Iatrogenic Heart Disease Research Articles

Iatrogeny in cardiology

The word iatrogeny derives from the Greek and concerns any disorder caused to the patient by inaproppriate medical practice. Unfortunately, the rise of an iatrogenic disease is related to the daily handline of cardiac disease. There are two types of iatrogeny: that caused by a medical action and omission iatrogeny, caused by the lack of a medical action. Iatrogeny occurs in all steps of medical practice starting with the patient-doctor relationship including diagnosis treatment and finally prevention of diseases. This article makes a brief commentary about iatrogenic heart disease and mentions some examples of it.

Clinical competence in electrocardiography. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology.

Clinical competence in electrocardiography. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology.

Right‐sided valvular regurgitation in normal children determined by combined colour‐coded and continuous‐wave Doppler echocardiography

Using Doppler echocardiography, the prevalence of tricuspid and pulmonary valve regurgitation was determined prospectively in 173 normal children, aged 8.3 +/- 2.7 (range 5-14) years. Pulmonary regurgitation was defined as a red-yellow or mosaic coloured regurgitant flow, continuing to end-diastole with continuous-wave Doppler. It was found in 84% of the children. Tricuspid regurgitation was defined as a blue-green or mosaic coloured regurgitant flow from the tricuspid valve into the right atrium lasting > 0.5 systole, as determined by continuous-wave Doppler. Tricuspid regurgitation was present in only 8% of the children. Tricuspid regurgitation flow of very short duration, considered to be due to valve closure, was found in 75%. No effect of age, presence of a vibratory innocent heart murmur or gender on the prevalence of right-sided valvular regurgitation could be demonstrated. All regurgitations were haemodynamically insignificant. Thus right-sided valvular regurgitation in normal schoolchildren is a normal physiological finding with relatively high prevalence. In the absence of functional reasons for these regurgitations and in the absence of structural pulmonary or tricuspid valve disease, these signals should be considered physiological in order to avoid iatrogenic heart disease.

Prevalence and Severity of Doppler-detected Valvular Regurgitation and Estimation of Right-sided Cardiac Pressures in Patients With Normal Two-dimensional Echocardiograms

To assess the prevalence and severity of Doppler-detected valvular regurgitation, as assessed by multiple Doppler modalities, in patients with structurally normal hearts, we analyzed Doppler echocardiograms in a consecutive sample of 206 referred patients who were found to have completely normal M-mode and two-dimensional echocardiograms. Valvular regurgitation was detected by Doppler in 94 percent, and 56 percent had regurgitation in at least two valves (mitral, tricuspid, and/or aortic). Mitral, tricuspid, and aortic regurgitation was detected in 73 percent, 68 percent, and 12 percent, respectively, with moderate regurgitation occurring in 6 percent, 5 percent, and 2 percent, respectively. The presence of mitral and tricuspid regurgitation was not related to age, although the prevalence of moderate regurgitation was three times more prevalent (p < 0.05) in those > 50 years old compared with those < or = 50 years. Aortic regurgitation was two to three times more prevalent (p < 0.01) in patients > 50 years compared with younger subjects, and moderate aortic regurgitation was three times more prevalent in older patients. Of those with measurable right-sided cardiac pressures, estimated right atrial pressure was < 10 mm Hg in 93 percent of patients, and estimated pulmonary artery systolic pressure was < or = 30 mm Hg in 57 percent of patients. Estimated right atrial pressure was > 10 mm Hg in only 7 percent, and only 13 percent had estimated pulmonary artery systolic pressure > or = 40 mm Hg. These data indicate a very high prevalence of trivial and mild mitral and tricuspid regurgitation in patients with otherwise "normal" hearts, suggesting that these findings are physiologically normal. These data should be considered when addressing management in patients with Doppler-detected valvular regurgitation in order to prevent "iatrogenic heart disease."

Valvar regurgitation in normal children: Is it clinically significant?

SummaryThis study aimed to assess the prevalence of “silent” valvar regurgitation in healthy Brazilian children; to determine whether variations in the gain settings of the machine interfered with its documentation; and to compare Doppler color flow mapping with the pulsed wave Doppler. Twenty-five healthy children were selected randomly. Echocardiographic equipment used was ALOKA 870. Fixed parameters were 3.5 MHz transducer, 400 Hz filter, reject of 7/14 and aperture of 30/80. Variable parameters were Doppler color flow mapping and pulsed wave Doppler gains. A protocol for evaluation of each cardiac valve was developed. Regurgitation was noted in 93% for the pulmonary valve, 74% for the tricuspid valve and 27% for the mitral valve. In the aortic valve, jets suggestive of mild valvar regurgitation were observed with the Doppler color flow mapping technique in two children but these findings were not corroborated by pulsed wave Doppler. Only in the aortic valve were findings from Doppler color flow mapping not in agreement with those from pulsed wave Doppler. Variations in the settings for gain did not interfere significantly in the documentation of regurgitation. Inter-observer variations were not significant (two independent operators). The clinical implications of these findings are yet to be established. Labeling these regurgitant jets as “normal” may be oversimplifying their meaning and perhaps overlooking the possibility of predisposition to endocarditis or progression of the valvar abnormality. Conversely, labeling them as “abnormal” can generate a more serious problem, which is that of iatrogenic heart disease. Prospective follow-up studies should be carried out in these subjects.

Labile repolarization changes in the ECG of patients without heart disease (author's transl)

Nine patients with suspicious repolarization (ST-T segment) changes in the ECG were further investigated. Each had ten different additional ECG tests (after various degrees of exercise, and orciprenaline, amylnitrite, glucose, potassium chloride, and propranolol injections). The ECG changes became normal in all patients, orciprenaline and propranolol injection providing optimal results. Clinical investigation, left-heart angiocardiography and coronary angiography were normal in all. The questionably abnormal repolarization distrubances were, therefore, judged to be benign. As both beta-stimulation and beta-blockade normalized the ECG it can be safely assumed that the ECG changes were induced by autonomic nervous system factors. Cardiac catheterization appears, therefore, not indicated in each case and a potential iatrogenic heart disease can be avoided by relatively simple means.

Computerogenic Heart Disease

To the Editor:— William Dressler, MD, may have indeed described the first case of computerogenic heart disease ( 208 :2338, 1969). He is correct in his assessment that physicians in the future will have to be aware of that possibility, just as they have in the past became aware of iatrogenic heart disease. At the annual convention of the American College of Cardiology, physicians were offered the opportunity of witnessing and participating in a demonstration of how a computer system may be used to interpret a large number of electrocardiograms in health screening or in clinical environments. Dr. Dressler rightly warns that if the computer diagnosis is handed to an apprehensive patient, without review by a physician, the result may be disastrous. As a matter of policy we have stressed that computer interpretations from our laboratory are not to be transmitted to laymen. Dr. Dressler comments that A word of caution is

Lectures on Preventive Cardiology

Cholesterol, lipids, lipoproteins are the three rings of the atheroma circus which have entertained and bewildered us in the past 20 years. In focusing on the current pandemic of premature (as well as appropriately mature) atherosclerosis, Dr. Stamler has produced a well-documented and smoothly readable guide for the perplexed in this proliferating field. Yet the book's contents are faithful to its title. One third of the book is given to hypertensive, cerebrovascular, pulmonary, rheumatic, and congenital diseases, completed by an incisive deterrent to iatrogenic heart disease in children. For each disease category, Dr. Stamler analyzes epidemiologic, clinical, and laboratory information followed by a concise synthesis of its present (1966) status. Lucid discussion of complexities is followed by concrete proposals for prevention and control based on current knowledge. The pervasive theme is mobilization of individual and collective effort to attack the roots of the disorders as well as any known steps

Effect of hyperventilation of precordial T waves of children and adolescents.

Following the taking of 12-lead routine electrocardiograms, three precordial leads were recorded before, during, and after 10 to 15 seconds of voluntary hyperventilation in 296 students, ranging in age from 8 to 17 years. Fifteen per cent of the total group, comprising 212 Caucasians and 84 Negroes, inverted one or more previously upright precordial T waves following hyperventilation. The incidence of T-wave inversion in children 12 years of age and under was nearly four times greater in Caucasians than in Negroes. There was no significant difference when the older Negro and Caucasian students were similarly compared. Sinus tachycardia, T-wave flattening, and "tucking," short of frank inversion, as well as junctional depression of the ST segment, were commonly seen following hyperventilation. The similarity of the hyperventilation-induced T-wave inversion in children to those previously documented in adults is noted, and the clinical implication of this study requires continued cognizance of the occurrence of "nonpathological" T-wave inversion in adults, so as to avoid iatrogenic heart disease.

The detection of heart disease in children. Results of mass field trials with use of tape recorded heart sounds. 3. The Chicago area high school study.

In a 1 in 6 stratified random sample of Chicago area high school students, urban and suburban, public and non-public, 49,753 of a potential 55,338 students (90 per cent) underwent the heart-sounds tape-recording procedure for the detection of heart disease in children. Based on an extensive educational and organizational effort among appropriate community, professional, voluntary, and public health agencies, the procedure was widely accepted and a high-response rate (90 per cent) obtained. The recorded prevalence rates were 1.4, 0.7, and 2.1 per 1,000 for congenital, rheumatic, and all heart disease, respectively, with detection of 105 students with heart disease, 46 of them (0.9 per 1,000) previously unknown. No significant differences in recorded prevalence of congenital or rheumatic heart disease were observed in strata of the Chicago area high school students, irrespective of age, sex, race, socioeconomic, geographic, urban-suburban, or public-nonpublic school classification. Correspondingly, students with previously undetected heart disease were found among all strata and sections of the community. With appropriate corrections-for validity rate of the procedure, for findings among non-respondents and among students absent at recall, for number of children at home or in hospital or special schools because of organic heart disease-it was possible to make extrapolated estimates of the prevalence rates of organic heart disease among the total Chicago area high school population (about 297,000 students). The estimated prevalence rates were 3.3, 2.8, and 6.1 per 1,000 for rheumatic, congenital, and all heart disease, respectively. Thus, for high school students, in contrast to elementary school students, prevalence rates of rheumatic heart disease were slightly higher than for congenital heart disease. When a history of cardiovascular disease or a gymnasium excuse for cardiovascular disease was present in the school records, students were seen at recall by the pediatric cardiologists, irrespective of the findings reported by the tape readers. As a result, iatrogenic heart disease was diagnosed in 106 students (2.1 per 1,000), and they were "delabeled." This-together with the detection of previously unrecognized heart disease-is a major built-in function and service of the heart-sounds tape-recording procedure. The detection of previously unrecognized heart disease and the correction of misdiagnosed heart disease ("delabeling" of iatrogenic heart disease) were accomplished with a recall rate of 3 per cent, thus reducing to a minimum the number of students seen by pediatric cardiologists. Continuing assessment of validity of the tape-recording procedure, particularly evaluation of the false-negative rate of the physician readers of the tape recordings, reaffirmed the high validity of this procedure (76 per cent or greater). Validity rate was shown to depend upon the precise nature of the material inserted to accomplish the validity assessment. A high level of validity for this mass-detection procedure was again shown to be achievable only with two trained physician readers evaluating the tape recordings. The findings further demonstrate the feasibility, utility, and validity of this method for the large-scale detection of heart disease among elementary and high school students, and for epidemiologic research on congenital and rheumatic heart disease among school populations.

IATROGENIC HEART DESEASE.

There are divergent opinions about the etiology of iatrogenic heart disease and certain common precipitating causes which need to be stressed to physicians at this period of high public awareness and fears of heart disease. The manifestations of the syndrome (cardiac neurosis) are a deep-seated fear of heart disease, associated with symptoms of fatigue, breathlessness, palpitation, chest pains, exhaustion, apprehension, tremulousness, and often signs of vasometer instability. Fifty cases of anxiety psychoneurosis, including 13 cases of severe cardiac neurosis (iatrogenic heart disease), were found in this study. None of the patients had heart disease, but all had been told they had, on the basis of misleading history, physical examination, or electrocardiographic evidence. The physician's interpretations included those of symptoms, physical findings, and electrocardiograms, inevitably leading to wrong or vague advice.

Straight Back Syndrome: A New Heart Disease

A new syndrome of heart disease has been presented that we have not found recorded in the literature heretofore. We prefer to call this the “straight back” syndrome. It may be described as a congenital straightening of the upper dorsal spine which decreases the anteroposterior diameter of the chest at this level. This results in compression phenomena which may either cause pseudocardiomegaly or cause mechanical murmurs. These murmurs are systolic in timing and would seem secondary to distortion or impingement of the great vessels. Simple physical examination will usually reveal the straight back syndrome. The degree of deformity may then be determined when lateral x-ray films are taken. The simple defects found in this syndrome may not be uncommon. Their recognition may prevent a common form of iatrogenic heart disease that has often interfered with employment, insurability and peace of mind.

The “straight back” syndrome: A new cause of pseudoheart disease ∗

We have presented a new syndrome of heart disease that has not been found recorded in the literature heretofore. We prefer to call this the “straight back” syndrome. It consists of a congenital straightening of the upper dorsal spine which decreases the anteroposterior diameter of the chest at this level. Compression phenomena result which may either cause pseudocardiomegaly or cause mechanical murmurs. These murmurs are systolic in timing and would seem secondary to impingement or distortion of the great vessels. The condition is easily recognized by simple physical examination and usually confirmed when lateral x-ray views are taken. These defects are simple and may not be uncommon. Recognition of this condition may prevent a common form of iatrogenic heart disease.

The electrocardiogram in neurocirculatory asthenia (anxiety, neurosis or asthenia patients and 757 healthy controls in the Framingham study.

Excerpt A number of reports have suggested that neurocirculatory asthenia, sometimes called anxiety neurosis or neurasthenia,1is a cause of or is associated with electrocardiographic abnormalities....

Heart scare, heart surveys, and iatrogenic heart disease; emotional and symptomatological effects of suggesting to one hundred sixty-two adults that they might have heart disease.

One hundred sixty-two individuals who, as a result of a chest x-ray examination made during the course of a tuberculosis survey, were informed that there might be something wrong with their heart were questioned to see if the suggestion that one has heart disease leads to the development of heart symptoms or symptoms of neuroses. It is not surprising to find persons upset by this procedure, but it is of interest to find that symptoms did not develop to any extent except in persons with preexisting neurocirculatory asthenia. There was no evidence that this procedure precipitated neurocirculatory asthenia (anxiety neurosis, cardiac neurosis, neurasthenia, effort syndrome). These individuals are not necessarily a representative sample of the general population or of patients seen in doctors' offices. The relation of the findings of this study to the concept of iatrogenic heart disease is examined.

Observations on the “juvenile pattern” of adult Negro males

1. 1. The unipolar electrocardiograms of 681 consecutive admissions to the Veterans Administration Hospital, Madison, Wisconsin, were studied for the incidence of the “juvenile pattern.” Of the total of 131 adult Negro males, fourteen (10.8 per cent) were found to show persistent or transient T wave inversion patterns in the unipolar leads V 1 through V 6. All fourteen patients were thought to have normal cardiovascular systems, with no clinical evidence of pericarditis. Cases 3, 7 and 9 were noted to have normal pericardiums at time of thoractomy. 2. 2. The “juvenile pattern” was consistently normalized by the oral administration of 10 gm. of potassium bicarbonate-citrate mixture and by the intravenous administration of 20–30 mg. of pro-banthīne. Hyperventilation consistently exaggerated the T wave inversion pattern, an effect which could be abolished by the administration of pro-banthīne. 3. 3. The “juvenile pattern” is believed to represent an expression of hypervagotonia and is considered to be a normal variant of the adult Negro. 4. 4. One must be cautious in the interpretation of these transient electrocardiogram changes in the adult Negro if one wishes to avoid erroneous diagnoses of “subepicardial myocarditis,” “myocardial ischemia” and “subacute pericarditis,” and the risk of promoting serious iatrogenic heart disease.

Iatrogenics and cardiac neurosis: a critique.

The adjective iatrogenic (from iatros —physician, and genes —caused by) is now applied to illnesses that supposedly stem from or have become aggravated by medical treatment. Something that the physician has said or done has frightened the patient into a state of chronic anxiety about his health. Thus, a diagnosis of iatrogenic heart disease is popularly attached to a persistent cardiac neurosis that is presumed to have been caused by a physician's carelessness or callousness in explaining heart symptoms or minor heart findings to his patient. Practitioners and lay persons have long suspected that suggestion may be a symptom determinant in a considerable variety of functional disturbances. With respect to the heart, Conner's 1 widely read and oft-quoted description of psychic factors in cardiac disorders served to direct medical attention to baneful suggestions that seem to precipitate symptoms. More recently, Edward Weiss, 2 in discussing emotional factors in cardiovascular diseases,

Iatrogenic heart disease.

Article1 January 1953IATROGENIC HEART DISEASEHARRY B. WEINBERG, M.D., F.A.C.P.HARRY B. WEINBERG, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-38-1-9 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptINTRODUCTIONIatrogenic means "caused by a physician." Iatrogenic heart disease is an illness in which symptoms referable to the heart, or symptoms interpreted by the patient as such, are produced as a result of the words or actions of a physician. It is of importance for the following reasons: (1) The disease produces considerable morbidity and may easily be more disabling than the average case of organic heart disease; (2) the disease should be and is preventable; and (3) the treatment of the disease is specific and differs from the management of any other type of cardiac disorder.The attention...Bibliography1. 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Author, Article, and Disclosure InformationAffiliations: Tulsa, Oklahoma*Received for publication August 15, 1952.From the Shapiro Clinic, Tulsa, Oklahoma.Read before the Iowa State Medical Society, Des Moines, Iowa, April 29, 1952. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byIatrogenic anxiety 1 January 1953Volume 38, Issue 1Page: 9-22KeywordsCardiovascular therapyHeart diseasesMorbidity ePublished: 1 December 2008 Issue Published: 1 January 1953 PDF downloadLoading ...

PSYCHOSOMATIC ASPECTS OF HEART DISEASE: ANXIETY HYSTERIA IN A PATIENT WITH PATENT DUCTUS ARTERIOSUS

Case Reports1 May 1949PSYCHOSOMATIC ASPECTS OF HEART DISEASE: ANXIETY HYSTERIA IN A PATIENT WITH PATENT DUCTUS ARTERIOSUSLEONARD MAHOLICK, M.D., R. BRUCE LOGUE, M.D., F.A.C.P.LEONARD MAHOLICK, M.D.Search for more papers by this author, R. BRUCE LOGUE, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-30-5-1043 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptNot long ago Oille1said, "Almost 60 per cent of the patients who consult a cardiac specialist are suffering either from an exaggerated or wholly unnecessary anxiety about their hearts, arising from suggestion and not based on reason." Nellis2stated that no layman he had ever questioned had noticed a relationship between emotional stress and heart action; even medical students failed to appreciate it. Yet this relationship is so familiar to physicians that they forget its clinical implications. These statements immediately make it clear that a doctor often has to look beyond the cardiovascular system into the psyche in order...Bibliography1. OILLE JA: Cardiac neurosis, Canad. Med. Assoc. Jr., 1941, xlv, 1. Google Scholar2. FOSTER NB: Psychic factors in the cause of cardiac disease, Jr. Am. Med. Assoc., 1927, lxxxix, 1017. CrossrefGoogle Scholar3. WEISS E: Anxiety and the heart, Clinics, 1942, i, 916. WEISS, E. and ENGLISH, S. O.: Psychosomatic medicine, Chap. IV, 1943, W. B. Saunders Company. Google Scholar4. CONNER LA: The psychic factors in cardiac disorders, Jr. Am. Med. Assoc., 1930, xciv, 447. CrossrefGoogle Scholar5. NEUHOF S: The neurotic element in organic cardiovascular disease, New York Med. Jr., 1922, cxv, 80. Google Scholar6. CONNER LA: Ibid., 1930, xciv, 448. Google Scholar7. AUERBACKGLIEBE APA: Iatrogenic heart disease, Jr. Am. Med. Assoc., 1945, cxxix, 338. CrossrefGoogle Scholar8. DUNBAR HF: Emotions and bodily changes, 2nd Ed., Columbia Univ. Press. Google Scholar9. ADLER A: The cause and prevention of neurosis, Jr. Abnorm. Psychol., 1928, xxiii, 4. Google Scholar10. CONNER LA: Ibid., 1930, xciv, 450. Google Scholar11. WEISS E: Ibid., Chapt. iv, 1943, p. 77. Google Scholar12. MCGREGOR : The emotional factors in visceral disease, 1938, Oxford U. Press. Google Scholar13. LIPKIN M: "Heart" pain with and without structural alteration, Psychosom. Med., 1944, vi, 237-261. Google Scholar14. GLIEBEAUERBACH PAA: Sighing and other forms of hyperventilation simulating organic disease, Jr. Nerv., and Ment. Dis., 1944, xcix, 600. CrossrefGoogle Scholar15. WOOD P: DaCosta's syndrome (or effort syndrome), Brit. Med. Jr., 1941, i, 767-772. CrossrefGoogle Scholar16. FRIEDMAN M: Studies concerning the etiology and pathogenesis of neurocirculatory asthenia. IV. The respiratory manifestations of neurocirculatory asthenia, Am. Heart Jr., 1945, xxx, 557-566. CrossrefGoogle Scholar17. PARKINSON J: Effort syndrome in soldiers, Brit. Med. Jr., 1941, i, 545-549. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Atlanta, Georgia*Received for publication January 20, 1948. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 May 1949Volume 30, Issue 5Page: 1043-1049KeywordsAnxietyCardiovascular therapyEmotionsHeartPatent ductus arteriosus Issue Published: 1 May 1949 PDF DownloadLoading ...