Correspondence

Of Nicks and Time

N Engl J Med 2001; 345:1576November 22, 2001

Article

To the Editor:

In the Clinical Problem-Solving article by Nallamothu et al. (Aug. 2 issue),1 the discussant rightly points to the need for a rapid diagnosis of cardiac tamponade. However, among all the complex and costly tests listed, there is no mention of a very simple, quick, noninvasive, low-cost test: determination of the presence or absence of pulsus paradoxus. A positive result would have indicated the presence of fluid in the pericardial cavity. The test was apparently not performed in this case.

Carlo Gambacorti-Passerini, M.D.
National Cancer Institute, 20133 Milan, Italy
gambacorti@istitutotumori.mi.it

1 References

1. 1

   Nallamothu BK, Saint S, Kolias TJ, Eagle KA. Of nicks and time. N Engl J Med 2001;345:359-363
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Dr. Gambacorti-Passerini that checking for pulsus paradoxus should be part of the initial evaluation of any patient with chest pain and unexplained syncope. However, sudden and severe aortic regurgitation, which frequently occurs in type A aortic dissection, rapidly elevates left ventricular end-diastolic pressure, resulting in decreased respiratory movement of the interventricular septum and the absence of pulsus paradoxus despite clinical tamponade.1 Thus, the absence of pulsus paradoxus in this clinical setting should not dissuade the clinician from performing further studies, such as prompt echocardiography.

Brahmajee K. Nallamothu, M.D., M.P.H.
Theodore J. Kolias, M.D.
Kim A. Eagle, M.D.
University of Michigan Medical Center, Ann Arbor, MI 48109-0022
bnallamo@umich.edu

1 References

1. 1

   Fowler NO. Cardiac tamponade: a clinical or an echocardiographic diagnosis? Circulation 1993;87:1738-1741
   Web of Science | Medline