The independent medical examination: cardiology assessment.

Insurance companies frequently seek medical opinions from various specialists concerning the severity of a medical problem, the appropriateness of a treatment plan and a assessment of the degree of medical impairment in persons who claim they are entitled to disability benefits. The insurer is requesting a medical opinion from a physician not involved in the care of the claimant and with no regular business ties to the insurance company; the insurance industry refers to this as an independent medical examination (IME). The purpose of the cardiology IME is to have an objective assessment concerning symptomatology and disease severity, and to reach a conclusion as to whether the cardiology problem is expected to prevent a return to work. The cardiologist needs to narrow the focus on the heart solely in terms of its primary function, that is, its ability to pump blood.

Maximal treadmill tests five years apart in asymptomatic men aged 45-72 years.

169 asymptomatic male volunteers aged 45-72 years not taking part in any fitness or intervention program performed two maximal treadmill tets (Bruce protocol) five years apart. Treadmill endurance time declined 4 to 8 seconds per year; 72% of subjects had changes in endurance time of less than one minute. Maximal heart rate declined about 1 beat/min-1 per year. Horizontal or downsloping ST segment depressions of 0.1 mv or more or slowly upsloping ST depressions of 0.2 mv or more occurred in 26% of subjects at test 1, 38% of subjects at test 2. 25% of subjects with ST abnormality at test 1 were normal at test 2, and 26% of subjects with a normal ST segment at test 1 were classified as abnormal at test 2. Ventricular ectopic beats during or after exercise occurred in 22% of subjects at test 1 and in 37% of subjects at test 2, and the frequency of complex ventricular ectopic activity increased from 2% at test 1 to 9% at test 2. There is a high frequency of exercise induced ventricular extrasystoles, and ST depression in a normal population of older men and it is not known whether there is any need for intervention.

Cardiac catheterization in infants and children can be an outpatient procedure.

Many cardiac catheterization procedures in infants and children can be performed on an outpatient basis. This has been the practice in a pediatric hospital for 18 years. Over the last 12 years 1,355 of 2,133 catheterization procedures were performed on an outpatient basis. Excluding newborns, 45 percent of infants under 1 year of age having catheterization procedures were studied as outpatients. After age 1 year, 83 percent of the patients were studied as outpatients. Many of the patients admitted to the hospital would have been suitable for outpatient study. There were no significant complications related to the outpatient program. The main advantage would seem to be a reduction in anxiety concerning the test for children and their parents.

Influence of spinal curvature on exercise capacity.

It is well recognized that scoliosis in excess of 65 degrees results in cardiorespiratory impairment. Lesser degrees of spinal curvature have been noted to have near normal respiratory function studies at rest. Because of the great cardiorespiratory reserve, decreases in function secondary to scoliosis may be masked in studies conducted at rest. To study this concept, an investigation of the work capacity of 38 adolescent children with varying degrees of adolescent idiopathic scoliosis was undertaken. The maximal oxygen capacity and endurance time was measured and compared with a group of normal controls. A significant negative correlation between percentile endurance time and degree of spinal curvature was found showing a reduction in endurance time with every 20 degrees increase in spinal curvature (p less than 0.006). The application of "the exercise capacity test" as an investigative tool for scoliosis was found to be practical, since endurance time is a reliable index of the cardio-pulmonary status.

Pericarditis.

The autopsy frequency of pericarditis is two to six percent excluding uremic pericarditis and pericarditis secondary to myocardial infarction. The hospital incidence in adults is about one per 1000 admissions.(7,8)Pericarditis is easily overlooked as a cause of chest pain, particularly if the pain is atypical and not too bothersome to the patient. Consideration of pericarditis in the differential diagnosis of chest pain, careful auscultation for a pericardial friction rub and the use of ultrasound to confirm pericardial effusion will increase the frequency of diagnosis. While the prognosis in viral pericarditis is usually excellent, caution is indicated in advice and follow up because of the frequency of recurrences, the possibility of irreversible myocardial damage and the occasional development of constriction. Etiologic factors other than acute viral infection must always be considered.

Circulation in neonates with intracranial arteriovenous fistula and cardiac failure.

Two newborn infants with severe cardiac failure caused by a large cerebral arteriovenous communication were studied with complete cardiac catheterization, indicator-dilution curves and angiography. In one infant, studied at age 10 hours, a large right to left shunt through the patent ductus was seen with retrograde aortic flow into the left carotid artery. The entire flow in the descending aorta was supplied from the ductus. The second infant, studied at age 5 days, had a 20 percent right to left shunt through the foramen ovale and the ductus was closed. Hypoxia was caused by inadequate oxygenation of pulmonary venous blood, atrial right to left shunting and possibly ductal right to left shunting. The hemodynamic findings in cases of cerebral arteriovenous fistula would seem to depend on the patient's age at the time the studies are carried out and the severity of the lesion. Cardiac output was more than twice the normal value and blood flow through the arteriovenous fistula was probably greater than 4 liters/min per m2.

Pulmonary hypertension in a child with mixed connective tissue disease.

Mixed connective tissue disease (MCTD) is characterized by high titers of antibody to ribonucleoprotein (RNP) in patients with features of several rheumatic diseases. We describe a child whose MCTD included arthritis, Raynaud's phenomenon, mucocutaneous ulcerations, sclerodermatous skin changes, restrictive lung disease, reduced carbon monoxide pulmonary diffusing capacity, abnormal esophogeal motility, and severe pulmonary hypertension. High antibody titers to ds-DNA and RNP were present. Clinical improvement followed therapy with prednisone and cyclophosphamide. Improvement in the degree of pulmonary hypertension was documented by repeat cardiac catheterization 8 months after the initiation of combination therapy.

Maximal supine exercise haemodynamics after open heart surgery for Fallot's tetralogy.

Maximal supine exercise studies at the time of heart catheterisation were performed one to five years after open heart surgery for Fallot's tetralogy on 29 subjects 6 to 16 years of age. During exercise right ventricular systolic pressure exceeded 50 mmHg in all but 2 subjects, and end-diastolic pressure increased to over 15 mmHg in 10 subjects. Pulmonary artery peak systolic pressure was abnormal in 5 patients. Maximal exercise cardiac index was below the normal range in only 2 subjects, but below the mean for normals in 80 per cent of the patients. Only 3 patients had clinical exercise performances below the 3rd centile of normal subjects using a maximal upright bicycle exercise test, and only 1 subject was below the normal range for endurance time on the Bruce treadmill test. The patients in this series performed better than those in other series, possibly because of their younger age at operation, the use of a large control series of normal subjects taken from a clinic population, the willingness of the patients to work to near exhaustion, and previous encouragement of the patients to become normally active children.

Recirculation times in exercising children.

Recirculation times were measured with indicator-dilution methods in 19 subjects, aged 5--14 yr, during near-maximal supine bicycle exercise. Recirculation times were as short as 4.5 s and peak recirculation occurred within 10 s. When rebreathing methods are used to measure exercise cardiac output in children, their very rapid recirculation needs to be considered.

Maximal exercise capacity of children with heart defects.

Maximal treadmill tests following the Bruce protocol were performed by 830 children with heart defects and the endurance times compared with normal values from 327 children seen in the same clinic because of normal murmurs and from 388 normal children randomly selected and tested in the schools. When values in the normal clinic children were used as the reference, only 21 percent of the patients with heart defects had endurance times below the 10th percentile line. This line was 14 percent higher in the normal school children, and 47 percent of the patient group had values below the 10th percentile when values in the school children were used as the reference. Maximal heart rate in children with heart defects was almost always in the normal range (180 to 210 beats/min) except in patients with cyanosis or severe valve disease and, when encouraged to continue exercising, even these children had a mean maximal heart rate of 175 beats/min. When comparing the exercise capacity of children with heart defects with that of normal children, the source of the normal children is important; body build needs to be considered, as well as physical activity habits. Clinic patients without heart defects probably serve as a better normal control group than children obtained from the school system. Maximal exercise tests do not necessarily distinguish between children with mild or severe heart disease. Only children with lesions causing cyanosis or children with obviously severe disease have consistent reductions in exercise capacity.