Annals for Educators - 4 June 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives4 June 2019Annals for Educators - 4 June 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201906040 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsMavacamten Treatment for Obstructive Hypertrophic Cardiomyopathy. A Clinical TrialObstructive hypertrophic cardiomyopathy is a debilitating and potentially life-threatening condition for which available therapies are few and frequently of limited benefit. This clinical trial assessed the potential benefits and risks of a novel oral agent for treatment of obstructive hypertrophic cardiomyopathy.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to list the symptoms of hypertrophic cardiomyopathy. How are these symptoms explained by the pathophysiology? What are the potential complications? Use the information in DynaMed Plus: Hypertrophic Cardiomyopathy, a benefit of your ACP membership. What pharmacologic interventions are currently used to treat hypertrophic cardiomyopathy? How effective are they?Is surgical myectomy or percutaneous alcohol septal ablation available at your center? Who is or is not a candidate? What are the risks? Is an implantable defibrillator recommended?Is genetic testing needed in patients with hypertrophic cardiomyopathy? What about their family members?What is the mechanism by which mavacamten might improve symptoms in hypertrophic cardiomyopathy? What were the results of this study? What are their limitations, and why are larger trials required?Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism. A Prospective Cohort StudyPatients with pulmonary embolism have increased risk for ischemic stroke, possibly due to paradoxical embolism through patent foramen ovale (PFO). This multicenter cohort study compares the frequency of stroke in patients with pulmonary embolism among those with and without PFO.Use this study to:Ask your learners when they should consider evaluation for possible PFO.How is a PFO diagnosed? Ask an echocardiologist to show your learners images of bubble contrast echocardiograms from patients with and without a PFO. Is a transesophageal echocardiogram needed? Use the accompanying editorial to help frame your discussion. How prevalent is PFO in the general population? How often was it found in this study? Do the results surprise your learners?How might the presence of PFO and the occurrence of paradoxical embolism influence the duration of therapy for pulmonary embolism?Should patients with PFO undergo closure of the atrial defect?Fournier Gangrene Associated With Sodium–Glucose Cotransporter-2 Inhibitors. A Review of Spontaneous Postmarketing CasesFournier gangrene is a rare urologic emergency characterized by necrotizing infection of the external genitalia, perineum, and perianal region. This case series describes 55 instances of Fournier gangrene in diabetic adults being treated with sodium–glucose cotransporter-2 (SGLT2) inhibitors.Use this report to:Ask your learners how Fournier gangrene presents. What are the risk factors? What are the potential complications?By what mechanism do SGLT2 inhibitors help decrease serum glucose levels? What adverse events are known to be associated with their use?Review how cases of Fournier gangrene were identified for this study. What is the FDA Adverse Event Reporting System (FAERS)? Is reporting voluntary or mandatory? In what way might that affect the results of this study?How did the investigators evaluate whether the presence of diabetes itself, rather than the use of an SGLT2 inhibitor, was a likely risk associated with Fournier gangrene? What did they find?What are potential benefits and limitations of case reports and case series such as this one?Do your learners think that SGLT2 inhibitors should be used? How might this case series influence further study? How should these results alter our care of patients with diabetes?In the Clinic: Preventing Firearm-Related Death and InjuryDeaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. This eminently practical review provides an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.Use this study to:Ask your learners what are the most common causes of firearm-related injury or death. Are mass shootings responsible for most?The authors discuss 3 categories of persons who are at increased risk for firearm-related death and injury. Review them with your learners.Do your learners think it is important to ask about firearms when risk factors for injury are present? What should be emphasized in such discussions with patients? How might they help to improve patient safety and prevent injury?Are patients who are at risk for suicide the only ones with whom we should discuss firearms? How about patients with small children or grandchildren? Patients with dementia or family members with dementia?Why don't physicians discuss firearms with patients as often as necessary? How can we overcome such barriers to promoting patient safety?Do your learners know what questions to ask, and how? Do they know how to counsel patients about safe firearm storage?Use the provided multiple-choice questions to introduce topics during a teaching session. And, log on to enter your answers and earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Patient: Central ProcessingDr. Lee recalls that her father, a retired surgeon, once said to her, “There are worse things than death.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether they have cared for patients with mild cognitive impairment or dementia. Have they asked whether they are aware of the deficits? What do patients fear? Should we ask them? What about their family members?Have you or any of your learners had an experience with a loved one similar to what Dr. Lee describes? How do a patient's cognitive deficits affect those around him or her? Are the challenges only emotional?MKSAP 18 QuestionAn 18-year-old man is evaluated as part of a preparticipation sports examination. He is attending college on a basketball scholarship. He reports no symptoms. Medical history is unremarkable, and he takes no medications.On physical examination, vital signs are normal. Cardiac examination reveals a brisk carotid upstroke. A grade 3/6 systolic crescendo-decrescendo murmur is heard best along the left sternal border; it decreases with squatting and is more pronounced in the upright position. Lungs are clear to auscultation.An electrocardiogram shows voltage criteria for left ventricular hypertrophy with abnormal repolarization. An echocardiogram demonstrates asymmetric septal hypertrophy with septal thickness of 18 mm. Systolic anterior motion of the mitral valve is present, and the peak instantaneous left ventricular outflow tract gradient at rest is 30 mm Hg.Which of the following is the most appropriate management regarding this patient's participation on the basketball team?A. Advise the patient that he should not play basketballB. Begin β-blocker therapyC. Refer for alcohol septal ablationD. Refer for implantable cardioverter-defibrillator placementCorrect AnswerA. Advise the patient that he should not play basketballEducational ObjectiveEvaluate the eligibility of a patient with hypertrophic cardiomyopathy for participation in sports.CritiqueThe most appropriate management is to advise this patient not to play basketball. This asymptomatic patient has findings consistent with hypertrophic cardiomyopathy (HCM). HCM is the single most common cause of sudden death in young athletes, presumably due to ventricular arrhythmia triggered by high-intensity physical activity. The risk for ventricular arrhythmias in competitive athletes with HCM exists in the absence of conventional risk factors for sudden cardiac death. Therefore, the degree and distribution of hypertrophy, the presence and magnitude of left ventricular outflow tract obstruction, and the presence or absence of obstructive symptoms should not influence recommendations regarding athletic participation in patients with phenotypic expression of HCM. According to current recommendations from the American College of Cardiology/American Heart Association, athletes with a probable or unequivocal diagnosis of HCM may participate in competitive sports that are considered static and low intensity (categorized as class Ia sports). Examples of these sports include golf, curling, bowling, and cricket.In patients with symptoms from HCM (such as dyspnea or syncope/near-syncope), medical therapy and lifestyle modification form the basis of therapy. Nonvasodilating β-blockers titrated to maximum tolerance are first-line treatment for symptomatic patients. However, β-blocker therapy should not be used for the sole purpose of allowing participation in athletics because the ability to effectively prevent sudden cardiac death with this strategy is unknown.Catheter-based alcohol septal ablation or open surgical septal myectomy should be considered only in patients with HCM who have moderate to severe symptoms of obstruction despite maximal medical therapy or patients with recurrent syncope not related to arrhythmia. These invasive procedures should not be performed for the sole purpose of allowing participation in athletics.Patients with HCM should be considered for implantable cardioverter-defibrillator therapy if they have any of the following risk factors for sudden cardiac death: (1) massive myocardial hypertrophy (wall thickness ≥30 mm), (2) previous cardiac arrest due to ventricular arrhythmia, (3) blunted blood pressure response or hypotension during exercise, (4) unexplained syncope, (5) nonsustained ventricular tachycardia on ambulatory electrocardiography, and (6) family history of sudden death due to HCM. An implantable cardioverter-defibrillator should not be placed solely for the purpose of allowing a patient to participate in high-intensity sports.Key PointAthletes with a probable or unequivocal diagnosis of hypertrophic cardiomyopathy may participate in competitive sports that are considered static and low intensity.BibliographyMaron BJ, Udelson JE, Bonow RO, Nishimura RA, Ackerman MJ, Estes NA 3rd, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66:2362-71. doi:10.1016/j.jacc.2015.09.035Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 4 June 2019Volume 170, Issue 11Page: ED11KeywordsArrhythmiaCardiomyopathiesDementiaFirearm injuriesHeartMedical risk factorsPulmonary embolismSportsSudden cardiac death ePublished: 4 June 2019 Issue Published: 4 June 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...