Diagnostic Criteria for Acute Pericarditis Need Closer Attention

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  • LETTERS TO THE EDITOR

    Diagnostic Criteria for Acute Pericarditis Need Closer Attention

    To the Editor:

    We read with great interest the work byElmouchi et al. published in a recent issue ofPacing and Clinical Electrophysiology.1 Thoughthe work is overall well done and is of interest,we have one concern about one of the definedmajor primary outcomes of this study, namely,postprocedure acute pericarditis. Authors havedefined acute pericarditis by only using a singleclinical characteristic, that is, pleuritic chestpain, which improved with leaning forward andabsence of other identifiable causes. However,in order to further categorize a pleuritic chestpain as acute pericarditis, presence of one of theadditional diagnostic characteristics is essential,namely, the presence of a pericardial frictionrub, characteristic electrocardiographic changes,or the presence of a new pericardial effusionon echocardiogram.25 The characteristic pleuriticchest pain alleviated by leaning forward is presentin only 24% of patients who have computed to-mography evidence of acute pericarditis.6 Thus, itis unclear if other diagnostic tests were performedaccordingly to confirm the diagnosis and distinctlyexclude other differentials of pleuritic chest pain

    doi: 10.1111/pace.12377

    among the study population. For instance, relyingonly on a single clinical characteristic, namely,characteristic chest pain, would miss a bunch ofpatients with the true diagnosis and may falselycharacterize other patients with this diagnosis,such as the ones with postprocedure pleuritis thatmay sometimes have a similar characteristic painas acute pericarditis but lack the other diagnosticcriteria.

    It is, thus, apparent that postprocedurepericarditis as an outcome measure was notprecisely defined, which may have significantoverall impact on the results of the study. Wewould greatly appreciate the authors response.

    LOVELY CHHABRA, M.D.,*VINOD K. CHAUBEY, M.D.,

    and DAVID H. SPODICK, M.D., D.SC.*Department of Cardiovascular Medicine,

    Hartford Hospital, Hartford,Connecticut; and Department of Medicine,

    Saint Vincent Hospital, Worcester,Massachusetts,

    E-mail: lovids@hotmail.com

    References1. Elmouchi DA, Rosema S, Vanoosterhout SM, Khan M, Davis

    AT, Gauri AJ, Finta B, et al. Cardiac perforation and leaddislodgement after implantation of a MR-conditional pacing lead:A single-center experience. Pacing Clin Electrophysiol 2014; 37:410.

    2. Spodick DH. Acute pericarditis: Current concepts and practice. J AmMed Assoc 2003; 289:11501153.

    3. Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R,Adler Y, Tomkowski WZ, et al. Guidelines on the diagnosis andmanagement of pericardial diseases executive summary; The Taskforce on the diagnosis and management of pericardial diseases

    of the European society of cardiology. Eur Heart J 2004; 25:587610.

    4. Chhabra L, Spodick DH. Pericardial disease in the elderly. In:Aronow WS, Fleg JL, Rich MW (eds.): Cardiovascular Disease in theElderly, 5th Ed. London, CRC Press, 2013, pp. 644668.

    5. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004;363:717727.

    6. Hammer MM, Raptis CA, Javidan-Nejad C, Bhalla S. Accuracy ofcomputed tomography findings in acute pericarditis. Acta Radiol2013 (in press; doi: 10.1177/0284185113515866[Epub ahead ofprint]).

    Response:

    We appreciate the opportunity to address thequestions raised by Chhabra et al., concerning thediagnosis of pericarditis as reported in our recentmanuscript.1 Although we focused on cardiacperforation as a complication of pacemaker leadplacement, we labeled the three patients withpresumed perforation on the basis of typicalpericardial pain alone, perhaps lacking a betterterm, with the designation of pericarditis. Inour experience, this syndrome is not a common

    complaint following pacemaker implantation, andindeed pain without effusion was not observedin the substantially larger 5076 lead populationin our study; both perforations in that groupwere associated with an effusion as well as pain.With respect to terminology, focal mechanicalpericardial injury is clearly a quite differentprocess than diffuse primary inflammation, andmay be expected to produce a friction rub and/orST elevation on electrocardiogram much lessfrequently, if ever. Thus, perforation rather thanpericarditis per se was the crucial issue in ourstudy, and to exclude the former on the basisof absent diagnostic criteria for the latter in our

    2014 Wiley Periodicals, Inc.

    658 May 2014 PACE, Vol. 37

  • LETTERS TO EDITOR

    opinion would be incorrect. However, the inabilityto conclusively prove that perforation occurred inthese three patients was acknowledged, and theirinclusion defended in the manuscript.

    DARRYL ELMOUCHISpectrum Health

    Grand Rapids, Michigandarryl.elmouchi@spectrumhealth.org

    Reference1. Chhabra L, Chaubey VK, Spodick DH. Diagnostic criteria for acute

    pericarditis needs closer attention. Pacing and Clin Electrophysiol2014; 37:658659.

    PACE, Vol. 37 May 2014 659

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