Acute Pericarditis
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In their review article on acute pericarditis, Lange and Hillis (Nov. 18 issue)1 estimate that in 9 of 10 patients with acute pericarditis, the cause of the disease is either idiopathic or viral. We suggest that this may change when the diagnostic strategy is different. The authors' estimates are based on two studies,2,3 and the noninvasive tests used in both were not exhaustive. Regardless of clinical suspicion, the patients with acute pericarditis whom we studied4 in Marseille, France, underwent a systematic battery of tests according to a predetermined protocol. This strategy resulted in the identification of specific causes in 52.4 percent of the patients, including cases of otherwise unsuspected Q fever (in 10 patients) and hypothyroidism (in 15). Both Q fever and hypothyroidism are treatable diseases.
The causes of acute pericarditis may also vary in different geographic regions. Finally, the incidence of specific causes of acute pericardial effusion depends on regional epidemiologic factors and on whether diagnostic tests are used systematically with reference to a predetermined protocol or intuitively.5
Pierre-Yves Levy, M.D.
Mohammad Khan, M.D., Ph.D.
Didier Raoult, M.D., Ph.D.
Faculté de Médecine
13385 Marseille, France
didier.raoult@medecine.univ-mrs.fr
References
Lange RA, Hillis LD. Acute pericarditis. N Engl J Med 2004;351:2195-2202.
Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericarditis: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623-630.
Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol 1995;75:378-382. [CrossRef][ISI][Medline]
Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003;82:385-391.
Levy PY, Moatti JP, Gauduchon V, Vandenesch F, Habib G, Raoult D. Comparison of intuitive versus systematic strategies for etiological diagnosis of pericardial effusion. Scand J Infect Dis (in press).
To the Editor: Lange and Hillis attribute elevated concentrations of troponin in acute pericarditis to "epicardial inflammation rather than myocyte necrosis." Most evidence indicates that cardiac troponin I is released into the circulation as a result of the death and disruption of myocardial cells.1 This is consistent with ST-segment elevation in acute pericarditis indicating injury of superficial myocardium and an element of localized myocarditis.2 Whether troponin I can be released from myocardial cells in response to reversible injury is controversial.
Rex MacAlpin, M.D.
David Geffen School of Medicine at UCLA
Los Angeles, CA 90095-1679
References
Coudrey L. The troponins. Arch Intern Med 1998;158:1173-1180.
Spodick DH. Acute, clinically noneffusive ("dry") pericarditis. In: Spodick DH, ed. The pericardium: a comprehensive textboook. New York: Marcel Dekker, 1997:94-113.
To the Editor: Lange and Hillis state that "there are no specific guidelines for evaluating or treating pericarditis." We are surprised that the authors do not mention the guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases.1 Furthermore, in their interesting discussion, Lange and Hillis do not mention nonproductive cough and shortness of breath as common symptoms of acute pericarditis.1,2
Nicola Mumoli, M.D.
Antonio Mancini, M.D.
Marco Cei, M.D.
Ospedale Civile
57100 Livorno, Italy
nimumoli@tiscali.it
References
Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary: the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004;25:587-610.
Spodick DH. Pericardial disease. In: Braunwald E, Zipes DP, Libby P, eds. Heart disease: a textbook of cardiovascular medicine. 6th ed. Philadelphia: W.B. Saunders, 2001:1823-76.
The authors reply: As Levy et al. state, the likelihood of identifying a cause of acute pericarditis is influenced by the patient population being studied, regional epidemiologic factors, and the breadth and depth of diagnostic testing. In addition, the yield of diagnostic evaluation is higher in patients who have pericardial effusions than in those who do not.1 Thus, in the study by Levy et al.2 of hospitalized subjects with pericardial effusions, a cause was identified in about 50 percent of patients.
As noted by MacAlpin, there is continued debate about whether troponin I may be released from reversibly (as opposed to irreversibly) injured myocytes. As a result, it is unknown whether the elevated troponin I concentrations sometimes observed in patients with acute pericarditis are reflective of transient epicardial inflammation or true necrosis.
Richard A. Lange, M.D.
Johns Hopkins Medical Institutions
Baltimore, MD 21287
L. David Hillis, M.D.
University of Texas Southwestern Medical Center
Dallas, TX 75390-9030
dhilli@parknet.pmh.org
The causes of acute pericarditis may also vary in different geographic regions. Finally, the incidence of specific causes of acute pericardial effusion depends on regional epidemiologic factors and on whether diagnostic tests are used systematically with reference to a predetermined protocol or intuitively.5
Pierre-Yves Levy, M.D.
Mohammad Khan, M.D., Ph.D.
Didier Raoult, M.D., Ph.D.
Faculté de Médecine
13385 Marseille, France
didier.raoult@medecine.univ-mrs.fr
References
Lange RA, Hillis LD. Acute pericarditis. N Engl J Med 2004;351:2195-2202.
Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericarditis: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623-630.
Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol 1995;75:378-382. [CrossRef][ISI][Medline]
Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003;82:385-391.
Levy PY, Moatti JP, Gauduchon V, Vandenesch F, Habib G, Raoult D. Comparison of intuitive versus systematic strategies for etiological diagnosis of pericardial effusion. Scand J Infect Dis (in press).
To the Editor: Lange and Hillis attribute elevated concentrations of troponin in acute pericarditis to "epicardial inflammation rather than myocyte necrosis." Most evidence indicates that cardiac troponin I is released into the circulation as a result of the death and disruption of myocardial cells.1 This is consistent with ST-segment elevation in acute pericarditis indicating injury of superficial myocardium and an element of localized myocarditis.2 Whether troponin I can be released from myocardial cells in response to reversible injury is controversial.
Rex MacAlpin, M.D.
David Geffen School of Medicine at UCLA
Los Angeles, CA 90095-1679
References
Coudrey L. The troponins. Arch Intern Med 1998;158:1173-1180.
Spodick DH. Acute, clinically noneffusive ("dry") pericarditis. In: Spodick DH, ed. The pericardium: a comprehensive textboook. New York: Marcel Dekker, 1997:94-113.
To the Editor: Lange and Hillis state that "there are no specific guidelines for evaluating or treating pericarditis." We are surprised that the authors do not mention the guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases.1 Furthermore, in their interesting discussion, Lange and Hillis do not mention nonproductive cough and shortness of breath as common symptoms of acute pericarditis.1,2
Nicola Mumoli, M.D.
Antonio Mancini, M.D.
Marco Cei, M.D.
Ospedale Civile
57100 Livorno, Italy
nimumoli@tiscali.it
References
Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary: the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004;25:587-610.
Spodick DH. Pericardial disease. In: Braunwald E, Zipes DP, Libby P, eds. Heart disease: a textbook of cardiovascular medicine. 6th ed. Philadelphia: W.B. Saunders, 2001:1823-76.
The authors reply: As Levy et al. state, the likelihood of identifying a cause of acute pericarditis is influenced by the patient population being studied, regional epidemiologic factors, and the breadth and depth of diagnostic testing. In addition, the yield of diagnostic evaluation is higher in patients who have pericardial effusions than in those who do not.1 Thus, in the study by Levy et al.2 of hospitalized subjects with pericardial effusions, a cause was identified in about 50 percent of patients.
As noted by MacAlpin, there is continued debate about whether troponin I may be released from reversibly (as opposed to irreversibly) injured myocytes. As a result, it is unknown whether the elevated troponin I concentrations sometimes observed in patients with acute pericarditis are reflective of transient epicardial inflammation or true necrosis.
Richard A. Lange, M.D.
Johns Hopkins Medical Institutions
Baltimore, MD 21287
L. David Hillis, M.D.
University of Texas Southwestern Medical Center
Dallas, TX 75390-9030
dhilli@parknet.pmh.org