How does one treat Atrial Fibrillation in the unmotivated and uninsured?

Gosh, atrial fibrillation can be hard to treat.

He lay in the ER bed with a light sweat, and an obvious discomfort from the rapid heart rate and high blood pressure.  He is my age.  The belly protrudes from a too small XL tee shirt, there is week old facial hair, and he looks up at me from under the bill of one of those foamy baseball hats with an NFL logo.  It is his fourth, or fifth, or sixth admission for atrial fibrillation.  Many good doctors have tried previously, but now an electrophysiologist gets the call, like an “expert” can magically modify behaviour.

Middle age can hit hard.  There was a good job, but now this is gone.  A divorce, and 12 daily beers poke at an already inflamed heart.  Of course, he has no insurance, and thus, there has been no follow-up since the last discharge weeks ago.  A measure of the blood thinner, the INR (should be 2.0-3.0), is greater than 10 –just a hair less than the mice in my house which I have not seen since laying out the dish of green coumarin pellets.  No job or insurance precludes buying all his medicine, and the heart races.

Minutes before in the doctors lounge at lunch, for some unclear reason, the TV was unusually loud.  President Obama was thumping the podium on the importance of passing healthcare reform, like doing so will spontaneously heal many.

“Doc, I am turning my life around.  I am done with the beer, and committed to helping myself.”

Ok, we will try again.

The moral of this story: any chance of success in treating AF requires a cooperative patient, and insurance to pay for the basics.  I may have the tools, and knowledge to help, but like a broken chain on an expensive bicycle, without mutual cooperation from the patient, moving forward is impossible.

JMM

3 comments

  1. John,
    I think in JAMA this week there was an article on how much money had been spent trying to change behavior and how little effect that it has. There are several cases like this guy each day.
    Bill

  2. My grandmother passed away recently from complications of her heart failure. I saw it coming a long time ago, so it was not a surprise. But perhaps the most saddening and frustrating part of it was that I saw the entirety of the slow, slippery decline, accelerated by lack of lifestyle changes.

    The medicine and oxygen relieved only the symptoms. Even my parents would say, with full faith, "the doctor is making her heart better. She is feeling a lot better."

    And when things got worse, it was the doctor's fault for not curing her.

    Ignorance is bliss when it allows you to misplace the blame.

  3. Being an electrophysiologist, I am in agreement with Dr. Mandrola that stand alone surgical procedures for atrial fibrillation tend to lack the typical scientific data that is seen in the electrophysiologic community. However, I think that we should not overlook the potential benefits that a surgical approach has to offer the patient and the physician. Certainly a clamp type device on the pulmonary veins in an attempt to isolated them is likely to do little benefit to the patient with valvular or ischemic heart disease with left ventricular dysfunction and an atrial size greater than 4.5 cm; as we all know that the arrhythmic disease has progressed far beyond a cure by isolating the pulmonary veins.
    We as physicians tend to bash other specialties when they attempt to enter into a territory that is consider "ours". As noted, the basis for an EP's approach to AF is based on the Cox procedure – pioneered by a surgeon. So it would seem that they might have something to offer.
    Dr Andy Kiser created a non-thoracotomy – minimally invasive – approach for the treatment of persistent AF. This is a patient population that is historically difficult to treat with catheter ablation. He team up with myself to develop the Convergent Procedure that combines the positive aspect of each discipline. Surgically offering robust ablation lesions with near complete isolation of the pulmonary veins, isolation of the posterior left atrium with the electrophysiologist completing the isolation of the veins, creating a mitral annular line, coronary sinus debulking and isthmus line. This requires approximately 3 hours of the EP's time with about 40 minutes of fluoro. One year data reveals a success rate of ~80% in this patient population which far exceeds catheter success rates. Early data was presented at AHA (Circulation. 2009;120:S707) and an additional abstract has been accepted at HRS.
    Let us not count out our surgical colleague's but work together to achieve the best outcomes for our patients.

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