Entrapped Coronary Arteries in Constrictive Pericarditis.

Pericardial constriction can be present without pericardial calcium and often without pericardial thickening. This epicardial coronary artery motion abnormality due to entrapment in a thickened, fibrotic pericardium, is characteristic of constrictive pericarditis, and differentiates this entity from other close differential diagnoses, such as restrictive and dilated cardiomyopathy.

Preparticipation Cardiovascular Screening of Student-Athletes with Echocardiography: Ethical, Clinical, Economic, and Legal Considerations.

PURPOSE OF REVIEW: To identify whether the use of echocardiography is a viable approach for the screening of athletes for the prevention of sudden cardiac death when considering ethical, clinical, economic, and legal issues. RECENT FINDINGS: Ethical musings, echocardiographic findings, economic calculations, and legal analysis suggest that echocardiographic screening may reduce sudden cardiac death on the athletic field. Ethical, clinical, economic, and legal considerations suggest echocardiographic screening is a viable option to meet the societal goal to prevent athletic field sudden death.

Cardiology consultation for non-cardiac surgery: Medical and legal explorations for clinicians.

Cardiologists performing preoperative cardiac evaluations for non-cardiac surgery have a unique opportunity to assess and optimize the patient's baseline and general health; determine the patient's inherent surgical risk based upon a comprehensive history, physical examination and pertinent laboratory data; ensure the patient has made an informed choice regarding surgery, and identify post-operative risks that must be considered to reduce the potential for major adverse cardiovascular events. There is always a small but inherent risk in surgical procedures. When an adverse outcome occurs there is potential for an allegation of negligence resulting in a detailed autopsy of the medical record. The best defense to an allegation of negligence is comprehensive documentation and a detailed rational for the cardiologist's management decisions.

Medical liability in the electronic medical records era.

Physicians encounter new medical liability risks in a medical milieu subjugated to electronic health information exchange. The budding electronic medical record systems have revolutionized how health care is dispensed. They alter the doctor-patient relationship in many uncertain and evolving ways. The shifting landscape of electronic information and medical liability risk is important for every practicing physician to understand. We review the historical changes of the electronic medical record, the emerging changes of the maturing electronic medical record, and the medical liability risk for physicians using the emerging electronic medical record systems. Because the electronic medical record appears to be here to stay, it is imperative that physicians adapt to efficient and effective use of the electronic information highway.

Syncope in Young Women: Broadening the Differential Diagnosis.

Syncope is defined as a sudden transient loss of consciousness (TLOC) with concomitant loss of postural tone followed by spontaneous recovery. It is a subset of a broader class of medical conditions, including postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension, and neurally mediated syncope (NMS), that may result in TLOC. The overlap of these clinical conditions leads to confusion regarding syncope classification that can hinder evaluation strategies, and pose challenges for diagnosis and treatment, particularly in young women. In this article, we review POTS, orthostatic hypotension, and NMS with an emphasis on NMS. These diverse orthostatic clinical entities may be associated with syncope and are frequently observed in young, healthy women. The importance of considering NMS as a diagnosis of exclusion cannot be overstated. We report a series of three young, otherwise healthy women, initially diagnosed with NMS, whose clinical course evolved over time into more sinister diagnoses that were overlooked and associated with devastating clinical outcomes. These cases highlight the importance of maintaining a broad differential diagnosis when considering the diagnosis of NMS. Each case synopsis provides key clinical features that must be considered to avoid overlooking more serious clinical conditions.

Ascending Aortic Aneurysm Is an Inherited Disease: A Contemporary Literature Review Based on Hill's Criteria of Specificity, Strength of Association, and Biological Coherence.

There is growing evidence of a differential etiological basis for thoracic aortic aneurysms (TAA), with ascending (As) TAAs being genetically mediated and descending (Des) TAAs more strongly related to acquired pathologies. A comprehensive literature review of this hypothesis has not been carried out. We carried out a systematic literature review based on the latest guidelines on TAA endorsed by the American Heart Association. The etiologies were classified as genetic and inherited, the studies were tabulated accordingly, and Hill's epidemiological criteria of causality were applied. We found 38 studies addressing the etiology of TAAs. Out of these, 17 were about genetic causes, 9 about acquired causes, and 4 had information regarding both etiologies. Multiple genetic studies showed a strong association of As TAA with different genetic mutations. Contrary to commonly held beliefs, acquired causes, that is, dyslipidemia, diabetes, and atherosclerosis, were negatively associated with As TAA and positively associated with Des TAA. Hypertension was only associated with Des TAA and dissections (TAAD), not with As TAA. Multiple studies fulfilled the criteria of strength of association (n = 4), consistency (n = 9), specificity (n = 5), temporality (24), biological gradient (n = 3), plausibility (n = 38), biological coherence (n = 25), experiment (n = 4), and analogy (n = 6). Our literature review supports the hypothesis that As TAA is genetically mediated and Des TAA is predominantly an acquired pathology, and supports the argument for genetic testing in all cases of As TAA.

Relationship of cardiac troponin to systolic global longitudinal strain in hypertrophic cardiomyopathy.

BACKGROUND: A high proportion of stable hypertrophic cardiomyopathy (HCM) patients have elevated serum cardiac troponin I (cTnI), but its clinical and echocardiographic determinants are unknown. Our objective was to determine the prevalence and clinical predictors of positive troponin (cTnI+) in a well-defined population of HCM patients using a highly sensitive assay. METHODS: We retrospectively interrogated medical records of 167 stable HCM patients from 1/2011 to 3/2014. cTnI >0.04 ng/mL was considered positive. RESULTS: Thirty-four percent were troponin-positive (median cTnI was 0.1 [0.07, 0.2] ng/dL). cTnI as a continuous variable correlated positively with maximal left ventricular wall thickness (LVT), maximal interventricular septal thickness, and global longitudinal strain (GLS) (P<.001). Unadjusted OR (95% CI) for positive troponin was 0.5 (0.3-0.9, P=.05) for obstructive HCM, 3.2 (1.7-5.9, P<.0001) for increased LVT, 0.3 (0.2-0.6, P<.0001) for -5% increase in GLS, 0.2 (0.04-0.9, P=.04) for moderate-to-severe mitral regurgitation, and 1.9 (0.9-3.9, P=.06) for implantable cardioverter defibrillator history. After adjusting for these variables, only maximum LVT (OR 2.5 [95% CI: 1.1-5.7, P=.02]) and GLS (OR 0.3 [95% CI: 0.2-0.6, P=.001]) were independent predictors. The percentage of patients with a positive cTnI increased from 19% to 24% and 57% across tertiles of LVT (P=.003) and decreased from 54% to 33% and 14% across tertiles of GLS (P<.0001). CONCLUSION: In this cohort of HCM patients, the association of reduced GLS and positive troponin was independent of LVT. Further studies are warranted to evaluate whether their combination adds prognostic value in identifying high-risk patients to define effective and early intervention strategies.

Deglutition syncope.

Deglutition syncope, also known as swallow syncope, is a neurally mediated reflex syndrome. The common intervention of the heart, esophagus, and stomach by the vagus nerve is central to its pathogenesis, whereby swallowing causes inhibition of the cardiac conduction system. It is most commonly associated with disorders of the esophagus, both organic and functional. Herein we describe the case of a 48-year-old man presenting with transient syncopal episodes that occurred while eating caused by an intrathoracic stomach due to a hiatal hernia.

Ventricular Septal Dissection Complicating Inferior Wall Myocardial Infarction.

Postmyocardial infarction ventricular septal defect is an increasingly rare mechanical complication of acute myocardial infarction. We present a case of acute myocardial infarction from right coronary artery occlusion that developed hypotension and systolic murmur 12 hours after successful percutaneous coronary intervention. Although preoperative imaging suggested a large ventricular septal defect and a pseudoaneurysm, intraoperative findings concluded a serpiginous dissection of the ventricular septum. The imaging technicalities are discussed.

A legal perspective on athlete screening and disqualification.

Physicians participate in the screening, routine medical supervision, and disqualification of student-athletes. In doing so, they should understand that eligibility/disqualification decisions inevitably have associated liability issues. It is the responsibility of physicians to take the lead role in the student-athlete medical assessment process to allow for optimum safety in sports programmes. The first duty of the physician is to protect the health and well-being of the student-athlete. However, because there is potential liability associated with the screening/disqualification process, physicians are wise to develop sound and reasonable strategies that are in strict compliance with the standard of care. This article focusses on cardiac screening and disqualification for participation in sports.

Medical Malpractice Stress Syndrome: A "Forme Fruste" of Posttraumatic Stress Disorder.

Physicians practicing medicine face many challenges in today's healthcare arena. The stress of practicing medicine is increasing exponentially as new medical information is exploding on a daily basis and new stresses to practicing are occurring in a burgeoning telecommunication world. The impact of rapidly increasing medical information and the era of electronic medical records allowing physicians to communicate with patients and physicians electronically, without the benefit of observing body language or clarifying misunderstandings, has had a huge impact on practicing physician-patient risk for misinterpretation of the electronically transmitted medical information. The risk of malpractice allegations is real even under the best circumstances. The potential risk to physicians alleged to be negligent has resulted in a clinical entity called medical malpractice stress syndrome; it is a "forme fruste" of posttraumatic stress disorder.

Hypertrophic cardiomyopathy with aortic dilation: a novel observation.

AIMS: Our goal was to identify the prevalence of aortic dilation in patients with hypertrophic cardiomyopathy (HCM), the most prevalent (0.2%) heritable, genetic cardiovascular disease. Aortic dilation also represents a spectrum of familial inheritance. However, data regarding the prevalence of aortic dilation in HCM patients is lacking. METHODS AND RESULTS: This is an observational retrospective study of all patients referred to our HCM centre. Aortic dilation was defined based on recent American Society of Echocardiography and European Association of Cardiovascular Imaging published guidelines. Of the 201 HCM patients seen between Jan. 1, 2011 and March 31, 2014, 18 (9.0%) met the definition of aortic dilation. Mean age was 56.3 ± 9.3 years, 77.8% were male, mean ascending aorta diameter was 4.0 ± 0.4 cm in males and 3.8 ± 0.2 cm in females, mean sinuses of Valsalva diameter was 4.2 ± 0.2 cm in males and 3.8 ± 0.4 cm in females, and 13 (72.2%) had left ventricular outflow tract obstruction. HCM patients with dilated aorta were more likely males, less likely hypertensive and had larger left ventricle diameter and more aortic valve regurgitation; remaining characteristics were similar. CONCLUSION: We report a novel observation with 9.0% prevalance of dilated aorta in HCM patients. Further studies are needed to help define the genetic and pathophysiologic basis as well as the clinical implications of this association in a larger group of HCM patients.

Should doctors still examine patients?

The physical examination skills of young physicians in training need careful examination as advancing technology seems to have replaced those skills compared to prior generations of physicians. A question to ponder is how should medical education address the convincing evidence that physician trainees of today are less astute at the physical examination than those that came before them? This inquiry must address whether the decline in physical examination skills hinders accurate, cost effective, and timely diagnoses. Additionally, it must consider whether the absence of a comprehensive physical examination impairs the patient-physician relationship. This type of inquiry leads to the conclusion that the physical examination and technology must be merged as the clinical situation dictates to provide accurate, cost effective and accurate diagnoses. The carefully performed physical examination in conjunction with a detailed history should dictate the use of our ever-advancing technologic advances in medicine.

The Importance of the Medical Record: A Critical Professional Responsibility.

Comprehensive, detailed documentation in the medical record is critical to patient care and to a physician when allegations of negligence arise. Physicians, therefore, would be prudent to have a clear understanding of this documentation. It is important to understand who is responsible for documentation, what is important to document, when to document, and how to document. Additionally, it should be understood who owns the medical record, the significance of the transition to the electronic medical record, problems and pitfalls when using the electronic medical record, and how the Health Information Technology for Economic and Clinical Health Act affects healthcare providers and health information technology.

Professional Liability Pertinent to Graduate Medical Education: The Intersection of Medical Education, Patient Care, and Law.

Physicians in training, nurse practitioners, physician assistants, attending physicians, and institutions that sponsor medical education are all at risk for potential professional liability issues. The unique relationship between healthcare providers and their sponsoring institution generates complex and evolving legal issues for all participants in medical education training. The law has played a great role integrating quality care and patient safety with excellent medical education for training physicians, while providing an avenue for relief when a medical error occurs. The intersection of law and medicine, while allowing for optimal medical education and patient care, exposes participating medical providers and the sponsoring institutions to specific professional liability issues. This article addresses these medical education settings and their potential professional liability issues.

ST-segment Elevation: Myocardial Infarction or Simulacrum?

A rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is mandatory for optimal treatment of an acute coronary syndrome. However, a small number of patients with suspected STEMI are afflicted with other medical conditions. These medical conditions are rare, but important clinical entities that should be considered when evaluating a STEMI alert. These conditions include coronary vasospasm, Takotsubo cardiomyopathy, coronary arteritis/aneurysm, myopericarditis, Brugada syndrome, left bundle branch block, early repolarization, aortic dissection, infective endocarditis with root abscess, subarachnoid hemorrhage, ventricular aneurysm after transmural myocardial infarction, and hemodynamically significant pulmonary embolism with right ventricular strain. Herein, we present several STEMI mimickers.

Why Patients Sue Physicians: Risk Management Strategies.

Physicians may head off allegations of negligence by developing a comprehensive understanding of why patients sue physicians and by appreciating what activities commonly lead to patient injury. With this knowledge, physicians can develop risk management strategies to reduce the likelihood of being named in a negligence lawsuit. We outline the common reasons why patients sue physicians, and what activities frequently lead to patient harm. The case examples emphasize the factors that can lead to allegations of negligence and patient harm.

Malpractice Considerations: New Concerns on the Horizon.

Physicians practicing medicine in today's ever-shifting and advancing medical world are at risk for malpractice liability. The introduction of a vast array of telecommunication media into the physician world is creating a growing area of malpractice risk for physicians. This article explores the new malpractice considerations facing physicians in our constantly evolving digital world. Although they are novel and just on the horizon, these risks are real, and it is prudent for every practicing physician to consider them carefully.