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Why Your A-fib Diagnosis May Not Be as Bad as You Think It Is

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By NORTIN HADLER, MD

With breathtaking speed, atrial fibrillation has gone from “Huh?” to parlance.

“A-fib”, a common cardiac cause of palpitations, is now in the front ranks of evils lurking to smite our well-being. There is no mystery to this transformation. In 2013, the Food and Drug Administration licensed three new drugs to prevent a stroke, the fearful complication of A-fib: apixaban (Eliquis), rivaroxaban (Xarelto) and dibatigatran (Pradaxa).

This unleashed the full might of pharmaceutical marketing: the scientific data for efficacy that convinced the FDA is tortured till it convinced “thought leaders” whose opinions convinced influential journalists. Sales pitches populate print, broadcast and social media. A-fib is now more than a worrisome disease; it is a product line.

Nonetheless, A-fib can be scary for those afflicted. There are lots of choices to make and a lot of confusing, conflictual and counter-intuitive advice to deal with. Troubled by this situation, Mr. X recently sought me out to have a dialogue about his situation.

Mr. X is a 70-year-old business executive who has enjoyed robust good health and is on no prescription drugs. He exercises vigorously and is a consumer of various over the counter treatments purveyed as salutary. Like many “health-wise” Americans, he also takes 80mg of aspirin a day unaware that the benefit is minimal at best and is counterbalanced by a similar magnitude of risk.

A month earlier he had the sudden onset of palpitations, a fluttering in his chest that made him exceedingly anxious and somewhat breathless. He waited an hour before asking his wife to drive him to the local emergency room. By the time he was first seen, another hour passed. The diagnosis of A-fib followed. Another hour passed to find the consulting cardiologists debating whether to convert the A-fib to a normal rhythm by using drugs or an electrical shock.

Before they could decide, Mr X’s heart decided to behave again; he was back in a normal rhythm. It was a frightening experience for Mr. and Mrs. X. He left the ED shaken and shaky.

He also left with a follow-up appointment with a cardiologist who specialized in rhythm disorders and a prescription for a drug that slowed the conduction of electrical impulses initiating in one heart chamber, the right atrium, and traversing the heart. The normal “pacemaker” is a specialized cluster of muscle cells in the right atrium that discharges at regular intervals, initiating a current that causes the heart to contract in the synchronized fashion termed Normal Sinus Rhythm.

In A-fib, for reasons that are poorly understood, multiple pacemakers form in the right atrium leading to chaotic discharging and circular currents in the right atrium. How many of these impulses manage to exit the atrium to traverse the heart depends on the capacity of the conducting tissues; most just stay confined to the atrium causing it to quiver ineffectively.

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The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak

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By Nortin Hadler, MD

Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”

The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.

I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.

I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.

So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.

There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).

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The End of the Era of Coronary Angioplasty

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By Nortin Hadler, MD

In a single generation, the evidentiary basis for the practice of medicine has grown from a dream to a massif. No longer need physicians rely solely on experience and opinion in formulating diagnostic and therapeutic approaches to the care of the patient.

However, for any given clinical challenge, the available science is never flawless, monolithic or comprehensive, nor is it likely to be durable in the face of newer studies.

The international medical community has mounted two approaches to sorting the wheat from the chaff: One targets the doctor in convening committees to formulate guidelines for patient care. The other targets the patient for evaluating options, so-called informed medical decision making. Both approaches are now sizable undertakings clothed in organizational imprimaturs and girded by self-promotion.

But they are largely parallel undertakings with work products that can cause considerable cognitive dissonance on the part of the patient and the physician. In a recent article in the British Medical Journal [1] the Guideline Development Group convened by the National Institute for Health and Clinical Excellence (NICE) summarized the thinking behind the guidance it was offering regarding the management of STEMI. This is an object lesson in such cognitive dissonance.

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How Misplaced Reimbursement Incentives Drive Healthcare Costs Up

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By David Mokotoff, MD

For all of those out there anticipating the 2014 official role out of Obamacare, also known as the ACA (Affordable Care Act), here is a cautionary tale.

Many years ago, as I was growing my cardiology practice, it became evident that diagnostic services for my specialty, like stress tests, echocardiograms, etc., were done less efficiently and cost more at the local hospital, then in the office. This stimulated many groups in the 1980s and 90s to install their own “ancillary” diagnostic services. Patients loved not having to deal with the long waits and higher copay prices at the hospitals. And yes, the cardiologists did increase their revenues with these tests. However, lower costs to patients, insurance companies, Medicare, and improved patient satisfaction were just as powerful a stimulus to the explosive growth of these diagnostic tests, and later even cardiac catheterization labs, when integrated into the physicians’ offices.

As the growth in testing spiraled upward, the hospital industry saw their slice of the outpatient revenue pie nosedive. Hospital lobbyists and policy-makers cried foul and complained of greed and self-referral, which they said was spiking the rapid rise in healthcare costs.

Studies laying blame on self-referrals being the major culprit for escalating healthcare costs, have been inconclusive. However, after years of lobbying and the passage of ACA, the hospital industry finally had the weight of the Federal government on their side. It did not take long for Medicare to start dialing back the reimbursements for in-office ancillary tests and procedures, and outpatient cardiac catheterization labs were one of their main targets. Hospitals had lost millions of dollars to the burgeoning growth of these labs inside the cardiologist’s office.

Our twelve-man group had a safe and successful lab for about ten years. Then after the ACA was passed, Medicare began to cut the reimbursements for global and technical fees in this area. The cuts were so Draconian that it became impossible financially to continue the service. Never mind that we could provide the same service as the hospital more efficiently, with better patient satisfaction, and at a third of the cost.

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My Grand, Sweeping Cardiovascular Predictions for 2013

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By Dr. Wes

Cardiovascular predictions for next year are always fun to contemplate this time of year.  So much is happening to the practice of medicine as we’ve known it that it can be helpful to highlight some of those changes, both good and bad, as our medical world continues to evolve.  While these predictions contain pure guesses, they also contain one doctor’s observations of our new evolving medical world.  Many of these changes will profoundly shape how doctors interact with their patients.

So grab some coffee and strap in.  Here are my 2013 predictions of life as a cardiologist in 2013.  (Please feel free to add your own predictions in the comments section.)

Valvular Heart Disease

  • TAVR for critical aortic stenosis will be applied to progressively younger and healthier patients.
  • As smaller delivery systems for percutaneous heart valves gain widespread acceptance, government payers will look for new and inventive techniques to restrict patient access to these devices.  No heart valve will remain untouched as creative uses of the approved devices are attempted in non-surgical patients.
  • Innovations valve design will improve the safety and effectiveness of this therapy.

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The Unheard Heart: A Metaphor For Medicine In the Digital Age

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By Clifton Meador, MD

A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.

He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.

There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”

I began to wonder. I called my longtime friend and colleague, also a cardiologist. I knew him to be one of the best heart listeners. I asked him if he still listens to hearts. He answered, “Of course I do. I could not practice medicine if I didn’t. But you know every week, several patients tell me when I listen to their hearts that I am the first doctor ever to do that. Can you imagine that?”

Playing the devil’s advocate, I challenged my friend to tell me what he learned from listening to hearts.

He answered, “How could anyone not want to hear those murmurs, sometimes ever so soft, like whispers? Murmurs from the heart, even very faint ones, are trying to tell us significant things. Some sounds are very localized, even hidden or obscured by layers of air. And then there is the rhythm and the beat and the cadence that you cannot hear on the paper strip of the EKG. Also, careful listening is the only way to appreciate the rubs of friction if there are any. The devices are important, but the heart has its own spoken and unspoken language if you know how to listen.

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What Am I Worth?

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By Dr. Wes

Recently I was asked to serve as a consultant on a medical matter.  Interestingly, they requested my hourly price for my services.  I thought about this and wondered, “What am I worth in per hour in the open market?”

It is an interesting question to ponder.

I have decided to ask the blog-o-sphere.  Call it a bit of “free market economics.”  For the record, 100% of my hourly wage for my services will be sent to our cardiovascular research fund at our hospital to avoid any conflict of interest.  I will not see ANY of the money the blog-o-sphere decides personally, but I really want to know what people think.

So where to begin?

Should I compare my hourly wage to MGMA standards for the annual physician salary of a physician of my subspecialty?  If so, do I pick the 50% percentile, 25th percentile, 75th percentile, or 95th percentile?  On what basis do I have to assure this is a fair price?  Who sets this price?  Are these data accurate or based on earlier years’ hospital data and physician surveys?  Can I verify that their hourly price is justified?  If so, how?  Or are their data proprietary?

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Can We Design a Heart Healthy Home?

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By SANJAY BASU, MD

There is increasing evidence that the quality of our homes and cities is a critical determinant of cardiovascular disease, diabetes and lung conditions. As urbanization and economic change occur globally, whether we live in a house free of dust in a city with open parks and traffic regulations, or in a dusty tenement building next to a major road, seems critically correlated with our likelihood for having shortened life expectancy, poor nutrition, heart disease and lung problems. In this week’s blog post, we look at some of the mechanisms relating the “built environment”—our human-made surroundings of daily living—to the risk of illness. We ask the question: can we do for our hearts and lungs what the Bauhaus movement did for functional design?

Indoor air quality

If Dwell Magazine had a feature edition on designing a healthy home, they’d have to tackle the major issue of indoor air quality. Much research on the built environment’s impact on health was revealed through a series of studies on asthma among children living in low-income public housing units in the United States. Poor indoor air quality resulting from dust and dirt in public housing units was a major cause of emergency room visits during the 1980’s and 90’s among these children, leading to new programs for housing quality checks and maintenance, which we featured in a previous post.Continue reading…

Hearts on Fire: a Tale of Two Californias

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By MATTHEW HOLT

The concept of practice variation raised its ugly head again this weekend in the northern California news media. And buried in the stories are several themes for our ages. But the conclusion is, the power of individual health systems and very small numbers of physicians to change patterns–and the cost–of care are enormous.

First the stories. Both about health care but also both revealing the future of investigative reporting. The BayCitizen is a non-profit blog about the San Francisco metro, created as response to the local papers cutting their reporting. It also provides stories to the NY Times–I’m unaware about how much of its revenue comes from the Times, but it’s part of  the Times’ entry into non-NY competition with retreating local papers.

For this story on heart program readmission picked up on an older UCSF press release and showed how UCSF used a $500K+ donation from the Gordon & Betty Moore Foundation (that’s the Moore of Intel & Moore’s law fame) to create a very sensible program that gave in-home support to newly discharged elderly cardiac patients. It cut readmission rates by 30%. The BayCitizen though will upset Gary Schwitzer as it did not include the actual numbers but the UCSF press release does, and yes this is a relative not an absolute cut. Here’s the key graf

Over the past 11 months, only 16 percent, on average, of the hospital’s heart failure patients were readmitted within a month of discharge, down from 23 percent in 2006. That’s well below the national 30-day readmission rate of 25 percent. The average readmission rate was 11.6 percent during the first four months of 2011.

So UCSF was about average and got much better and seems to be getting better still–but there’s quite a way to go. But it is an indication that at least one AMC is capable of moving the ball in the right direction. Of course UCSF is a leader in the pro-Dartmouth “use resources sensibly” camp, and we may or may not see the “keep em alive at all costs” folks at UCLA follow suit.

Meanwhile up in rural northern California it looks like the same Dartmouth data set is about to bring a series of visits from the FBI. Continue reading…

CABG in Decline

By MERRILL GOOZNER

The number of Americans with serious heart disease in need of hospital treatment is on the decline. A new study in today’s Journal of the American Medical Association shows the overall rate of coronary revascularizations — ranging from the coronary artery bypass graft (CABG) surgeries to in-and-out catheter-based procedures like angioplasties and stent insertions — fell from just under 1,500 per million adults a quarter in 2001 to less than 1,250 per million adults a quarter in 2008, a 15 percent decline.

The most intriguing finding in the data was that virtually all of the decline was in the most serious cases — those requiring CABG, which fell by about a third. The rate of percutaneous coronary interventions (where they snake a catheter through the thigh into the blood vessels feeding the heart, propping them open with either drug-eluting or bare metal stents) remained virtually unchanged.

The study authors, who hailed from the Philadelphia Veterans Affairs Medical Center, suspect the decline in CABG was driven by “a sizable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous coronary interventions” using catheters (so-called PCI). In other words, in recent years people with serious heart disease are more likely to be treated with the less invasive procedure.Continue reading…