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.

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.

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.

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.

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.

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.

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.

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.

Association between alcohol consumption and systolic ventricular function: a population-based study.

BACKGROUND: Although moderate alcohol consumption is associated with decreased clinical heart failure, there are no population-based studies evaluating the relationship between alcohol consumption and left ventricular (LV) systolic function. We sought to evaluate the relationship between alcohol consumption and LV systolic function in the community. METHODS: In a population-based random sample of 2,042 adults, age ≥45 years, we assessed alcohol consumption by a self-administered questionnaire. Responders were categorized by alcohol consumption level: abstainer, former drinker, light drinker (<1 drink a day), moderate drinker (1-2 drinks a day), and heavy drinker (>2 drinks a day). Systolic function was assessed by echocardiography. RESULTS: We identified 38 cases of systolic dysfunction in 182 abstainers, 309 former drinkers, 1,028 light drinkers, 251 moderate drinkers, and 146 heavy drinkers. A U-shaped relationship was observed between alcohol consumption and moderate systolic dysfunction (LV ejection fraction [LVEF] ≤40%), with the lowest prevalence in light drinkers (0.9%) compared to the highest prevalence in heavy drinkers (5.5%) (odds ratio 0.14, 95% CI 0.04-0.43). This association persisted across different strata of risk factors of systolic dysfunction as well as in multivariate analysis. No significant association between alcohol consumption and systolic function was seen in subjects with LVEF >50% or ≤50%. CONCLUSIONS: There is a U-shaped relationship between alcohol consumption volume and LVEF, with the lowest risk of moderate LV dysfunction (LVEF ≤40%) observed in light drinkers (<1 drink a day). These findings are parallel to the relationship between alcohol consumption and cardiovascular disease prevalence.

Guiding the management of ventricular arrhythmias in patients with left ventricular noncompaction cardiomyopathy: a knowledge gap.

Left ventricular noncompaction (LVNC) is a cardiomyopathy that occurs due to an arrest of myocardial maturation during embryogenesis. The diagnostic echocardiographic features in individuals with LVNC include a thick, bilayered myocardium, prominent ventricular trabeculations, and deep intertrabecular recesses. Clinical features associated with LVNC vary in asymptomatic and symptomatic patients, and include the potential for heart failure, conduction defects (eg, left bundle branch block), supraventricular and ventricular arrhythmias, thromboembolic events, and sudden cardiac death. The authors report five cases that emphasize asymptomatic and apparently benign symptoms in patients with LVNC; despite normal physical examination and 12-lead electrocardiogram results, all of these cases unveiled potentially serious clinical consequences. These cases highlight the concern that LVNC patients with mild to moderate left ventricular systolic dysfunction, particularly in the presence of ventricular arrhythmias or a family history of sudden cardiac death, may need consideration for an implantable cardioverter defibrillator (ICD). All potential benefits of an ICD need to be balanced by the risk of device infection, lead and device malfunction, and potential for inappropriate shocks.

Double jeopardy in the echocardiography laboratory: coexistence of two distinct cardiomyopathies?

BACKGROUND: In our Hypertrophic Cardiomyopathy (HCM) Center, we identified 6 patients each with what appeared to be the occurrence of 2 rare diseases that prompted investigation for a common derivative. METHODS: We reviewed our database, searching for all patients with a diagnosis of HCM, amyloid heart disease and left ventricular noncompaction (LVNC). RESULTS: Using transthoracic echocardiography and magnetic resonance imaging, we identified 6 patients with apical hypertrabeculations and myocardium suggestive of LVNC; 4 of the patients had HCM and 2 of the patients had cardiac amyloidosis. CONCLUSIONS: The significance of these possible concomitant cardiomyopathies is not presently well understood. We did not identify a common derivative when looking for a genetic link, but it is most likely hidden in the genetic substrate, yet to be identified.

The practical role of echocardiography in selection, implantation, and management of patients requiring LVAD therapy.

Viable treatment options for advanced heart failure have not emerged as the number of people afflicted with this condition has grown. Although heart transplantation is the only curative strategy for patients with end-stage heart failure, the relative shortage of donors has led to a worldwide plateau of this option over the past 20 years. The result is an unacceptably high mortality rate among patients with advanced heart failure. Interest in developing alternative curative strategies based on chronic circulatory support, with the aim of prolonging and improving quality of life for these patients, has grown. Patients supported with left ventricular assist devices require structured longitudinal care from a team of providers. An integrated approach using basic echocardiography is critical to patient selection, implantation, and continued surveillance and success of patients with left ventricular assist devices.

Risk management principles for physicians.

The swift pace of medical practice today makes it imperative for physicians to carry a toolbox jam-packed with risk management principles. The toolbox must be overflowing with utensils that allow a complete execution of the physician's fiduciary responsibility to the patient: all-inclusive informed consent, comprehensive documentation, fulfilling the standard of care, the significance of second opinions, transparency, crisis-management skills, and how to discuss an unfortunate result/outcome.

The chaotic physician work world.

Physicians are immersed in a work environment where daily challenges seem to represent a condition or place of increasing disorder and confusion. The degree of "entropy" in the physician workplace is increasing exponentially. Healthcare systems are in a state of chaos and are dynamic--meaning the behavior at one time influences its behavior in the future. The initial changes have future exponential fluctuations that have created a state of healthcare crisis. These systems are nonlinear; the metaphor to describe the unruly nature of the physician work world is that in which the flap of a butterfly wing in Brazil can set off a tornado in Texas. The tornado affecting physician work life must be understood to be rectified. Physicians must slow down and pay attention.

Liability of physicians supervising nonphysician clinicians.

Physicians confront a variety of liability issues when supervising nonphysician clinicians (NPC) including: (1) direct liability resulting from a failure to meet the state-defined standards of supervision/collaboration with NPCs; (2) vicarious liability, arising from agency law, where physicians are held accountable for NPC clinical care that does not meet the national standard of care; and (3) responsibility for medical errors when the NPC and physician are co-employees of the corporate enterprise. Physician-NPC co-employee relationships are highlighted because they are new and becoming predominant in existing healthcare models. Because of their novelty, there is a paucity of judicial decisions determining liability for NPC errors in this setting. Knowledge of the existence of these risks will allow physicians to make informed decisions on what relationships they will enter with NPCs and how these relationships will be structured and monitored.

Physicians in transition: practice due diligence.

The landscape of healthcare is changing rapidly. That landscape is now a business model of medicine. That rapid change resulting in a business model is affecting physicians professionally and personally. The new business model of medicine has led to large healthcare organizations hiring physicians as employees. The role of a physician as an employee has many limitations in terms of practice and personal autonomy. Employed physicians sign legally binding employment agreements that are written by the legal team working for the healthcare organization. Thus physicians should practice due diligence before signing the employment agreement. "Due diligence" refers to the care a reasonable person should take before entering into an agreement with another party. That reasonable person should seek expertise to represent his or her interests when searching a balanced agreement between the physician and organization.

The corpulent and sedentary society: epitome of a healthcare crisis.

Obesity is killing our patients and draining our healthcare resources. The First Amendment is an available tool to reverse the tragic state of our nation's health. Through educational programs, across all economic, educational, and cultural stratifications of our society, emphasizing the importance of diet and exercise, we can reverse the tragic physical, emotional, and health consequences of obesity. This must be a physician-led strategy that empowers patients across all age groups to be personally responsible for their personal health.

Left ventricular noncompaction: a diagnostically challenging cardiomyopathy.

Diagnosing left ventricular noncompaction (LVNC) cardiomyopathy is a challenge for the medical community because the condition shares morphologic features of hypertrophic and dilated cardiomyopathies. The uncertainty surrounding the diagnosis of LVNC is related to the lack of a "perfect diagnostic tool," such as a reproducible genetic marker. The diagnosis requires expertise in the broad spectrum of overlapping cardiomyopathies. The demarcation between LVNC and normal phenotypic variations is often indistinct. Echocardiography, used in routine clinical practice to identify the typical morphologic features of LVNC, can be overly sensitive and lack specificity with the presently defined measurements and ratios used to diagnose LVNC. The available diagnostic criteria show a propensity toward overdiagnosing LVNC. The complex clinical sequelae of atrial and ventricular arrhythmias, heart failure, thromboembolic events and sudden death associated with LVNC make a valid and reproducible diagnosis critical. The trend to using a morphologic/pathophysiologic, instead of a solely morphologic, approach holds promise in the quest for an accurate, reliable diagnosis of LVNC. We must understand the distinction between morphological findings and morphological findings with pathophysiology. Our future understanding of LVNC depends on an integration of cardiac morphology, physiology, pathophysiology and evolving genetics.