We have got to get back to AF.
I enjoyed some fun text messages today–from a really smart primary care doctor out yonder, in the hinterlands of Kentucky. We text and exchange quick pics a lot. Call it iTeleMedicine.
PCP: â€œI have a patient on [AF-drug X] (guess) who has diarrhea.â€
Me: â€œStop the drugâ€¦Itâ€™s a typical adverse effect.â€
PCP: â€œHow do I keep him out of AF?â€
Me: â€œHaâ€¦Thatâ€™s funny.â€
PCP: â€œIâ€™m serious.â€
Me: â€œI know u r. If I could keep patients out of AF, I might make the big dollars.â€
PCP: â€œK, Iâ€™ll get the patient an appointment with you.â€
All kidding aside, this string of text messages highlights two important principles about treating AF. The first is that AF treatment often has adverse effects. In this case, the drug used to prevent AF episodes was disrupting bowel function. Thatâ€™s not good. No further explanation is warranted. AF isnâ€™t cancer; we should not expect patients to endure toxicity from treatment.
The other slightly more subtle issue here is that treating AF with rhythm-controlling drugs does not modify the disease or improve outcomes. Itâ€™s different than treating high blood pressure or diabetes. The purpose of AF drugs is to decrease the burden of symptoms. No study has conclusively shown that taking an AF rhythm drug lowers the chance of CHF-congestive heart failure or stroke. (Don’t even start with the Greek-named trials.)
Let me explain this concept with an example: Take the patient with long-standing high blood pressureâ€”not responsive to lifestyle changes–who develops an adverse effect with a BP-medicine. In this case, itâ€™s frequently a good idea (after a suitable washout) to substitute another drug. You would start another medicine here because the disease of high blood pressure is still present and you donâ€™t want to risk complications from untreated high pressures.
I rarely use AF drugs this way. In the patient discussed in the text string, I would have stopped the offending AF drug and then waited to see if (or how much) AF recurs. If it did indeed come back, weâ€™d have a conversation about what to do next. The choices would range from tolerating intermittent episodes, trying another medicine or considering ablation. This approach helps prevent over-treatingâ€”a problem I work very hard to avoid. I am always asking myself whether the patient with AF still requires treatment.
Since I see it nearly everyday, it bears repeating: Never make the treatment of AF worse than the disease.
Important disclosure: When writing briefly about medical treatments, I always worry about the dangers of oversimplification. These posts, this blog, my ramblings, should NEVER substitute for the patient-doctor relationship. Rather, my aim is to help–with information. In fact, sometimes I wonder whether my white boards in the office exam rooms help nearly as much as does making 75 burns in the left atrium. In the treatment of AF, knowledge fosters wellness.
13 replies on “A Common Error in the Treatment of Atrial Fibrillation”
“Never make the treatment of AF worse than the disease.”
Hippocrates couldn’t have said it better.
I was put on amiodarone to treat my AF. I was physically and mentally miserable. First I thought I was going to die and then I worried that I wasn’t going to die. I was an amiodarone zombie. I should not have been driving.
I was taken off amiodarone when I flat out refused a second cardioversion. (Hey guys, you are beating a dead horse and it’s MY dead horse. Leave him alone.) It took a month or more to shake off most of the effects. I still have thyroid issues as a souvenir of those months on amiodarone. Life is much better now.
I am no longer so far behind the curve in understanding my AF and the treatment options as I was when all this started. Trust levels have been adjusted accordingly.
John – NO NEED to worry about oversimplification, as your writing is excellent and equally valid for patients (it “hit home” with FredB) – as well as for primary care clinicians. Your 2 key principles presented in this blog on AFib are the messages primary care clinicians need to hear and need to present in collaborative fashion to their patients who should assist in choice of whether or not to initiate treatment – and if/when side effects occur – whether or not to continue antiarrhythmic treatment – vs simply rate control with anticoagulation as appropriate.
White boards in the exam room? Great idea!
Gonna need to talk to my office manager.
WOW-white boards in the exam room. How cool. My office manager is not going to be happy about this one… 🙂
Heart attacks? AFIB causes heart attacks?
I used heart attacks as an example of a ‘hard’ outcome. I am editing it to CHF-congestive heart failure. Thanks for helping me along with better precision of the written word.
Thank you for your blog, it is excellent and compelling reading.
When the doctor tells me that I can induce/exit aFib by massaging my carotid artery then I know that I would rather live with infrequent bouts of aFib then take propafenone/metoprolol which depress the heart beat to 30 bpm and make my legs feel like I am walking around in a wetsuit filled with water around my ankles and knees.
I believe my aFib was caused by a six month fight with whooping cough and wonder how about the effect of viruses on the heart.
“Never make the treatment of AF worse than the disease.” This would have made a fine statement to “Sharpie” on my shattered helmet and present to my HMO ‘s customer service department. Why the shattered helmet? After I presented at Urgent Care with post-ablation arrhythmia, a doc I’d never seen before and a cardiologist who didn’t know my long history with AF and flutter independently prescribed diltiazem (new to me) and flecainide (used previously with pro-arrhythmic effects). End result: sudden syncope and crash while bicycling to work and an ambulance trip to the regional trauma center. It could have been a lot worse…
Ooh. Sorry about that.
When an afib drug makes you unable to sleep, and kills your ability to exercise, that’s two strikes against the 7 rules mentioned in an earlier blog.
When an anti-coagulant makes it impossible to eat properly, that makes it 3 strikes.
3 strikes and you are out . . . . .
I was diagnosed with AF 15 years ago.
I’m in it all the time but feel pretty good.
Until we discover what causes AF in an individual it’s difficult to cure it.
When I think back to what might have started my AF, I come up with (1) one bad dose of food poisoning that made all of me quiver – not just my heart – (2) a possible overload on my heart running one night intoxicated (3) heavy drinking as a youngster (4) having sleep apnea.
A common denominator: inflammation.
Thanks for the inflammation Dr.