Clinical Dilemma - Cardiac Memory vs Myocardial Ischemia.

Cardiac memory (CM) is a commonly unrecognized entity in which electrocardiograph (EKG) changes demonstrate T wave inversions (TWI) that appear consistent with ischemia. Inability to recognize and distinguish CM from actual ischemia can be a burden for both patients and hospitals, leading to unnecessary hospital admission, cardiac testing, and cardiac catheterization. Simple EKG analysis and meticulous interpretation of T-wave axis and morphology can help differentiate between the two. We present a case with such a dilemma, and an overview literature and physiology behind this entity.

A covert complication of arteriovenous fistulas.

Our patient is a 65-year-old man with a history of hypertension, aortic stenosis, and end-stage renal disease on hemodialysis who presented with worsening dyspnea. On examination, he exhibited signs of volume overload and had a radiocephalic arteriovenous fistula (AVF) with a significantly palpable thrill. Coronary angiogram showed normal coronary arteries. Cardiac catheterization revealed a cardiac output of 10.6 L/min by thermodilution. Ultrasound of the AVF access demonstrated an abnormally high velocity with flow >5 L/min. The patient was diagnosed with high-output heart failure (HOHF) secondary to his arteriovenous fistula. HOHF is an uncommon entity associated with certain pathologic states such as hyperthyroidism, skeletal and dermatologic disorders. It is defined as a high cardiac output >8 L/min, resting cardiac index >2.5-4.0 L/min per m2, and low systemic vascular resistance. Cardiac catheterization is often required for definitive diagnosis. The increased cardiac output may result in overt heart failure in patients with underlying heart disease. Treatment of HOHF secondary to an extracardiac shunt involves flow reduction procedures, ligation, or peritoneal dialysis. Our patient was successfully treated with AVF banding. Early recognition of this complication is critical, as many cases are reversible. 8 L/min, resting cardiac index >2.5-4.0 L/min per m2 and low systemic vascular resistance, is an uncommon entity associated with conditions such as hyperthyroidism, skeletal disorders, and dermatologic disorders. It is an often-missed complication in patients with arteriovenous fistulas, particularly those with underlying heart disease. The Kidney Foundation guidelines recommend arteriovenous fistula monitoring by physical examination and monthly flow measurements for patients at risk.>.

Reliability and validity of clinician ECG interpretation for athletes.

BACKGROUND: Electrocardiogram (ECG) with preparticipation evaluation (PPE) for athletes remains controversial in the United States and diagnostic accuracy of clinician ECG interpretation is unclear. This study aimed to assess reliability and validity of clinician ECG interpretation using expert-validated ECGs according to the 2010 European Society of Cardiology (ESC) interpretation criteria. METHODS: This is a blinded, prospective study of diagnostic accuracy of clinician ECG interpretation. Anonymized ECGs were validated for normal and abnormal patterns by blinded expert interpreters according to the ESC interpretation criteria from October 2011 through March 2012. Six pairs of clinician interpreters were recruited from relevant clinical specialties in an academic medical center in March 2012. Each clinician interpreted 85 ECGs according to the ESC interpretation guidelines. Cohen and Fleiss' kappa, sensitivity, and specificity were calculated within specialties and across primary care and cardiology specialty groups. RESULTS: Experts interpreted 189 ECGs yielding a kappa of 0.63, demonstrating "substantial" inter-rater agreement. A total of 85 validated ECGs, including 26 abnormals, were selected for clinician interpretation. The kappa across cardiology specialists was "substantial" and "moderate" across primary care (0.69 vs 0.52, respectively, P < 0.001). Sensitivity and specificity to detect abnormal patterns were similar between cardiology and primary care groups (sensitivity 93.3% vs 81.3%, respectively, P = 0.31; specificity 88.8% vs 89.8%, respectively, P = 0.91). CONCLUSIONS: Clinician ECG interpretation according to the ESC interpretation criteria appears to demonstrate limited reliability and validity. Before widespread adoption of ECG for PPE of U.S. athletes, further research of training focused on improved reliability and validity of clinician ECG interpretation is warranted.

Atypical stress-induced cardiomyopathy: a case series.

Stress-induced cardiomyopathy (SIC) is characterized by reversible left ventricular (LV) systolic dysfunction, which appears to be triggered by an intense, stressful event in the absence of significant coronary artery disease. It manifests typically with transient left ventricular wall motion abnormalities (WMA) involving the apical and/or mid-ventricular myocardial segments, associated with minimal troponin rise (<5 ng/ml), and typical EGG changes. Described are 3 cases of stress-induced cardiomyopathy with atypical distribution of wall motion abnormalities. Possible contributing mechanisms to the pathogenesis and the variability in WMA are discussed.

Practical management: a systematic approach to the evaluation of exercise-related syncope in athletes.

Syncope and presyncope are relatively common presentations among athletes. The distinction between post-exercise and during-exercise syncope is critically important. While the great majority of these episodes occur just after exercise and are benign, syncope can be an indication of serious underlying cardiovascular disease if it occurs during exercise. Syncope presents a challenging differential diagnosis, as well as a daunting array of diagnostic tests and advanced imaging strategies. Sequencing a proper evaluation, and deciding who requires consultation and restriction, can be difficult for the medical provider. We present a systematic approach that assists the sports physician in arriving at a diagnosis and organizing an initial management strategy.

The athletic preparticipation evaluation: cardiovascular assessment.

Thousands of young athletes receive preparticipation evaluations each year in the United States. One objective of these evaluations is to detect underlying cardiovascular abnormalities that may predispose an athlete to sudden death. The leading cardiovascular causes of sudden death in young athletes include hypertrophic cardiomyopathy, congenital coronary artery anomalies, repolarization abnormalities, and Marfan syndrome. Because these abnormalities are rare and difficult to detect clinically, it is recommended that family physicians use standardized history questions and examination techniques. Athletes, accompanied by their parents, if possible, should be asked about family history of cardiac disease and sudden death; personal cardiac history; and exercise-related symptoms, specifically syncope, chest pain, and palpitations. The physical examination should include blood pressure measurement, palpation of radial and femoral pulses, dynamic cardiac auscultation, and evaluation for Marfan syndrome. Athletes with "red flag" signs or symptoms may need activity restriction, special testing, and referral if the diagnosis is unclear.

Hypertension, athletes, and the sports physician: implications of JNC VII, the Fourth Report, and the 36th Bethesda Conference Guidelines.

Over the past decade, numerous studies have contributed to a growing evidence-based recommendation that the prevention, diagnosis, and management of hypertension can significantly lower cardiovascular morbidity and mortality. Several leading guidelines have been updated recently. Because hypertension is a common cardiovascular disease in athletes, sports medicine providers must remain vigilant in diagnosing this disorder and current with treatment and participation recommendations.

A pilot study of clinical agreement in cardiovascular preparticipation examinations: how good is the standard of care?

OBJECTIVE: To evaluate the interobserver agreement between physicians regarding a abnormal cardiovascular assessment on athletic preparticipation examinations. DESIGN: Cross-sectional clinical survey. SETTING: Outpatient Clinic, United States Military Academy, West Point, NY. PARTICIPANTS: We randomly selected 101 out of 539 cadet-athletes presenting for a preparticipation examination. Two primary care sports medicine fellows and a cardiologist examined the cadets. INTERVENTIONS: After obtaining informed consent from all participants, all 3 physicians separately evaluated all 101 cadets. The physicians recorded their clinical findings and whether they thought further cardiovascular evaluation (echocardiography) was indicated. MAIN OUTCOME MEASURES: Rate of referral for further cardiovascular evaluation, clinical agreement between sports medicine fellows, and clinical agreement between sports medicine fellows and the cardiologist. RESULTS: Each fellow referred 6 of the 101 evaluated cadets (5.9%). The cardiologist referred none. Although each fellow referred 6 cadets, only 1 cadet was referred by both. The kappa statistic for clinical agreement between fellows is 0.114 (95% CI, -0.182 to 0.411). There was no clinical agreement between the fellows and the cardiologist. CONCLUSIONS: This pilot study reveals a low level of agreement between physicians regarding which athletes with an abnormal examination deserved further testing. It challenges the standard of care and questions whether there is a need for improved technologies or improved training in cardiovascular clinical assessment.

Electrocardiographic findings in sports medicine: normal variants and the ones that should not be missed.

There are a few "red flag" findings in the history and physical examination of an athlete that may require obtaining an electrocardiogram (ECG) as part of a cardiac evaluation. In this article we discuss the normal variants seen in the ECG brought on by regular physical training and ECG abnormalities that are seen with a few of the structural and conduction abnormalities associated with an increased risk of sudden cardiac death. These conditions are all relatively uncommon and the ECG may reveal the first clue to the presence of a potentially significant underlying abnormality. After reading this article the sports medicine practitioner should be able to 1) confidently return to play those athletes with normal variants on their ECG, and 2) not miss the ECG abnormalities of an athlete who requires further evaluation for potentially significant abnormalities prior to participating in athletics.

Sudden cardiac death: ethical considerations in the return to play.

The team physician-athlete relationship prompts many basic questions in medical ethics. Return-to-play decisions form many of the core responsibilities facing team physicians, and occasionally these decisions can have overriding ethical dilemmas. Therefore, a structured ethical decision-making process is a valuable skill for every successful sports medicine physician. An ethical question is confronted here in a case presentation that weighs the risk of repeat sudden cardiac death and the potential for failed cardiac resuscitation against the athlete's interest to play competitive basketball. The article applies a four-step framework for ethical decision making in sports medicine. The important first step includes gathering medical information and understanding the preferences of the athlete. Step 2 brings together the decision-making stakeholders, the team physician as a member, to define ethical issues and apply ethical principles: beneficence, non-maleficence, and patient autonomy. Step 3 selects a course of action with unbiased analysis and arrives at a good choice that merits an action plan in step 4. This decision need not be perfect, but should reinforce the team physician's responsibilities to the athlete and center on the athlete's welfare.

Diagnosis and management of myocarditis in athletes.

Myocarditis is a pathologic entity that has serious potential consequences for competitive athletes. Myocarditis is an inflammation of the myocardium accompanied by myocellular necrosis. Cardiotropic viruses, in particular the Coxsackie B virus, have been implicated as the most common cause of acute myocarditis in the United States. A thorough history, physical examination, electrocardiogram, echocardiogram, elevated cardiac enzymes, and an elevated sedimentation rate help make the diagnosis. Athletes recovering from acute myocarditis should abstain from moderate to vigorous activity for 6 months, have normal cardiac function, and have no demonstrable arrhythmia before returning to sports.

Asymptomatic Aortic Insufficiency in a Runner.

In brief The case of an asymptomatic 21-year-old male college sprinter demonstrates that aortic insufficiency may go undiagnosed despite severe underlying cardiac pathology: A murmur detected during the preparticipation exam was the first sign. Activity modification was an important initial intervention. Echocardiography documented severe aortic regurgitation. An exercise multiple gated acquisition (MUGA) scan identified abnormal ejection fractions. After valve replacement, the patient's return to competition was guided by echocardiography, exercise testing, and input of the medical team and family.