Homocysteine is not a risk factor for subclinical coronary atherosclerosis in asymptomatic individuals

Sangwoo Park; Gyung-Min Park; Jinhee Ha; Young-Rak Cho; Jae-Hyung Roh; Eun Ji Park; Yujin Yang; Ki-Bum Won; Soe Hee Ann; Yong-Giun Kim; Shin-Jae Kim; Sang-Gon Lee; Dong Hyun Yang; Joon-Won Kang; Tae-Hwan Lim; Hong-Kyu Kim; Jaewon Choe; Seung-Whan Lee; Young-Hak Kim

doi:10.1371/journal.pone.0231428

Peer Review History

Original SubmissionDecember 18, 2019
18 Feb 2020 Decision Letter - Timir Paul, Editor PONE-D-19-35017 Homocysteine is not a risk factor for subclinical coronary atherosclerosis in asymptomatic individuals PLOS ONE Dear Dr. Park, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by Apr 03 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Timir Paul Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: - Park, Gyung-Min, et al. "Prediabetes is not a risk factor for subclinical coronary atherosclerosis." International journal of cardiology 243 (2017): 479-484. - Lim, Doo-Ho, et al. "Serum uric acid level and subclinical coronary atherosclerosis in asymptomatic individuals: An observational cohort study." Atherosclerosis 288 (2019): 112-117. The text that needs to be addressed involves some sentences of the Introduction and of the Discussion. In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. 3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This manuscript is well written. In this manuscript authors have described the effect of homocysteine on sublcinical atherosclerosis in asymptomactic Korean population. These patients underwent Coronary CT as part of their general exam and then they were evaluated for homocysteine levels as well. Authors did not find any significant relation between homocysteine and sub clinical atherosclerosis. Studies have not shown any relationship between homocysteine lower therapies and reduction in adverse cardiac outcomes. This study adds to existing clinical data. However as authors described these results are not generalizable to other population yet and further studies are needed to test it. I would say this article gives enough clinical information and is good to be published Reviewer #2: Park S. et al has presented data supporting no relation between homocysteine levels and risk of subclinical coronary atherosclerosis in asymptomatic individuals. Overall manuscript is well written and authors have accepted major limitations of the study except few which I would like to point out. It would be great if authors could revise and include them in the manuscript 1) Artifacts caused by CCTA especially blooming artifact caused by Calcium, inability to clearly delineate coronary artery disease in distal segments of the major epicardial coronary arteries. Author should also include methodology of image aquisition in detail as it is the major source of coronary information obtained for this research. 2) Another major limitation of the study is inclusion of self reported history of hypertension, hyperlipidemia or diabetes and then using that population in multivariate analysis to adjust the statistical relation between homocysteine levels and subclinical coronary atherosclerosis. Assuming patients having condition based on their word and not strictly based on clinical parameters / lab results can significantly confound the study results. 3) Structural heart disease is one of the exclusion criteria which should be defined further in detail. 4) Another exclusion criteria is "prior history of open heart surgery". Its not clear if author means coronary artery bypass grafting (CABG) or any cardiac surgery. Should be clearly stated as one should not assume it mean CABG. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0231428.r001
Revision 1
10 Mar 2020 Author Response In reply to the Editor and Reviewers We thank the Editor and Reviewers' for time, effort, and previous comments. First above all, we would like to express our gratitude for providing us another opportunity to address our study. We appreciate the Editor and Reviewers' contribution, time, and invaluable comments, which were truly meaningful to the revision of our manuscript. We gratefully accepted the Editor and Reviewers' advice and revised the manuscript. We are submitting the revised manuscript, on which we provide a detailed list of changes in response to all comments of the Editor and Reviewers in a point by point fashion. We hope that you will find our paper suitable for publication in your journal, and we look forward to hearing from you. Journal Requirements: When submitting your revision, we need you to address these additional requirements: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf Authors’ response: We appreciate the Editor’s valuable comments. With the response to the Editor’s comments, we revised our manuscript according to PLOS ONE's style requirements 2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: - Park, Gyung-Min, et al. "Prediabetes is not a risk factor for subclinical coronary atherosclerosis." International journal of cardiology 243 (2017): 479-484. - Lim, Doo-Ho, et al. "Serum uric acid level and subclinical coronary atherosclerosis in asymptomatic individuals: An observational cohort study." Atherosclerosis 288 (2019): 112-117. The text that needs to be addressed involves some sentences of the Introduction and of the Discussion. In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. Authors’ response: We appreciate the Editor’s meaningful comments. With the response to the Editor’s comments, we revised the manuscript appropriately. We addressed and cited our previous works in in the Introduction and Discussion. 3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place. Authors’ response: We appreciate the Editor’s invaluable comments. With the response to the Editor’s comments, we revised and provided sufficient details in the Figure 1 and Method section, as much as we can. Demographic details of the study population can be found in overall column of Table 1. Reviewers' comments: Reviewer #1: This manuscript is well written. In this manuscript authors have described the effect of homocysteine on subclinical atherosclerosis in asymptomatic Korean population. These patients underwent Coronary CT as part of their general exam and then they were evaluated for homocysteine levels as well. Authors did not find any significant relation between homocysteine and sub clinical atherosclerosis. Studies have not shown any relationship between homocysteine lower therapies and reduction in adverse cardiac outcomes. This study adds to existing clinical data. However as authors described these results are not generalizable to other population yet and further studies are needed to test it. I would say this article gives enough clinical information and is good to be published Authors’ response: Thank you very much for your encouraging comments. Reviewer #2: Park S. et al has presented data supporting no relation between homocysteine levels and risk of subclinical coronary atherosclerosis in asymptomatic individuals. Overall manuscript is well written and authors have accepted major limitations of the study except few which I would like to point out. It would be great if authors could revise and include them in the manuscript. 1) Artifacts caused by CCTA especially blooming artifact caused by Calcium, inability to clearly delineate coronary artery disease in distal segments of the major epicardial coronary arteries. Author should also include methodology of image aquisition in detail as it is the major source of coronary information obtained for this research. Authors’ response: We appreciate the Reviewer’s meaningful comments. We fully agreed with the Reviewer’s valuable comments. We omitted the methodology of image acquisition because there was significant overlapping text with our previous studies. However, as the Reviewer mentioned, it is important information for this study, so we have described it in the CCTA image acquisition and analysis section. And, with the response to the Reviewer’s comments, we added the following sentences in the Results. CCTA image acquisition and analysis, Methods, page 7 CCTA was conducted using either single-source 64-slice CT (LightSpeed VCT, GE, Milwaukee, WI, USA) or dual-source CT (Somatom Definition, Siemens, Erlangen, Germany). Subjects with no contraindication to β-adrenergic blocking agents and with an initial heart rate greater than 65 beats per minute received an oral dose of 2.5 mg bisoprolol (Concor, Merck, Darmstadt, Germany) 1 hour before the CT examination. CT scanning was performed in the prospective ECG-triggering mode or the retrospective ECG-gating mode with ECG-based tube current modulation. Two puffs (2.5 mg) of isosorbidedinitrate (Isoket spray, Schwarz Pharma, Monheim, Germany) were sprayed into the patient’s oral cavity before contrast injection. During CCTA acquisition, 60-80 mL of iodinated contrast (Iomeron 400, Bracco, Milan, Italy) was injected at 4 mL/second, followed by a 40 mL saline flush. A region of interest was placed in the ascending aorta, and image acquisition was automatically initiated once a selected threshold (100 HU) had been reached using bolus tracking. A standard scanning protocol was used, and the tube voltage and tube current-time product were adjusted according to the patient’s body size as follows: 100 kVp or 120 kVp tube voltage; 240 to 400 mAs per rotation (dual-source CT); and 400 to 800 mA (64-slice CT) tube current. All CCTA scans were analyzed using a dedicated workstation (Advantage Workstation, GE; or Volume Wizard, Siemens) by experienced cardiovascular radiologists (DHY, JWK, and THL). CCTA findings, Results, page 12 A total of 121 (0.2%) coronary segments were not interpretable due to artifacts. 2) Another major limitation of the study is inclusion of self reported history of hypertension, hyperlipidemia or diabetes and then using that population in multivariate analysis to adjust the statistical relation between homocysteine levels and subclinical coronary atherosclerosis. Assuming patients having condition based on their word and not strictly based on clinical parameters / lab results can significantly confound the study results. Authors’ response: We appreciate the Reviewer’s invaluable comments. We fully agreed with the Reviewer’s comments. The reliability of self-reported data compared with objective sources could vary by study population and by diagnosis. We acknowledge the limitation of self-reported data and described it in the Limitation section. Limitations, page 18 Second, our study relied on self-reported past medical history. The reliability of self-reported data compared with objective sources could vary by study population and by diagnosis, which might affect obtained findings. 3) Structural heart disease is one of the exclusion criteria which should be defined further in detail. Authors’ response: We appreciate the Reviewer’s valuable comments. We presented the frequency of structural heart disease in detail, i.e., hypertrophic cardiomyopathy (n=33), moderate to severe valvular heart disease (n=11), atrial septal defect (n=2), dilated cardiomyopathy (n=1), myxoma (n=1), and dextrocardia (n =1). With the response to the Reviewer’s comments, revised sentences in the Methods. Methods, page 5 We excluded subjects with 1) unmeasured Hcy; 2) a previous history of angina or myocardial infarction; 3) abnormal rest electrocardiographic results, i.e., pathological Q waves, ischemic ST segments or T wave changes, or left bundle-branch blocks; 4) incomplete medical records; 5) structural heart diseases, i.e., hypertrophic cardiomyopathy, moderate to severe valvular heart disease, atrial septal defect, dilated cardiomyopathy, myxoma, or dextrocardia; 6) a prior history of any open heart surgery or percutaneous coronary intervention; 7) a previous cardiac procedure; or 8) renal insufficiency (creatinine > 1.5 mg/dL). Finally, 3186 subjects were enrolled (Fig 1). 4) Another exclusion criteria is "prior history of open heart surgery". Its not clear if author means coronary artery bypass grafting (CABG) or any cardiac surgery. Should be clearly stated as one should not assume it mean CABG. Authors’ response: We appreciate the Reviewer’s meaningful comments. We apologize to have caused the confusion. With the response to the Reviewer’s comments, revised sentences in the Methods. Methods, page 5 We excluded subjects with 1) unmeasured Hcy; 2) a previous history of angina or myocardial infarction; 3) abnormal rest electrocardiographic results, i.e., pathological Q waves, ischemic ST segments or T wave changes, or left bundle-branch blocks; 4) incomplete medical records; 5) structural heart diseases, i.e., hypertrophic cardiomyopathy, moderate to severe valvular heart disease, atrial septal defect, dilated cardiomyopathy, myxoma, or dextrocardia; 6) a prior history of any open heart surgery or percutaneous coronary intervention; 7) a previous cardiac procedure; or 8) renal insufficiency (creatinine > 1.5 mg/dL). Finally, 3186 subjects were enrolled (Fig 1). Attachments Attachment Submitted filename: CCTA_Homocysteine_Responses_to_Reviewer_R1.doc https://doi.org/10.1371/journal.pone.0231428.r002
24 Mar 2020 Decision Letter - Timir Paul, Editor Homocysteine is not a risk factor for subclinical coronary atherosclerosis in asymptomatic individuals PONE-D-19-35017R1 Dear Dr. Park, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. With kind regards, Timir Paul Academic Editor PLOS ONE Additional Editor Comments (optional): No further revision required https://doi.org/10.1371/journal.pone.0231428.r003
Formally Accepted
26 Mar 2020 Acceptance Letter - Timir Paul, Editor PONE-D-19-35017R1 Homocysteine is not a risk factor for subclinical coronary atherosclerosis in asymptomatic individuals Dear Dr. Park: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Timir Paul Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0231428.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .