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PostScript

CORRESPONDENCE

(Fundamental and Clinical Cardiology), Marcel Dekker, New York 1997’.

Persistent J-ST elevation: a sign of persistent perimyocardial irritation

Provenance and peer review Not commissioned; internally peer reviewed.

Dear Editor: We greatly enjoyed reading the recently published case by Cudmore et al.1 The case emphasises the importance of keeping a broad differential and a low threshold for suspecting an ominous diagnosis viz. ‘secondary pericardial metastasis or encroachment’, especially with the history of a known systemic malignancy. Metastatic and infiltrative/invasive involvement of the pericardium may often be the initial sign of cardiac involvement as a result of malignant disease elsewhere. The most common initial presenting feature is a pericardial effusion or even more deceptively clinical spectrum and ECG changes resembling ‘acute pericarditis’, especially when a strong fibrinous inflammatory pericardial reaction ensues.2 Patients with ‘metastatic or invasive pericarditis’ often have J-ST elevations lasting for days to weeks, implying a persistent perimyocardial irritation.2 It is often in contrast to idiopathic or viral pericarditis where patients will exhibit dynamic 4-stage ECG changes.3 In the presented case, the patient had a subacute presentation with preceding clinical symptomatology of 2-week duration and initial ECG showed J-ST elevation suggesting persistent pericardial irritation. In addition to the described ECG findings, we would also like to bring the readers’ attention to yet another finding on the provided ECG illustration that is, a concave JT-segment elevation with a slight downsloping TP-segment, also now referred to as the ‘Spodick sign’.4 Spodick sign is present in about 80% of the patients affected with acute pericarditis and best visualised in the lead II and lateral precordial leads. When used along with PR-segment depression, it often serves as an important electrocardiographic tool for distinguishing acute pericarditis from acute coronary syndrome.4

To cite Chhabra L, Spodick DH. Heart 2014;100:1301.

Lovely Chhabra,1 David H Spodick2 1 Department of Cardiovascular Medicine, Hartford Hospital, University of Connecticut School of Medicine, Hartford, Connecticut, USA 2 Department of Cardiovascular Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, Massachusetts, USA

Correspondence to Dr Lovely Chhabra, 80 Seymour Street, Hartford, CT (06102), USA; [email protected] Contributors Both authors have contributed significantly to the writing of this manuscript. Competing interests DHS receives royalties from his textbook, ‘The Pericardium: A Comprehensive Textbook

Published Online First 14 May 2014

▸ http://dx.doi.org/10.1136/heartjnl-2014-305663 Heart 2014;100:1301. doi:10.1136/heartjnl-2014-306079

REFERENCES 1

2 3

4

Cudmore JA, Lam W, Kirkpatrick ID, et al. Pleuritic chest pain in a 58-year-old man. Heart 2014;100: 1271. Spodick DH. The pericardium: a comprehensive textbook. Marcel Dekker, New York, 1997:301. Chhabra L, Spodick DH. Ideal isoelectric reference segment in pericarditis: a suggested approach to a commonly prevailing clinical misconception. Cardiology 2012;122:210–2. Chhabra L, Spodick DH. A comment on thyrotoxic pericarditis. Int J Cardiol 2014;173(3):587.

Comments on: ‘The infective endocarditis team: recommendations from an international working group’ To the Editor, Chambers et al1 give some wise recommendations regarding infective endocarditis management. They recognise the grim prognosis of the disease (mortality: 20–64%), the importance of dedicated teams of experts, and the prominent role of early surgery; despite this, they suggest that some patients can be adequately managed in centres without dedicated teams of experts and surgical facilities, and propose nine indications for transfer of patients to a surgical centre. In our opinion, every patient with infective endocarditis should be evaluated and treated in centres with dedicated experts and surgical facilities for several reasons: (1) severe complications may appear at any time and may require urgent diagnosis and treatment by experts; moreover, transferring a patient with septic shock or acute pulmonary oedema contributes to more clinical and haemodynamic instability; (2) an abscess, one of the indications proposed for transferring, and other periannular complications, may be missed by Heart August 2014 Vol 100 No 16

non-experts in imaging; (3) failure to respond to antibiotics is defined in the guidelines as the persistence of positive blood cultures 7–10 days after the initiation of antibiotic therapy,2 but this arbitrary cut-off point may be too late;3 (4) emboli can be silent or with subtle symptoms, and can be easily missed even by experts; (5) severe regurgitation in the context of a valve with important tissue damage can be difficult to assess. Our experience is in agreement with this concept. We used to recommend that patients could stay at their hospital if no high-risk markers were present; eventually, some of those patients were transferred to our centre with poorer clinical condition. Infective endocarditis is the cardiac disease with the highest rate of death, much higher than acute myocardial infarction and many types of cancers, which needs a combined medico-surgical therapeutic approach, which should be undertaken at medico-surgical centres. J A San Román,1 I Vilacosta,2 J López1 1

Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clinico Universitario, Valladolid, Spain 2 Cardiology Department, Hospital Clinico San Carlos, Madrid, Spain Correspondence to Dr J A San Román, Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clinico Universitario, Valladolid ES47005, Spain; [email protected] Contributors We certify that neither this manuscript nor one with substantially similar content under our authorship has been published or is being considered for publication elsewhere. The authors confirm that we have all contribute to this article. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.

To cite San Román JA, Vilacosta I, López J. Heart 2014;100:1301–1302. Published Online First 10 June 2014

▸ http://dx.doi.org/10.1136/heartjnl-2013-304354 Heart 2014;100:1301–1302. doi:10.1136/heartjnl-2014-306230

REFERENCES 1

2

Chambers J, Sandoe J, Ray S, et al. The infective endocarditis team: recommendations from an international working group. Heart 2014;100:524–7. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective

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Downloaded from http://heart.bmj.com/ on March 8, 2015 - Published by group.bmj.com

Persistent J-ST elevation: a sign of persistent perimyocardial irritation Lovely Chhabra and David H Spodick Heart 2014 100: 1301 originally published online May 14, 2014

doi: 10.1136/heartjnl-2014-306079 Updated information and services can be found at: http://heart.bmj.com/content/100/16/1301.1

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Persistent J-ST elevation: a sign of persistent perimyocardial irritation.

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