Expertise In Cardiology Research Articles

Subclinical Thyroid Dysfunction: A Joint Statement on Management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and The Endocrine Society

UBCLINICAL THYROID DYSFUNCTION is a common clinical problem for which there are many controversial issues regarding screening, evaluation, and management. Subclinical hypothyroidism is defined as an elevated serum thyroidstimulating hormone (TSH) level associated with normal total or free thyroxine (FT4) and free triiodothyronine (FT3) levels. The overall prevalence is 4% to 10% in the general population, and up to 20% in women older than 50 years (1‐3). Several alternative names have been proposed to describe this condition and include “compensated hypothyroidism,” “preclinical hypothyroidism,” “mild thyroid failure,” and “mild hypothyroidism.” While each term has subtle implications that may be more or less appropriate in various circumstances, we will use the term “subclinical hypothyroidism” in the interest of consistency with a recent publication that is the topic of this discussion. Subclinical hyperthyroidism is defined as low serum TSH levels associated with normal FT4 and FT3 levels. The prevalence is approximately 2%, being more common in women, in blacks, and in the elderly (4,5). In order to develop an evidence-based approach to the various unresolved clinical issues regarding subclinical thyroid disease, the American Association of Clinical Endocrinologists (AACE), the American Thyroid Association (ATA), and The Endocrine Society (TES) jointly sponsored a Consensus Development Conference, which was held in September 2002. A number of questions were presented to a panel of 13 experts, including 8 experts in thyroid disease; the remaining 5 had expertise in cardiology, epidemiology, biostatistics, evidence-based medicine, health-services research, general internal medicine, and clinical nutrition. The consensus panel report is the result of an extensive review of the published literature on these topics available at the time. The conference participants meticulously followed the principles of evidence-based medicine (EBM) to summarize all existing pertinent data (a summary of the data reviewed is available at www.endo-society.org/education/evidencereport.cfm) and to make EBM recommendations on the controversial issues of screening, evaluation, and management of patients with subclinical thyroid disease. The recently published consensus panel’s conclusions and recommendations (6) were developed independently and therefore did not require official review or approval by the three sponsoring societies. Recognizing the EBM methodology cannot adequately address gray areas where existing evidence is inadequate and that EBM-based guidelines cannot specifically address the multitude of variations encountered by clinicians in their management of individual patients, the consensus authors also published an accompanying case-based discussion illustrating how the guidelines could be applied in several patient scenarios (7). The authors of these two outstanding articles are to be congratulated for these excellent publications and thanked for their service to the community of providers who care for patients with thyroid disorders. Subsequently, having carefully studied the consensus conference data, summaries, and recommendations, the leadership of AACE, ATA, and TES determined that it would not be appropriate for practicing clinicians and the regulatory elements of the health care industry to be left with the impression that the membership of these three organizations unanimously agreed with all of the consensus conference recommendations, despite their sponsorship of the conference itself. They felt that the data in several areas were inconclusive and that further alternative interpretations and recommendations was not only reasonable but also warranted in the interest of academic fairness. Two members from each of these respective organizations were therefore invited to form a panel to review the consensus conference recommendations to determine if there were areas of legitimate and significant disagreement. All members of this panel

Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report?

This paper was guest edited by Dr. E. Fleck. Deutsches Herzzentrum Berlin, Germany Cardiovascular magnetic resonance (CMR) is established in clinical practice for the diagnosis and management of diseases of the cardiovascular system. However, current guidelines for when this technique should be employed in clinical practice have not been revised since a Task Force report of 1998.1 Considerable technical and practice advances have been made in the intervening years and the level of interest from clinicians in this field is at an unprecedented level. Therefore the aim of this report from a Consensus Panel of established experts in the field of CMR is to update these guidelines. As CMR is a multi-disciplinary technique with international interest, the Consensus Panel was composed of European and American cardiologists and radiologists with major input from members with additional established expertise in paediatric cardiology, nuclear cardiology, magnetic resonance physics and spectroscopy, as well as health economics. The Consensus Panel was originated, approved and funded in its activities by the Working Group on CMR of the European Society of Cardiology and the Society for Cardiovascular Magnetic Resonance. The Consensus Panel recommendations are based on evidence compiled from the literature and expert experience. If there is insufficient evidence in the literature, this is indicated in the report but usually no recommendations are made under these circumstances. The appropriateness of using CMR is described for the frequent disease entities where imaging information may be warranted. The diagnostic use of CMR will be described in the context of other, competing imaging techniques, with particular emphasis on the differential indications with respect to echocardiography. The usefulness of CMR in specific diseases is summarized by means of the following classification:

American society of echocardiography guidelines and standards for performance of the fetal echocardiogram

Fetal echocardiography is the ultrasonic evaluation of the human fetal cardiovascular system. General antepartum obstetrical ultrasound has become a standard part of gestational care and is commonly used for the determination of fetal age, size, gender, or well-being and for the detection of congenital anomalies. A variety of maternal or fetal disorders may result in abnormality of the fetal cardiovascular system to a degree which demands evaluation at a level above and beyond that attainable with standard antepartum obstetrical ultrasound. In these circumstances, a fetal echocardiogram should be performed. Improved operator skill amongst physicians performing general antepartum obstetrical ultrasound, in combination with increased sensitivity of present day ultrasound systems, has resulted in improved detection of fetal cardiovascular abnormalities and increased requirements for more detailed evaluation. Congenital heart disease is the most common congenital anomaly found in the human. As the detection rates for congenital anomalies continue to increase, the demand for fetal echocardiography has grown. Accurate diagnosis of congenital heart disease via fetal echocardiography provides many benefits. It allows for a smooth transition between the preand post-natal states, with the opportunity to provide immediate care at birth, thereby avoiding the onset of hemodynamic compromise. Recent

A Newborn Who Has Previously Undiagnosed Hydrops Fetalis

A 36-week appropriate-for-gestational age male was born with hydrops fetalis that was not diagnosed prenatally. The birth hospital had a Level II nursery. Pertinent points in the history include: Born to a 24-year-old G2P0010 (previous first-trimester spontaneous abortionwoman by emergency cesarean section due to failure to progress and decreased fetal heart rate variability. ### Prenatal Laboratory Results Preterm labor occurred 1 week prior to delivery, but was stopped successfully with tocolysis, and the mother was sent home after 6 hours of observation. Rupture of membranes occurred 6 hours prior to delivery with clear fluid. At delivery, the infant appeared grossly edematous, dusky, and floppy, with no spontaneous respiratory effort. Endotracheal intubation was difficult because of airway edema. Resuscitation consisted of positive pressure ventilation, chest compressions, and epinephrine administration via an umbilical venous catheter. ### Initial Arterial Blood Gas Results A chest radiograph showed bilateral pleural effusions. A kidney-ureter-bladder (KUB) radiograph showed ascites. Pleurocentesis released 45 mL of straw-colored fluid from the left side of the chest, but none from the right side of the chest. A total of 15 mL of straw-colored fluid was removed from the abdomen via paracentesis. ### Follow-up Arterial Blood Gas Results On physical examination, the infant exhibited gross body edema but no dysmorphic features. A II/VI systolic murmur was heard at the left sternal border. The liver was palpable 3 cm below the costal margin. There was mild glandular hypospadias with a minimal chordee, but testes were descended bilaterally. The infant developed seizures and received a loading dose of 20 …

The Bali bombings of 12 October, 2002: lessons in disaster management for physicians

The Bali bombings of 12 October, 2002: lessons in disaster management for physicians

Effects of Psychological and Social Factors on Organic Disease: A Critical Assessment of Research on Coronary Heart Disease

An extensive research literature in the behavioral sciences and medicine suggests that psychological and social factors may play a direct role in organic coronary artery disease (CAD) pathology. However, many in the medical and scientific community regard this evidence with skepticism. This chapter critically examines research on the impact of psychological and psychosocial factors on the development and outcome of coronary heart disease, with particular emphasis on studies employing verifiable outcomes of CAD morbidity or mortality. Five key variables identified as possible psychosocial risk factors for CAD are addressed: acute and chronic stress, hostility, depression, social support, and socioeconomic status. Evidence regarding the efficacy of psychosocial interventions is also presented. It is suggested that, taken as a whole, evidence for a psychological and social impact on CAD morbidity and mortality is convincing. However, continued progress in this area requires multidisciplinary research integrating expertise in cardiology and the behavioral sciences, and more effective efforts to communicate research findings to a biomedical audience.

A logit model for the effect of telecardiology on acute newborn transfers.

The deregionalization of neonatal intensive care in the United States has shifted the site of care for many newborn infants away from academic medical centers where subspecialty support is available. To investigate the effect of immediate echocardiogram interpretation via telemedicine on rates of neonatal transfer to academic medical centers. A logit model was developed to predict the probability of transfer from two regional level 3 neonatal intensive care units to academic medical centers. One of these units implemented a telecardiology program and the other acted as a comparison institution with on-site cardiology expertise. The telecardiology intervention began 18 months into the 36-month study period. Infants (n = 2,142) admitted to neonatal intensive care at either of the two institutions during calendar years 1994 through 1996. A statistically significant reduction in the rate of transfer to academic medical centers was observed. Telecardiology was associated with a 58% reduction of such transfers (p = .001, 95% CI = 30%, 75%). No such reduction was noted at the comparison institution. It is estimated that approximately 30 transfers were eliminated during the study period, resulting in the elimination of approximately $150,000 in hospital charges. In addition, the infants that were transferred after the adoption of telemedicine were more often transferred to their telemedicine partner institution (p < .02).

Evidence-Based, Cost-effective Risk Stratification and Management After Myocardial Infarction

Current management of patients after an acute myocardial infarction (AMI) reflects a variety of approaches ranging from conservative to aggressive. Although each method is appropriate in certain subgroups, their application frequently lacks a scientific basis. Current, clinically relevant, evidence-based practice guidelines are needed for secondary prevention for survivors after an AMI. To meet this need, the California Cardiology Working Group was assembled to evaluate the available data from clinical trials and other published studies and develop evidence-based, cost-effective guidelines for clinicians to use as a basis for patient management after an AMI. The group consisted of 18 members, including cardiologists from academic institutions and physicians working in cardiac intensive care, private practices, and managed care settings, representing a broad spectrum of expertise pertaining to patients who have had an AMI. The members had expertise in cardiac intensive care, interventional cardiology, nuclear cardiology, lipid disorders, echocardiography, and cardiac rehabilitation. The intended audience for these practice guidelines includes all physicians who treat survivors of MI. A literature review of all relevant clinical trials and other published data about the natural history after AMI and the effects of current therapeutic modalities are discussed herein. Case histories served as models for application of the literature-based data. The recommendations for management were reached by consensus vote based on the scientific evidence. When more than 1 management option applied, this was recognized in the recommendations. The recommendations accompany the text.

Cardiac Problems in Pregnancy: Diagnosis and Management of Maternal and Fetal Disease

The multiauthor textbook has become the most convenient way of collating a comprehensive body of new information. Elkayam and Gleicher state that their purpose is to acquaint the adult and pediatric cardiologist with the developing field of fetal cardiology and to offer the obstetrician an understanding of maternal cardiology. The two editors, a cardiologist and an obstetrician, have accomplished both goals in their collaborative effort. They have written, either alone or together, about one third of the 49 chapters of the text and delegated the remainder to about 60 of their colleagues with established expertise in cardiology, pediatrics, obstetrics, surgery, anesthesiology, and pertinent basic sciences. The second edition has maintained the original organization, which combines in a single volume two loosely related surveys of maternal and fetal cardiology. Several chapters have been added, and some of the older ones have been updated or rewritten, but only a few of the

Staffing in cardiology in the United Kingdom 1988: Fifth biennial survey.

This is the fifth survey of staffing (consultants and senior registrars) in cardiology in the United Kingdom. Data from previous years--including the fourth survey (1986) that was not published separately--are used to show the trends over the past decade. In 1988 there were less than six cardiologists per million population. The United Kingdom, with Ireland, has fewer cardiologists than all other European countries with reliable figures. The ratio for Europe as a whole is approximately 45 per million population; the recommended figure for the United States of America is 60 per million. The distribution of cardiologists in England and Wales is still very uneven. Seven million people--nearly 15% of the population--have no immediate access to special expertise in cardiology. Women are particularly poorly represented in the specialty. This survey indicates that the crisis in staffing for cardiology continues. It will worsen as the possibilities grow for effective management of heart disease and as needs increase with the greater average age of the population. Resolution of this crisis should be a major priority in policies aimed at countering the ravages of heart disease.

Staffing in cardiology in the United Kingdom 1988. Fifth biennial survey.

This is the fifth survey of staffing (consultants and senior registrars) in cardiology in the United Kingdom. Data from previous years--including the fourth survey (1986) that was not published separately--are used to show the trends over the past decade. In 1988 there were less than six cardiologists per million population. The United Kingdom, with Ireland, has fewer cardiologists than all other European countries with reliable figures. The ratio for Europe as a whole is approximately 45 per million population; the recommended figure for the United States of America is 60 per million. The distribution of cardiologists in England and Wales is still very uneven. Seven million people--nearly 15% of the population--have no immediate access to special expertise in cardiology. Women are particularly poorly represented in the specialty. This survey indicates that the crisis in staffing for cardiology continues. It will worsen as the possibilities grow for effective management of heart disease and as needs increase with the greater average age of the population. Resolution of this crisis should be a major priority in policies aimed at countering the ravages of heart disease.

Task force V: Training in nuclear cardiology and nuclear magnetic resonance

A. General training (2 months) for all cardiology fellows is designed to make the fellow conversant with the field of nuclear cardiology (level 1). B. Specialized training (4 months) for individuals who wish to have special expertise in clinical nuclear cardiology and responsibility for all clinical nuclear cardiologic activity (level 2). C. Advanced training (1 year) for trainees who wish to pursue an academic direction in nuclear cardiology including patient care, teaching and research (level 3).

Provision of services for the diagnosis and treatment of heart disease in England and Wales. Third report of a Joint Cardiology Committee. Royal College of Physicians of London and the Royal College of Surgeons of England.

The principal conclusions of the report are as follows. Cardiology continues to change rapidly. In the five years since the issue of the Second Report of the Joint Cardiology Committee in 1980 the specialty has been affected principally by the increase in coronary artery surgery and the increasing importance of non-invasive techniques of diagnosis, particularly echocardiography. The burden of heart disease in Britain shows some decline recently, but this falls short of that which has occurred in other countries. The vital role of the initial assessment of patients to ensure the efficient use of limited resources falls upon physicians and paediatricians in district general hospitals. Each district general hospital should have at least one physician, practising general medicine but having a special expertise and training in cardiology. He should undertake echocardiography, stress testing, ambulatory monitoring, emergency pacing, rehabilitation, and cardiac intensive care, with the necessary facilities and staff. He will also play an important part in the follow up of patients assessed and treated at cardiac centres. Paediatricians should continue to evaluate children with heart disease and their training should include periods at cardiac centres. Cardiac centres currently undertaking invasive investigations and cardiac surgery need to expand to cope with demand. A target figure of 750-1000 coronary artery bypass operations annually is suggested. This implies three or four surgeons and six cardiologists per centre. Other staffing should be based on these figures. Smaller centres are not necessarily non-viable but should be encouraged to expand or merge. Funding should be clarified so that regional contributions to regional services are identified and not lost in district budgets. Expensive capital equipment should be regionally funded whether sited in cardiac centres of district general hospitals. (7) Supraregional centres for the cardiac problems of infants under the age of one year have been identified ans should receive supraregional funding. Their staffing and equipment should be appropriate to the exceptional demands of this work. If such a centre is sited within an existing cardiac centre the staff will be additional to those needed for the adult work. Facilities for older children should continue to be provided, as at present, at all cardiac centres. (8) Cardiac transplantation should be funded supraregionally. (9) The medical audit of cardiac work should be supported by the Department of Health and Social Security (DHSS). (10) Research remains a high priority, and cardiac centres should be provided with the facilities, and staff with the contracts and time, to undertake it. (11) A revision of this report is recommended within five years.

Measures of knowledge and attitude toward preventive cardiology.

In this paper, the authors describe the development and validation of an inventory of preventive cardiology at the University of Virginia. The inventory contains two instruments designed to measure medical students' preinstructional and postinstructional knowledge of and attitude toward preventive cardiology. The knowledge test subscales provide unique and significant information about knowledge in preventive cardiology and can discriminate among groups differing in level of instruction and expertise in preventive cardiology. The attitude survey provides information about two attitude factors: cardiovascular disease prevention and cardiovascular disease research priorities. In the study reported here, attitudes appeared not to differ among groups of students with different preventive cardiology instructional levels and expertise. Both instruments were demonstrated to be useful measures of medical students' knowledge and attitudes concerning preventive cardiology educational programs.