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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 3, May/June 2015
AFRICA
103
From the Editor’s Desk
A patient presenting with a large pericardial effusion of
uncertain aetiology is a relatively common clinical problem
facing practitioners in Africa. The optimal management of
such patients, particularly in resource-constrained environments,
remains unclear. Tuberculosis is generally considered to be the
most important likely cause, particularly if numerous fibrin
strands are seen to be present on echocardiography, and many
practitioners would advocate the immediate institution of
treatment for this disease under these circumstances. The issue is
far from clear however.
Treatment for tuberculosis, in addition to its obvious benefits,
carries some risk of serious adverse events but it also has
significant ‘minor’ side effects that are thoroughly unpleasant for
patients. In addition, there is the risk of missing other treatable
causes of such an effusion. While acknowledging that such a
risk is real, many would argue it is relatively unimportant, given
the fact that most alternative diagnoses are neither treatable nor
curable.
The counter-argument is that detailed and comprehensive
investigation of all pericardial effusions may enhance diagnostic
certainty and identify the few patients who may benefit from
alternative treatment. The problem is that detailed investigations,
including pericardiocentesis, advanced imaging studies or open
biopsy carry their own risks, are often not available and if they
are, the results of such investigations are largely untested in
terms of diagnostic sensitivity and specificity. The case report of
Tembani-Munyandu and colleagues (online, page e7) serves to
highlight this problem.
There is a great need for a properly structured, adequately
powered study to evaluate the risks and benefits of instituting
empirical therapy for tuberculosis, compared to aspiration and
detailed investigation in patients with large pericardial effusions
in Africa. Such a study would be complex, needing to recruit
a range of patients, including persons both HIV positive and
negative, but given the scope of the problem and the importance
of the question being addressed, it is essential that it be
conducted.
The effects of liver disease on cardiac structure and function
have been argued and discussed for decades with varied outcomes.
Bekler and colleagues (page 110) demonstrated that patients with
non-alcoholic fatty liver disease (NALFD) had right ventricular
diastolic dysfunction. It is not clear whether the authors
considered that these abnormalities of cardiac function were
directly related to the NALFD or to accompanying components
of the metabolic syndrome. Any therapeutic intervention that
may be contemplated will require clarity in this regard.
In hospital-based practice, it is alarming to see just how often
QT prolongation on the ECG is ignored, missed and/or under-
reported, and knowledge of the hazards of administering agents
prolonging the QT interval and situations where such agents may
be harmful is often limited. The case report of McCuthcheon
and Manga (page 145) serves to draw attention to the use of
commonly used drugs, in this case erythromycin, that can cause
lethal arrhythmias in predisposed individuals when they are used
inappropriately.
Sahin and colleagues (page 121) report on the frequency
of atrial fibrillation after surgery for left atrial myxoma. Not
surprisingly, age proved to be one of the predictors of atrial
fibrillation in this situation, as it does in all others. The
mechanism/s of the powerful effects of age on the development
of atrial fibrillation are complex and not fully explained but
an age-associated relationship with the development of atrial
fibrillation is not unexpected.
Pat Commerford
Editor-in-Chief
Professor PJ Commerford