Letters to the Editor [8] Martínez-González MÁ, Corella D, Salas-Salvadó J, et al. Cohort profile: design and methods of the PREDIMED study. Int J Epidemiol 2012;41:377–85. [9] Kang JX. Reduction of heart rate by omega-3 fatty acids and the potential underlying mechanisms. Front Physiol 2012;3:416.
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[10] Zazpe I, Sanchez-Tainta A, Estruch R, et al. A large randomized individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study. J Am Diet Assoc 2008;108:1134–44.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.074
Comment on: Idiopathic pericarditis presenting large hemorrhagic pericardial effusion George Lazaros ⁎, Christodoulos Stefanadis From the First Cardiology Department, University of Athens, Hippokration Hospital, Greece
a r t i c l e
i n f o
Article history: Received 28 August 2013 Accepted 23 November 2013 Available online 3 December 2013 Keywords: Cardiac tamponade Hemorrhagic effusion Idiopathic pericarditis Malignancy
Dear Editor, We have read with interest the ‘Letter to the Editor’ by Pyung Chun Oh et al. entitled ‘Idiopathic pericarditis presenting large hemorrhagic pericardial effusion’ [1]. In the case reported, extensive diagnostic work up excluded malignancy and tuberculosis and effusion was finally attributed to idiopathic pericarditis. As ‘take home message’ the authors emphasize that the detection of large hemorrhagic pericardial effusion does not per se definitely preclude a diagnosis of idiopathic pericarditis. In our opinion some points of this paper need to be clarified further. Although we certainly agree with the authors' concept, we wish to stress that clinicians should be very cautious in ‘labeling’ the underlying pericardial disease according to the nature, hemorrhagic or not, of pericardial effusion. Actually, when iatrogenic causes of bloody pericardial effusion in patients presenting with tamponade have been excluded, malignant tumors, idiopathic pericarditis and complications of acute myocardial infarction appear as the most common underlying causes [2]. In patients with hemorrhagic effusions leading to tamponade, malignancy is unveiled only in ~2% of cases [2]. On the contrary, when a malignancy has been previously diagnosed, this percentage increases to 26% [2]. The relevant prevalence of tuberculosis highly depends on local epidemiology, but it is fairly low when Western countries are taken into consideration. ⁎ Corresponding author at: First Cardiology Department, University of Athens, Hippokration Hospital, 114 Vas. Sofias Ave., 115 27 Athens, Greece. Tel.: + 30 2132088099; fax: + 30 2132088676. E-mail address: [email protected] (G. Lazaros). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.073
Taking into account the aforementioned data, the detection of hemorrhagic fluid in the case described is rather not surprising. Actually, our group has also previously reported a similar case of idiopathic pericarditis presenting with cardiac tamponade in which 2000 ml of sanguineous fluid were percutaneously drained [3]. The etiologic assessment of patients presenting with cardiac tamponade and hemorrhagic effusions is a clinical challenge [4]. Although patients with tamponade and bloody effusions should in any case be triaged for malignancies and tuberculosis, it should not be overlooked that idiopathic pericarditis is a quite common underlying etiology, in particular when we deal with patients without a history of malignancy. Thus, although massive bloody pericardial effusions should alert physicians to exclude secondary causes of pericardial effusion, it should not be misleading, since the diagnosis of idiopathic pericarditis is not exceptional. Awareness of this piece of information would prevent from ordering unnecessary diagnostic procedures in those patients. We hope that the above comment will add to the unquestionable value of the manuscript of Pyung Chun Oh et al. and will contribute to the optimal management of patients presenting with large hemorrhagic pericardial effusions. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
References [1] Oh PC, Baek SJ, Moon J, Han SH, Park KY, Koh KK. Idiopathic pericarditis presenting large hemorrhagic pericardial effusion. Int J Cardiol 2013;168:4467–9. [2] Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? Chest 1999;116:1564–9. [3] Lazaros G, Tsiachris D, Stefanadis C. Swinging without feeling. Int J Cardiol 2011;148:389–91. [4] Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology 2013;124:224–32.
301
[10] Zazpe I, Sanchez-Tainta A, Estruch R, et al. A large randomized individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study. J Am Diet Assoc 2008;108:1134–44.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.074
Comment on: Idiopathic pericarditis presenting large hemorrhagic pericardial effusion George Lazaros ⁎, Christodoulos Stefanadis From the First Cardiology Department, University of Athens, Hippokration Hospital, Greece
a r t i c l e
i n f o
Article history: Received 28 August 2013 Accepted 23 November 2013 Available online 3 December 2013 Keywords: Cardiac tamponade Hemorrhagic effusion Idiopathic pericarditis Malignancy
Dear Editor, We have read with interest the ‘Letter to the Editor’ by Pyung Chun Oh et al. entitled ‘Idiopathic pericarditis presenting large hemorrhagic pericardial effusion’ [1]. In the case reported, extensive diagnostic work up excluded malignancy and tuberculosis and effusion was finally attributed to idiopathic pericarditis. As ‘take home message’ the authors emphasize that the detection of large hemorrhagic pericardial effusion does not per se definitely preclude a diagnosis of idiopathic pericarditis. In our opinion some points of this paper need to be clarified further. Although we certainly agree with the authors' concept, we wish to stress that clinicians should be very cautious in ‘labeling’ the underlying pericardial disease according to the nature, hemorrhagic or not, of pericardial effusion. Actually, when iatrogenic causes of bloody pericardial effusion in patients presenting with tamponade have been excluded, malignant tumors, idiopathic pericarditis and complications of acute myocardial infarction appear as the most common underlying causes [2]. In patients with hemorrhagic effusions leading to tamponade, malignancy is unveiled only in ~2% of cases [2]. On the contrary, when a malignancy has been previously diagnosed, this percentage increases to 26% [2]. The relevant prevalence of tuberculosis highly depends on local epidemiology, but it is fairly low when Western countries are taken into consideration. ⁎ Corresponding author at: First Cardiology Department, University of Athens, Hippokration Hospital, 114 Vas. Sofias Ave., 115 27 Athens, Greece. Tel.: + 30 2132088099; fax: + 30 2132088676. E-mail address: [email protected] (G. Lazaros). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.073
Taking into account the aforementioned data, the detection of hemorrhagic fluid in the case described is rather not surprising. Actually, our group has also previously reported a similar case of idiopathic pericarditis presenting with cardiac tamponade in which 2000 ml of sanguineous fluid were percutaneously drained [3]. The etiologic assessment of patients presenting with cardiac tamponade and hemorrhagic effusions is a clinical challenge [4]. Although patients with tamponade and bloody effusions should in any case be triaged for malignancies and tuberculosis, it should not be overlooked that idiopathic pericarditis is a quite common underlying etiology, in particular when we deal with patients without a history of malignancy. Thus, although massive bloody pericardial effusions should alert physicians to exclude secondary causes of pericardial effusion, it should not be misleading, since the diagnosis of idiopathic pericarditis is not exceptional. Awareness of this piece of information would prevent from ordering unnecessary diagnostic procedures in those patients. We hope that the above comment will add to the unquestionable value of the manuscript of Pyung Chun Oh et al. and will contribute to the optimal management of patients presenting with large hemorrhagic pericardial effusions. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
References [1] Oh PC, Baek SJ, Moon J, Han SH, Park KY, Koh KK. Idiopathic pericarditis presenting large hemorrhagic pericardial effusion. Int J Cardiol 2013;168:4467–9. [2] Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? Chest 1999;116:1564–9. [3] Lazaros G, Tsiachris D, Stefanadis C. Swinging without feeling. Int J Cardiol 2011;148:389–91. [4] Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology 2013;124:224–32.
