2014 Heart Rhythm Society Sessions — My massive recap:

Hey Everyone,

I recently returned from the Heart Rhythm Society meeting in San Francisco. I attended the meeting as both a physician-journalist-columnist for theHeart.org and as a practicing electrophysiologist. As it so often is with international meetings, I returned energized and rejuvenated about the practice of medicine. Medical meetings are great this way.

It’s quite sad that fewer doctors are traveling to meetings. It’s a missed opportunity for learning, and shall I say, rekindling of the spirit of doctoring. Sure, social media allows a semblance of virtual attendance, and this is better than no attendance, but it is just not the same as in person.

Before I tell you about the topics that I chose to write about, let me share some of the non-technical thrills of the conference, or as my European colleagues call it, the congress.

On writing:

It was a true honor that so many doctors came up to me out of the blue to say, “I read your blog.” Many of them said they enjoyed the writing, but others just left it as: “I read your blog.” This was nice…and humbling. And I am grateful for the chance that Shelley Wood and theHeart.org people took with me. I’ve learned a lot about writing and reporting. I continue to revel in my place on the steep portion of the learning curve. It’s like being a Cat-4 bike racer or medical resident: you can’t stop thinking about getting better. Being a newbie is a fine place to be.

On seeing old friends:

I was able to have dinner with a friend from Germany and his Italian colleague. These guys are leading researchers in the field, but I call them friends. The value of exchanging information in this informal way is immense. We talked late into the night on matters big and small, in electrophysiology, in healthcare, and of course, in life. There’s nothing like learning about healthcare policy from first-hand experiences in other countries. This might sound naïve but I can’t help thinking we don’t look enough to other country’s strengths and weaknesses. I also got a chance to spend time with my two virtual-now real-buds, Doctors Wes Fisher and Jay Schloss. So good, these guys are.

On making new friends from social media friends:

I was able to connect IRL—in real life–with some long-time social media friends. A few of us had dinner and then many met for the first annual Tweet-up session. Meeting in real life can sometimes be tricky–but not with these folks. It seemed we got along better in real life than we do on Twitter.

Now to the reporting:

There was big news made at the meeting. It gets right to the heart of one of my favorite topics: the treatment of atrial fibrillation.

Atrial Fibrillation – A brand new way of thinking about the disease:

As you know, the disease AF afflicts millions of people. Billions of dollars are spent trying to treat this disease. AF ablation costs (charges) up to $100,000 per procedure in the US; the risk of serious complications run as high as 5% in some published databases, and multi-procedure success rates get to only 70-80%.

I’ve long felt that AF is a disease that doctors and patients misunderstand. Rather than see AF as a modifiable problem related to lifestyle choices, both parties look at AF as if it is a fixable problem that can be solved with a pill or procedure. Over the past few years, I’ve found myself doing fewer AF ablations (even though it’s my chief source of income and I’ve grown quite practiced at it) because, in my heart, I know that it’s often too big a hammer for a problem that could be solved with common sense and motivation. I’ve been encouraging the electrophysiology community to see our roles as stewards to patients and the healthcare system alike.

Now a group of prominent and well-respected researchers are proving me correct.

Yes, I believe, we are doing too many AF ablations.

The work of Prash Sanders in Adelaide Australia deserves your attention. They have shown, first in animal models, then in humans and now after ablation, that aggressive—not lip service—attention to weight reduction, sleep, blood pressure, diabetes, and alcohol intake can radically reduce AF burden. It’s real; and it’s not just a blogger who says so.

The president-elect of the Heart Rhythm Society, Dr. John Day, says he thinks AF may be unnecessary.

Here is my report of the most important presentation at HRS2014:

Is Atrial Fibrillation Necessary? The Most Important Study Presented at the Heart Rhythm Society 2014 Scientific Sessions

I also found an example of how wireless digital medicine saves lives. In patients with cardiac defibrillators, a prior (2010) study had shown those patients who used the remote monitoring capability of their device enjoyed a much lower chance of dying. At HRS2014, there were numerous studies that extended these observations to patients with pacemakers and all types of ICDs. I was drawn to this story because of my inherent bias that we may be over-monitoring human life. In the case of implantable cardiac devices, this is probably wrong thinking. Wireless monitoring allows for earlier detection of hardware failures and atrial fibrillation, among other benefits. Here is my piece:

HRS 2014: Remote Monitoring of Cardiac Devices: Hard Evidence for the Digital Transformation of Medicine

—-

Simple is best:

Another story I covered was the Simple Trial. This was a comparison of doing or not doing a test of a defibrillator at the time of implant. In the old days, when we implanted an ICD, we were not sure the shock would terminate the arrhythmia that might cause cardiac arrest. We called this voltage the defibrillation threshold. So, to determine that a patient would be saved by a future shock, we actually put them into ventricular fibrillation at the time of implant and watched the device work. If the implanted device didn’t work, we’d shock the patient with external pads, and reposition the lead or add more leads.

But then, over the years, device manufacturers beginning making better leads and higher-voltage “cans.” These improvements led to a situation where DFTs nearly always worked. Doctors began not doing DFTs, which was really a remarkable trend given that they were paid to do the easy test.

The Simple Trial, therefore, simply compared two groups of patients (test v no-test) and followed them for three years. They found no difference; in fact, there was a trend to more side effects in the test arm.

I liked this story for a couple of reasons. One is that it was an elegant trial, and the other is that it confirms a practice that we thought we knew was correct. Here is the piece:

SIMPLE Stuff? What We Think We Know

—-

The first day of HRS 2014 featured too much for me to pick just one story. My choice for a report on Day 1, therefore, was to do a roundup of stories that I found worthy of a paragraph. This included an opening plenary session from four leading futurists in medicine. Dr. Eric Topol, author of the Creative Destruction of Medicine, and editor of theHeart.org, had the line that most struck me: he spoke of  the upcoming “doctorless” patient in the future. And…Who will need hospitals, he asked?

I wrote about this remarkable plenary session along with a paragraph or two on six other selected themes of the day:

  • A Canadian study on the referral bias of electrophysiologists who do ablation; (if you have a hammer study)
  • Multiple studies looking at brain health after AF ablation; (sobering data indeed)
  • Two studies on the results of ablation in patients with hypertrophic cardiomyopathy (thick heart); (also sobering)
  • A Dutch study on the long view of patients implanted ICDs; (No, ICDs do not confer immortality, and all should remember that.)
  • An Australian study on how inflammation, blood vessel disease and atrial fibrillation are connected; (of course, it’s all connected.)
  • A Cleveland Clinic study on the heartiness of the human body.

Here is the link to the 1600-word post: Day 1 Roundup of the HRS 2014 Scientific Sessions. One note is that in the comment section of that post I was brashly and anonymously dubbed the Fox News of EP…neither fair nor balanced. That made me grin.

These were just my takes. Steve Stiles, a veteran journalist with theheart.org, covered the meeting as well. His professionally done news stories are worth a read. They are here at theHeart.org HRS page. 

JMM

Comments

  1. michael says

    Nice synopsis Dr M! I agree with the to much AF ablation going on also….It appears that it has become an ego thing and industry driven. Someday we will know based on genetics if you will be prone to it and if you are at risk for adverse events. The hospitals don’t want to curb the volume because of the 100K and they also could care less about the effects that EP’s get from long term radiation exposure and orthopedic issues of doing these procedures.

  2. says

    I really enjoy your blog and love your perspective on medicine and health. I am a nutritionist that works closely with cardiologists and patients in a cardiac wellness program that aims to prevent and reverse coronary artery disease through a plant-based diet. I follow your tweets and was impressed by the research of Dr. Prash Sanders showing that lifestyle changes can drastically reduce Afib. It’s also exciting that the impact of nutrition and lifestyle are gaining attention among electrophysiologists.
    While it’s a great that more physicians recognize that many cases of Afib, may be treated or prevented with lifestyle modifications, real change is not going to occur unless patients are able to successfully make radical, sustained changes. Outside of a few highly motivated individuals, this is not going to happen in a clinic setting. Thirty minute counseling sessions from a physician or nutritionist usually fail- and in most cases this is not because the provider has poor motivational skills.
    The problem will likely get much worse before it gets better. In our pediatric population, we’re seeing young children with the antecedents of adult cardiovascular disease. It’s not uncommon to see children who have already developed obesity, hypertension and LVH by age 10. Others have metabolic syndrome and even obesity associated kidney diseases. I can’t imagine the burden this is going to place on the healthcare system in the next decade as these children transition into adult care.
    Our Adolescent Medicine department has an intensive obesity program for teens with only mediocre results. This is largely due to the toxic food environment with readily available, inexpensive processed food that is heavily marketed to the public, particularly children. To suggest that making healthy choice is “common sense” is an oversimplification. Deceptive health claims appear on processed junk food. Making the best choice is not so obvious to the average person and especially difficult for less educated people. In fact, many unhealthy foods come with the American Heart Association’s seal of approval. As Dr. Robert Lustig says in his book, “If we continue to subsidize corn, promote processed foods and espouse personal responsibility for obesity, there won’t be any prevention.”
    I believe major public health reform is needed before we are going to see major changes. There is a new documentary called Fed Up featuring several physicians that I think you would find interesting if you haven’t seen it already.
    http://fedupmovie.com/#/page/home

  3. Jeff says

    Thanks for the summaries on the effectiveness of ablations in the HCM population. I could not find any literature on that issue prior to making my ablation decision.

    Do you know if HCM is a cause of afib, or just a co-morbid that some people with afib happen to have. Seems like an important question because if it is a cause, lifestyle change might not be a very effective treatment option, but it is just a co-morbid, changing lifestyle might be a viable option to ablation.

    Jeff

  4. Jeff Patten says

    Well thanks a lot for making me feel guilty about the ablation I opted for – rather than experiencing worsening and lengthening AF episodes, rather than experiencing the debilitating effects and short-lived effectiveness of the anti-meds.

    You show me a life-style change that will make a difference and I’ll show you how quickly and completely an individual who’s aware of his health and quality of life can actually change.

    It would be wonderful if prevention of AF were actually possible for ALL of us.

    My electrophysiologist found nothing physically wrong that would explain my AF.
    I never had any of the risk factors that have been mentioned here – on drjohn or beyond.
    The attitude trending here is, however, challenging my mellowness!

    Don’t patronize the patient.

    • says

      Jeff…Sorry. There are indeed a small number of patients with AF that have it because of a genetic fluke or accident of life. Eg: it just happened. In my practice in Kentucky, a rough (generous) guess puts this in the range of one in ten patients.

      Dr Sanders’ work pertains to obese, hypertensive, sleep apnea patients who likely drink alcohol and don’t care for themselves well. That’s the majority of AF practice.

      Over at theHeart.org, there is a thread on the comment string suggesting skinny and athletic equate to healthy. My impression is that many (not all) athletes with AF are not achieving a “healthy” balance in life–and I’m not just talking about physical exercise alone.

      Dr Sanders and I discussed the threat his work poses to doctors, in terms of fewer procedures. We both feel there will be plenty of patients with AF to go around even with lifestyle changes.

      With the limitation in technology, risks, costs of AF ablation, and the clear role of lifestyle in almost all AF patients, I’m just trying to keep us from considering this a disease as something that always requires a fix with a pill or procedure. Look where that thinking got us with high blood pressure, type 2 diabetes and a host of other lifestyle diseases. People now take pills for high blood pressure instead of eating, sleeping and moving well.

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