, compatible with a transmural impairment of LV function [1,5]. Longitudinal strain of the LV base could also be diminished in several segments, notwithstanding the basal hypercontractility perception in TTS at
baseline [20]. Despite previous reports of a significant apex-to-base gradient of strain [20], Pestana et al found a smaller basal/apical longitudinal strain ratio in TTS patients, indicative of a more generalized myocardial dysfunction [8].
Post-systolic shortening (PSS) is defined as a further shortening / thickening occurring after the end-systole. It is a non-specific, but sensitive, marker of regional myocardial dysfunction and reflects a subtle systolic stunning that cannot be detected by conventional systolic
Parameters [14,20]. Pathological PSS can be found in 78% of acutely ischaemic myocardial segments, with a similar incidence during the acute phase of TTS [20].
Three-dimensional (3D) speckle tracking echocardiography is feasible to assess regional LV function and its recovery in TTS. Consistent with WMA in TTS, Kobayashi et al found that the average peak systolic 3D radial strain value of LV base is higher than those of mid and apex at baseline, decreasing significantly after six months, whereas those of mid and apex increase significantly [14].
Coronary microcirculation assessment
Non-invasive evaluation of distal LAD flow by doppler echocardiography could also help differentiate TTS from AMI [21]. LAD flow is expected to be absent in anterior AMI due to artery occlusion, but is detectable in TTS [9] (Figure 3). Diastolic to systolic velocity ratio of the LAD flow is decreased in patients with significant LAD stenosis, and may also be useful in this differentiation [22].
In addition, coronary
flow reserve (CFR) is transiently impaired in TTS [22], but at a lower grade compared with AMI, despite a poorer WMSI, suggesting the involvement of other mechanisms than direct microcirculatory damage in the pathogenesis of WMA [21]. At follow-up, there is an improvement of nearly 40% of CFR (above of the 10% of intra-individual variability), correlating with the recovery of LV systolic function [9]. Current evidence does not allow the reliable distinction of the two entities through this method, translating in a limited utility of the non-invasive evaluation of coronary assessment at the present day.
Global and regional diastolic dysfunction has been observed in the early phase of TTS, as evidenced by impaired LV untwisting and increased E/e’ ratio [9]. Despite the worse systolic function in TTS patients, LV filling pressure appears to be lower than in those with AMI, which explains better clinical outcome in the former patients [23]. Increased stiffness of akinetic segments is possibly related to scar formation or more transmural involvement in AMI. Diastolic function parameters appear to have a good correlation with the extent of myocardial fibrosis and viability [23].
LV outflow obstruction and mitral regurgitation
In some patients with TTS, systolic anterior motion (SAM) and LV outflow tract obstruction (LVOTO) may develop as a result of LV basal wall hyperkinesis, occurring in about 10% to 25% [11,17,22] (Figure 4). It typically resolves with medical management and gradual ventricular recovery [11,22]. Mitral regurgitation may also develop as a result of two different mechanisms: tethering and SAM of the anterior mitral leaflet. Transient LV dilatation with or without mitral annular dilatation may cause apical tethering of the mitral leaflets, resulting in decrease leaflet coaptation and a Carpentier III mechanism [11,22].
Right ventricle involvement
A careful assessment of global and regional RV function should be recommended, since about one-quarter of patients with TTS shows RV impairment, uncommon in LAD diseas [2,3,11,22]. The pattern of RV regional WMA is similar to the LV, so a right ventricular or biventricular “ballooning” may be observed [3,24]. Impaired global RV function in TTS seems to be predominantly caused by mid-ventricular and apical RV free wall strain reduction [24].
Strain imaging has higher sensitivity in the quantification of RV function than the global parameters RV fractional area change and tricuspid annular plane systolic excursion (TAPSE) [24]. TAPSE and RVS′ may not be suitable to perceive isolated abnormalities in distal RV segments. Global longitudinal strain detects RV involvement in TTS at a rate of 58%, the highest among all the parameters [2] (Figure 5). The group of Heggemann et al found that RV PSS >-19.1% indicates RV dysfunction in TTS patients, with a sensitivity of 85% and specificity of 71%. However, it only accounts the RV free wall [24].RV involvement in TTS is associated with significantly lower LVEF and lower LV global strain at baseline, being also an important prognostic factor, as these patients are generally older and have a more severe clinical course [24,25].
Stress echocardiography
Citro et al refer to a potential role of low-dose dobutamine stress echocardiography in assessing reversibility of myocardial dysfunction in suspected TTS, through demonstration of myocardial viability [9]. However, because of the role of catecholamines in inducing TTS, they also state that dobutamine should be administered with caution and probably avoided in the early phase [9,16]. It also has the potential to exacerbate or induce LVOTO, in particular in patients with myocardial hypertrophy, leading to an increased risk for hemodynamic deterioration and associated complications [9]. Current evidence doesn’t support the routine use of stress echocardiography in the diagnostic management of TTS patients.
Recovery
Despite the rapid resolution of WMA and LVEF [5,14] subtle LV dysfunction seem to persist for a few weeks, indicating that complete recovery may not occur as rapidly as previously though [20,27]. 2D strain can still be lower comparing to controls, emphasising that LVEF is insufficient in quantifying intrinsic myocardial contractility [27] (Figure 6). Furthermore, Heggemann et al state that more than half of LV segments also showed PSS even with WMA normalization, suggesting that PSS could be an indicator of persisting abnormalities of LV regional function into the early recovery period [20].
Even though TTS patients present circular LV dysfunction, the recovery pattern is not uniform [13,21]. For example, in mid-LV, longitudinal strain showed slower recovery than circumferential strain [25]. Due to this asymmetrical and partial recovery of segmental contractility a few days later, TTS may mimic LV dysfunction observed in patients with coronary artery disease, making the distinction from AMI more challenging if a patient is evaluated only at this stage [9,13]. Temporal evolution of TTS is variable, remaining to be determined the exact time-course of the recovery process (possibly 21 days to 6 months) and whether these findings have potential therapeutic and prognostic implications [1,20]. Table 1 summarizes the main differences between TTS and AMI discussed in this review.
Patients that present with a suggestive clinical picture and an acute ST-segment elevation on the electrocardiogram require emergent coronary angiogram. On the other hand, in the absence of ST-segment elevation and if clinically appropriate, the differential diagnosis between AMI and TTS could be made, to obviate unnecessary invasive procedures. Although the echocardiographic findings of TTS could mimic those of AMI, the regional WMA pattern, myocardial strain, diastolic dysfunction and degree of RV involvement differ. LV dysfunction is completely reversible in TTS, even though the recovery duration seems to be variable. Currently, despite the presence of echocardiographic findings suggestive of TTS, coronary angiography remains essential for the definitive diagnosis. Alternatively, and if available, cardiac computed tomographic angiography could be applied to exclude high-grade coronary artery stenosis in patients with a highly suggestive clinical picture of classic TTS.
Conflicts of interest: none
Acknowledgements: Câmara Municipal de Loulé
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
