New-onset Heart Failure With Atrial Fibrillation: A Distinct Type of Cardiomyopathy?

OBJECTIVE: There is limited research comparing demographic and clinical characteristics between patients who present with atrial fibrillation (AF) and new-onset cardiomyopathy (CM) to patients with new-onset CM without dysrhythmia. We aimed to evaluate clinical characteristics and outcomes in patients with new-onset CM with and without AF and to report their real-world treatment. METHODS AND RESULTS: The study population was identified using patient records from our healthcare system from January 1, 2012 to September 30, 2016. Patients with a left ventricular ejection fraction ≤40% without a prior history of CM were divided into two groups; those with an antecedent or concomitant diagnosis of AF (AF-CM group) and those with no history of dysrhythmia (CM group). Patients in the AF-CM group (n=196) were older, more likely to be male, had a higher burden of comorbidities but lower levels of cardiac biomarkers, and had lower voltage on surface electrocardiogram than the CM group (n=197). In AF-CM, symptom onset was insidious, leading to a higher likelihood of outpatient diagnosis; 88.3% of AF-CM patients presented with atypical symptoms of AF. The AF-CM group had higher mortality on follow-up. Only 8.7% of patients in this group underwent an ablation procedure. Women, those with a history of coronary artery disease, and older patients were less likely to receive a cardioversion or ablation procedure. CONCLUSIONS: Patients presenting with new-onset CM associated with AF have a markedly different risk factor and demographic profile, clinical presentation, and outcomes. In real-world practice, a minority of patients undergo a rhythm control strategy.

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.

Medical informed choice: understanding the element of time to meet the standard of care for valid informed consent.

Medical informed choice is essential for a physician meeting their fiduciary duty when proposing medical and surgical actions, and necessary for a patient to consent or cull the outlined therapeutic approaches. Informed choice, as part of a shared decision-making model, allows widespread give-and-take of ideas between the patient and physician. This sharing of ideas results in a partnership for decision-making and a responsibility for medical and surgical outcomes.Informed choice is indispensible to the patient education process that meets the desired outcome of any covenant-an offer of and acceptance of the proposed treatment. The covenant anchors a true patient-physician partnership with parity and equality in decision-making and medical/surgical outcomes.Medical informed choice flows from ethical and legal principles necessary to meet the acknowledged standard of care. This is codified by statute and fortified in general common law. This espouses a fiduciary relationship where the patient and physician understand and accede to the degree of autonomy the patient requests.The growth of an equal patient-physician relationship requires time. There is no alternative to the time variable when developing a physician-patient relationship. Despite physicians being under pressures to perform more clinical and administrative duties in less time in the corporate model of medicine, time remains the most critical variable when considering informed choice and shared decision-making. Videos, pamphlets and alternate healthcare providers cannot and should not substitute for physician time.

Heightened malpractice risk for hospitalist physicians in the USA: what to know and what to do.

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

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.

Unintended consequences of the electronic medical record on physicians in training and their mentors.

For physicians in training and their mentors, the process of learning and teaching clinical medicine has become challenging in the electronic medical record (EMR) era. Trainees and their mentors exist in a milieu of incessant box checking and laborious documentation that has no clinical educational value, limits the time for teaching and curtails clinical cognitive skill development. These unintended consequences of the EMR are juxtaposed against the EMR's intended benefits of improved patient care and safety with reduced medical errors, improved clinical support systems, reduced potential for negligence with clinical data and metadata data supporting compliance with the standard of care. Although the mindset was technology would be the solution to many healthcare issues, there was not an appreciation of the cumulative impact of the non-educational workload on physician time and education. The EMR was intended to improve the efficiency of medical care and time management. It appears that the unintended consequences of the EMR with numerous checkboxes, automatic filling of computer screens, pre-worded templates, and automatic history and physical examination functions with detailed administrative oversight and compliance monitoring were not appreciated, and many believe that burden has overwhelmed the intended benefits of the EMR. This juxtaposition of the intended and unintended consequences of the EMR has left trainees and mentors struggling to optimise medical education and development of clinical skills while providing high-quality patient medical care. Physician educators must identify how to use the benefits of the EMR and overcome the unintended consequences. A major unintended consequence of the EMR is time dedicated to automate functions that detract from the time spent with mentors and patients. This time loss has the potential to restrict the physician from meeting the essential canons of medical informed consent and interfere with a physician meeting her fiduciary duties to the patient. To raise awareness and stimulate a search for solutions that benefit medical education and patient care, we will explore the intended and unintended consequences of the EMR and potential solutions using the intelligent systems of the EMR.

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.

Physician alert: the legal risks associated with 'on-call' duties in the USA.

On-call physicians encounter a diverse aggregate of interfaces with sundry persons concerning patient care that may surface potential legal peril. The duties and obligations of an on-call physician, who must act as a fiduciary to all patients, create a myriad of circumstances where there is a risk of falling prey to legal ambiguities. The understanding of the doctor-patient relationship, the obligations of physicians under the Emergency Medical Treatment and Labor Act, the meaning of medical informed consent and the elements of negligence will help physicians avoid the legal risk associated with the various encounters of being on call. After introducing the legal concepts, we will explore the interactions that may put physicians at legal risk and outline how to mitigate that risk. Being on call is time consuming and arduous. While on call, physicians have a duty to act morally and ethically in the best interest of the patients.

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.

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.

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.