To the Editor.
—I am grateful to Dr Hancock for the warm and perceptive review of my new book.1 At the risk of seeming churlish, I feel compelled to address the very few errors because they are of clinical (ie, factual) and conceptual importance. First, low voltage in the electrocardiogram in pericardial diseases is pluricausal and not universal. It is clearly stated in the text that in cardiac tamponade the degree of change is not related to the severity of hemodynamic compromise.1(p57) Second, myocardial ischemia does not occur during pericardial effusion and tamponade. Indeed, it is clearly stated that with normal coronary arteries "coronary blood flow is decreased but remains adequate to support aerobic metabolism because there is proportional reduction in cardiac work.... Even coronary vasodilator reserve, capacitance, and resistance are not significantly impaired."1(pp186,187) In constrictive pericarditis, discrete coronary obstruction has been repeatedly reported. Third, true pulsus
Spodick DH. Pericardial Disease. JAMA. 1997;278(9):704. doi:10.1001/jama.1997.03550090028025