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To the Editor: Dr Meier and colleagues¹ present intriguing data that individuals with a first acute myocardial infarction (AMI) were less likely than matched controls to have used tetracycline antibiotics or quinolones in the previous 3 years. The authors raise the possibility that organisms susceptible to these antibiotics may be involved in the pathogenesis of coronary heart disease. However, several methodological limitations lead to other possible explanations for the observed associations.

First, confounding remains a real explanation for the associations. It would be helpful if the authors presented cardiovascular risk factors by antibiotic user status. In addition, it would be useful to see a comparison of crude, unadjusted risk ratios with adjusted estimates. This would permit the reader to assess the impact of confounding and gauge the possibility of residual confounding. Second, exclusion of the traditional risk factors of hypertension, diabetes mellitus, and hyperlipidemia may introduce selection bias. Patients who . . . [Full Text of this Article]

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