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Volume 18, Number 3 - 2017

Volume 18, Number 3 - 2017

Table of Contents

A Call to Action to Develop Integrated Curricula in Cardiorenal Medicine
With the adoption of the new definition and classification of cardiorenal syndrome (CRS) and its relevant subtypes, much attention has been placed on elucidating the mechanisms of heart and kidney interactions. The pathophysiologic pathways are of great interest by which acute heart failure may result in acute kidney injury (AKI; type 1), chronic heart failure accelerates the progression of chronic kidney disease (CKD; type 2), AKI provokes cardiac events (type 3), and CKD increases the risk and severity of cardiovascular disease (type 4). A remarkable interest has also been placed on the acute and chronic systemic conditions, such as sepsis and diabetes, that simultaneously affect heart and kidney function (type 5). Furthermore, the physiology of acute and chronic heart-kidney crosstalk is drawing attention to hemodynamics (fluids, pressures, flows, resistances, perfusion), physiochemical (electrolytes, pH, toxins) and biologic (inflammation, immune system activation, neurohormonal signals) processes. Common clinical scenarios call for recognition, knowledge, and skill in managing CRS. There is a clear need for medical and surgical specialists who are well versed in the pathophysiology and clinical manifestations that arise in the setting of CRS. With this editorial, we make a call to action to encourage universities, medical schools, and teaching hospitals to create a core curriculum for cardiorenal medicine to better equip the physicians of the future for these common, serious, and frequently fatal syndromes. [Rev Cardiovasc Med. 2017;18(3):93–99 doi: 10.3909/ricm0891] © 2017 MedReviews®, LLC
Syncope in Young Women: Broadening the Differential Diagnosis Disease State Review
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. [Rev Cardiovasc Med. 2017;18(3):100–114 doi: 10.3909/ricm0865] © 2017 MedReviews®, LLC
Atrioesophageal Fistula Following Radiofrequency Catheter Ablation of Atrial Fibrillation
Atrioesophageal fistula (AEF) is a rare but catastrophic complication of catheter ablation of atrial fibrillation (AF), with an incidence of 0.03% to 1.5% per year. We report two cases and review the epidemiology, clinical features, pathogenesis, and management of AEF after AF ablation. The principal clinical features of AEF include fever, hematemesis, and neurologic deficits within 2 months after ablation. The close proximity of the esophagus to the posterior left atrial wall is considered responsible for esophageal injury during ablation and the eventual development of AEF. Prophylactic proton pump inhibitors, esophageal temperature monitoring, visualization of the esophagus during catheter ablation, esophageal protection devices, esophageal cooling, and avoidance of energy delivery in close proximity to the esophagus are some techniques to prevent esophageal injury. Eliminating esophageal injury during AF ablation is of utmost importance in preventing AEF. A high index of suspicion and early intervention are necessary to prevent fatal outcomes. Early surgical repair is the mainstay of treatment. [Rev Cardiovasc Med. 2017;18(3):115–122 doi: 10.3909/ricm0883] © 2017 MedReviews®, LLC