Letters
8. Klil-Drori A, Azoulay L. The role of selection in the risk of bleeding with dabigatran in patients with atrial fibrillation. JAMA Intern Med. 2015;175(7). doi:10.1001/jamainternmed.2015.1277.
Corresponding Author: David C. Peritz, MD, University of North CarolinaChapel Hill, Department of Medicine/Pediatrics, 160 Dental Cir, CB 7075, Chapel Hill, NC 27599 ([email protected]). Conflict of Interest Disclosures: None reported.
In Reply We thank Drs Gati, Merghani, and Sharma for their interest in our discussion about the challenges of left ventricular hypertrabeculation in athletes.1 Like many rare diseases, the diagnostic criteria for left ventricular noncompaction (LVNC) are derived from small cohorts, which inherently lead to poor specificity. Given the low prevalence of this disease, a long-term registry is likely needed before diagnostic criteria with high specificity can be produced. Our understanding of incidental T-wave inversions on ECG is evolving. In the precordial leads, T-wave inversions could be a manifestation of arrhythmogenic right ventricular cardiomyopathy (ARVC). Twave inversion and reduced systolic function appear useful as part of the diagnostic criteria for LVNC as well.2 Of note, a recent paper by Brosnan et al3 describes T-wave inversions in healthy endurance athletes recorded in leads V2-3. They hypothesized that this is likely secondary to displacement of the RV toward the axilla rather than RV dilation or hypertrophy and therefore unlikely to be pathologic.3 Interesting study findings like those from Brosnan et al imply that magnetic resonance imaging (MRI) results should be part of this reformed criteria for LVNC. The majority of studies used to develop diagnostic criteria to date have used echocardiography as the imaging modality of choice, but MRI has been shown be useful at distinguishing clinically relevant noncompaction and should be utilized in future criteria.4 Using pregnancy as a model, Gati et al5 have suggested that left ventricular hypertrabeculation is an epiphenomenon occurring in response to stress or increased preload. If this is the case, as with the pregnancy model, hypertrabeculation in the athlete should regress, if not resolve, when the preload conditions change.5 This would be in opposition to LVNC that, as an inherited disorder, is likely present regardless of circulatory conditions and therefore less responsive to detraining. It remains unclear how hypertrabeculation in the athlete progresses over time along with changes in training intensity or with medical treatment. Using MRI, a group from the Netherlands reported a marked decrease in trabeculations in a 58-year-old male after standard heart failure treatment was started.6 Would it be possible to reverse hypertrabeculation in the healthy athlete through detraining or even medical treatment? In our patient, detraining has been considered. But limiting conditioning and/or practice for several weeks (or more) even in the off-season are not easy tasks. The field of sports cardiology must continue to seek how best to identify those athletes with high-risk features from those with natural adaptation to high-intensity exercise. David C. Peritz, MD Eugene H. Chung, MD Author Affiliations: University of North Carolina-Chapel Hill, Department of Medicine/Pediatrics, Chapel Hill (Peritz); University of North Carolina-Chapel Hill, Department of Medicine, Division of Cardiology, Cardiac Electrophysiology (Chung).
jamainternalmedicine.com
1. Peritz DC, Vaughn A, Ciocca M, Chung EH. Hypertrabeculation vs left ventricular noncompaction on echocardiogram: a reason to restrict athletic participation? JAMA Intern Med. 2014;174(8):1379-1382. 2. Gati S, Chandra N, Bennett RL, et al. Increased left ventricular trabeculation in highly trained athletes: do we need more stringent criteria for the diagnosis of left ventricular non-compaction in athletes [published correction appears in Heart. 2013;99(7):506.]? Heart. 2013;99(6):401-408. 3. Brosnan MJ, Claessen G, Heidbuchel H, Prior DL, Le Gerche A. Right precordial T-wave inversion in healthy endurance athletes can be explained by lateral displacement of the cardiac apex. JACCCEP. 2015;1(1):84-91. doi:10.1016/j.jacep.2015.03.007. 4. Choudhary P, Hsu CJ, Grieve S, et al. Improving the diagnosis of LV non-compaction with cardiac magnetic resonance imaging. Int J Cardiol. 2015; 181:430-436. 5. Gati S, Papadakis M, Papamichael ND, et al. Reversible de novo left ventricular trabeculations in pregnant women: implications for the diagnosis of left ventricular noncompaction in low-risk populations. Circulation. 2014;130(6): 475-483. 6. Eurlings LW, Pinto YM, Dennert RM, Bekkers SC. Reversible isolated left ventricular non-compaction? Int J Cardiol. 2009;136(2):e35-e36.
Editor's Note
Late Reply We publish this letter in reply by Drs Peritz and Chung to a previously published letter1 regarding their article,2 to which Peritz and coauthors were not given an opportunity to review prior to publication. We apologize for this oversight and present their reply herein. Rita F. Redberg, MD, MSc Conflict of Interest Disclosures: None reported. 1. Gati S, Merghani A, Sharma S. Increased left ventricular trabeculation does not necessarily equate to left ventricular noncompaction in athletes. JAMA Intern Med. 2015;175(3):461-462. 2. Peritz DC, Vaughn A, Ciocca M, Chung EH. Hypertrabeculation vs left ventricular noncompaction on echocardiogram: a reason to restrict athletic participation? JAMA Intern Med. 2014;174(8):1379-1382.
CORRECTION Error in Text and Table: In the Original Article by Dzeng et al titled “Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life,” published online April 6, 2015, in JAMA Intern Med (doi:10.1001 /jamainternmed.2015.0295), there was an error in the third sentence of the third paragraph of the Introduction section. The sentence should read as follows: “Some have argued that do-not-resuscitate (DNR) decisions should be tailored to 3 distinct patient populations: (1) those whom CPR should be considered a plausible option, (2) those whom CPR should be recommended against, or (3) those whom CPR should not be offered (ie, those imminently dying or who have no chance of surviving to discharge).15” Also, in Table 1, the geographic locations for Hospital A and Hospital B were inadvertently reversed. This article was corrected online. Error in Byline: In the Original Investigation titled “A Targeted Infection Prevention Intervention in Nursing Home Residents With Indwelling Devices: A Randomized Clinical Trial,” published online March 16, 2015, in JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.132), the third author’s name should have been listed as Sanjay Saint, MD. This article was corrected online. Error in Table: In the Original Article by Ebell et al titled “Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After In-Hospital Cardiopulmonary
(Reprinted) JAMA Internal Medicine July 2015 Volume 175, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Northern Illinois University User on 08/22/2016
1247
8. Klil-Drori A, Azoulay L. The role of selection in the risk of bleeding with dabigatran in patients with atrial fibrillation. JAMA Intern Med. 2015;175(7). doi:10.1001/jamainternmed.2015.1277.
Corresponding Author: David C. Peritz, MD, University of North CarolinaChapel Hill, Department of Medicine/Pediatrics, 160 Dental Cir, CB 7075, Chapel Hill, NC 27599 ([email protected]). Conflict of Interest Disclosures: None reported.
In Reply We thank Drs Gati, Merghani, and Sharma for their interest in our discussion about the challenges of left ventricular hypertrabeculation in athletes.1 Like many rare diseases, the diagnostic criteria for left ventricular noncompaction (LVNC) are derived from small cohorts, which inherently lead to poor specificity. Given the low prevalence of this disease, a long-term registry is likely needed before diagnostic criteria with high specificity can be produced. Our understanding of incidental T-wave inversions on ECG is evolving. In the precordial leads, T-wave inversions could be a manifestation of arrhythmogenic right ventricular cardiomyopathy (ARVC). Twave inversion and reduced systolic function appear useful as part of the diagnostic criteria for LVNC as well.2 Of note, a recent paper by Brosnan et al3 describes T-wave inversions in healthy endurance athletes recorded in leads V2-3. They hypothesized that this is likely secondary to displacement of the RV toward the axilla rather than RV dilation or hypertrophy and therefore unlikely to be pathologic.3 Interesting study findings like those from Brosnan et al imply that magnetic resonance imaging (MRI) results should be part of this reformed criteria for LVNC. The majority of studies used to develop diagnostic criteria to date have used echocardiography as the imaging modality of choice, but MRI has been shown be useful at distinguishing clinically relevant noncompaction and should be utilized in future criteria.4 Using pregnancy as a model, Gati et al5 have suggested that left ventricular hypertrabeculation is an epiphenomenon occurring in response to stress or increased preload. If this is the case, as with the pregnancy model, hypertrabeculation in the athlete should regress, if not resolve, when the preload conditions change.5 This would be in opposition to LVNC that, as an inherited disorder, is likely present regardless of circulatory conditions and therefore less responsive to detraining. It remains unclear how hypertrabeculation in the athlete progresses over time along with changes in training intensity or with medical treatment. Using MRI, a group from the Netherlands reported a marked decrease in trabeculations in a 58-year-old male after standard heart failure treatment was started.6 Would it be possible to reverse hypertrabeculation in the healthy athlete through detraining or even medical treatment? In our patient, detraining has been considered. But limiting conditioning and/or practice for several weeks (or more) even in the off-season are not easy tasks. The field of sports cardiology must continue to seek how best to identify those athletes with high-risk features from those with natural adaptation to high-intensity exercise. David C. Peritz, MD Eugene H. Chung, MD Author Affiliations: University of North Carolina-Chapel Hill, Department of Medicine/Pediatrics, Chapel Hill (Peritz); University of North Carolina-Chapel Hill, Department of Medicine, Division of Cardiology, Cardiac Electrophysiology (Chung).
jamainternalmedicine.com
1. Peritz DC, Vaughn A, Ciocca M, Chung EH. Hypertrabeculation vs left ventricular noncompaction on echocardiogram: a reason to restrict athletic participation? JAMA Intern Med. 2014;174(8):1379-1382. 2. Gati S, Chandra N, Bennett RL, et al. Increased left ventricular trabeculation in highly trained athletes: do we need more stringent criteria for the diagnosis of left ventricular non-compaction in athletes [published correction appears in Heart. 2013;99(7):506.]? Heart. 2013;99(6):401-408. 3. Brosnan MJ, Claessen G, Heidbuchel H, Prior DL, Le Gerche A. Right precordial T-wave inversion in healthy endurance athletes can be explained by lateral displacement of the cardiac apex. JACCCEP. 2015;1(1):84-91. doi:10.1016/j.jacep.2015.03.007. 4. Choudhary P, Hsu CJ, Grieve S, et al. Improving the diagnosis of LV non-compaction with cardiac magnetic resonance imaging. Int J Cardiol. 2015; 181:430-436. 5. Gati S, Papadakis M, Papamichael ND, et al. Reversible de novo left ventricular trabeculations in pregnant women: implications for the diagnosis of left ventricular noncompaction in low-risk populations. Circulation. 2014;130(6): 475-483. 6. Eurlings LW, Pinto YM, Dennert RM, Bekkers SC. Reversible isolated left ventricular non-compaction? Int J Cardiol. 2009;136(2):e35-e36.
Editor's Note
Late Reply We publish this letter in reply by Drs Peritz and Chung to a previously published letter1 regarding their article,2 to which Peritz and coauthors were not given an opportunity to review prior to publication. We apologize for this oversight and present their reply herein. Rita F. Redberg, MD, MSc Conflict of Interest Disclosures: None reported. 1. Gati S, Merghani A, Sharma S. Increased left ventricular trabeculation does not necessarily equate to left ventricular noncompaction in athletes. JAMA Intern Med. 2015;175(3):461-462. 2. Peritz DC, Vaughn A, Ciocca M, Chung EH. Hypertrabeculation vs left ventricular noncompaction on echocardiogram: a reason to restrict athletic participation? JAMA Intern Med. 2014;174(8):1379-1382.
CORRECTION Error in Text and Table: In the Original Article by Dzeng et al titled “Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life,” published online April 6, 2015, in JAMA Intern Med (doi:10.1001 /jamainternmed.2015.0295), there was an error in the third sentence of the third paragraph of the Introduction section. The sentence should read as follows: “Some have argued that do-not-resuscitate (DNR) decisions should be tailored to 3 distinct patient populations: (1) those whom CPR should be considered a plausible option, (2) those whom CPR should be recommended against, or (3) those whom CPR should not be offered (ie, those imminently dying or who have no chance of surviving to discharge).15” Also, in Table 1, the geographic locations for Hospital A and Hospital B were inadvertently reversed. This article was corrected online. Error in Byline: In the Original Investigation titled “A Targeted Infection Prevention Intervention in Nursing Home Residents With Indwelling Devices: A Randomized Clinical Trial,” published online March 16, 2015, in JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.132), the third author’s name should have been listed as Sanjay Saint, MD. This article was corrected online. Error in Table: In the Original Article by Ebell et al titled “Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After In-Hospital Cardiopulmonary
(Reprinted) JAMA Internal Medicine July 2015 Volume 175, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Northern Illinois University User on 08/22/2016
1247
