LETTERS TO THE EDITOR

In conclusion we stress the following three points: (1) M mode echocardiographic monitoring is needed to assess the presence and amount of pericardial effusion in uremic pa- tients. (2) In patients who have had open heart surgery an M mode echocardiogram positive for pericardial effusion must be supplemented with a two dimensional study. (3) For the therapeutic removal of pericardial effusion pericardiotomy- pericardiectomy is strongly suggested for all patients shown to have a significant amount of fluid on M mode echocardi- ography and is considered the method of choice for patients assessed with two dimensional echocardiography after open heart surgery.

Maria Lengyel, MD Mihaly KGkeny, MD Hungarian Institute of Cardiology Budapest, Hungary

Janos Mako, MD Department of Urology Semmelweis Medical School Budapest, Hungary

References

1. Wang B, Murphy J, Chang CJ, Hassanain K, Dunn M. The risk of pericardiocentesis. Am J Cardiol 1979;44:11 l-4.

2. Homa MB, Bchuftz CB, Bifnuat EB, Hwrtam DC, Pqtp RL Sensit~ity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 1974;50:239-47.

REPLY

We are very much interested in the experience of Lengyel et al. with echocardiography, pericardial effusion and pericar- diotomy. In our institution we have not used pericardiotomy as the treatment of choice for management of uremic peri- cardial effusion. Our nephrologists usually manage the asymptomatic uremic patient with a small pericardial effusion by increasing the frequency of dialysis. The uremic patient with a large pericardial effusion or with clinical signs of tam- ponade usually undergoes pericardiocentesis. We have been able to obtain excellent drainage of the pericardium with pericardiocentesis. To achieve this we will at times place a catheter in the pericardial sac for overnight drainage. Re- currence of pericardial effusion has been unusual. We have managed recurrent pericardial effusion in the uremic patient with repeat pericardiocentesis and instillation of cortico- steroids or with pericardiotomy/pericardiectomy.

We have had no major complications with pericardiocen- tesis in uremic patients. However, on the basis of our experi- ence with echocardiography, we would be reluctant to perform pericardiocentesis on patients with a maximal anterior clear space of less than 10 mm and would consider these patients for pericardiotomy or pericardiectomy.

The data of Lengyel et al. nicely demonstrated the point that postoperative open heart surgical patients with cardiac tamponade may often have loculated pericardial effusion that cannot be reached with the usual subxiphoid approach to

pericardiocentesis. Thus, these patients should be managed surgically. Two dimensional sector echocardiography is a helpful adjunct to M mode echocardiography. We have also found computed tomography to be a sensitive method for detecting the presence and location of pericardial effusion.

Bert Y. S. Wong, MD, FACC College of Health Sciences and Hospital Kansas City, Kansas

THE SPINOUS T WAVE

The spinous T wave with a narrow base (0.10 to 0.15 second) has been described in 37.1 percent of alcoholic subjects who are neither intoxicated nor hypokalemic.ls2 There is some difference of opinion as to whether this phenomenon is more likely to be long-lasting2 or transient.3

We examined the electrocardiograms of 100 consecutive men admitted to an alcohol detoxification unit and 41 age- comparable men without known heart disease newly admitted to a psychiatric unit.

T waves were defined as peaked if the height was 6 mm or greater, and was equal to or greater than the width. The electrocardiograms of 29 of the 100 alcoholic men fulfilled these simple criteria. In 18 the same criteria were met on a previous admission, 10 had no previous electrocardiogram and one did not have peaked T waves on a previous admission. These changes were maximal in lead Vs, V3 or Vd. In 9 of these 29 men electrocardiograms repeated 2 weeks later revealed persistence of the changes. Four men showed persistent changes 3 weeks later and one man 4 weeks later. Thus the changes persisted at least 2 weeks in 14 subjects We noted a return to normal of these T wave changes in one subject be- tween repeated admissions and, conversely, the persistence of such changes despite abstinence from alcohol for periods of 1 to 4 years in three subjects.

Similar peaked T waves were found on admission in 9 (22 percent) of the 41 otherwise normal untreated psychiatric patients; 6 of the 9 reported moderate to heavy use of alcohol and 1 was a light drinker; the drinking habits of the other 2 subjects could not be confirmed.

Peaked T waves, as defined, are common in alcoholics and tend to persist. The relation to “alcoholic cardiomyopathy” has not been adequately studied.

Kenneth Gardner, MD David Nicholson, MD Veterans Administration Medical Center University of Arkansas Medical School Little Rock, Arkansas

References

1. Evam W. The electrocardiogram of alcoholic cardiomyopathy. Bf Heart J 1959;21: 445-56.

2. Levln HD, Plantma TE. Mowa KE. A brisk electrocardiogram observed in chronic al- coholics. Am Haart J 1985:893140-2.

3. Evans W. Alcoholic cardiomyopathy. Progr Cardiovasc Dis 1964;7:151-71

July 1981 The Amerlcsn Journal of CARDIOLOGY Volume 48 201