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Update: Social justice of AF care, NOAC monitoring, population health and two new podcasts

Hi All,

Here is a short update of the past week.

The first thing to say is the Atrial Fibrillation Care: Put the Catheter (and Rx Pad) Down post has gotten a lot of attention. It stayed on the most popular list all week. It has over a 130 comments, and I have received many emails on it. It is a big moment in AF care.

Screen Shot 2015-04-16 at 2.29.45 PMI would also point you to an interview I did with Dr. Prash Sanders from Adelaide. Prash is the senior researcher on the LEGACY trial. His team’s work has been most responsible for the change in thinking of AF care. The title of the post: LEGACY PI Throws Down the Gauntlet to US Physicians

Is AF care fair?

One aspect of AF care that I discussed recently with one of my partners was the notion of social justice. An AF ablation costs $100,000; a redo ablation costs $100,000. That is a lot of money. And now we know that in most cases, lifestyle changes either eliminate the need for procedures or render them more likely to succeed.

So…how fair is to spend $200,000-plus to treat a patient with AF? Think of what could be accomplished if that much money was used to care for the needy in our community? Is it right or just to allocate that many resources to a disease that is most often due to life’s excesses?

Population Health?

This leads me to population health–a hot topic in the hospital these days. The thinking goes that hospitals will be charged with delivering health to the population it serves. That is funny. As if health comes from hospitals. My mantra on the matter of health in populations: #BuildParksNotCathLabs.

Monitoring of NOAC drugs:

My column last week delved into the issue of monitoring patients who take the new anticoagulant drugs dabigatran, rivaroxaban and apixaban. Conventional wisdom–powered by marketing–has it that these drugs are more convenient than warfarin because less monitoring is required. A new study suggests otherwise. Researchers from Stanford looked at 67 VA medical centers and found great variation in patient’s adherence to the drug (dabigatran). They also discovered a yet unappreciated benefit from pharmacists.

The title and the link of the post is here: Should NOACs Be Monitored Like Warfarin . . . and by Pharmacists?

Two new podcasts:

In This Week in Cardiology for April 17th, I discussed NOAC monitoring, news from the FDA, including a warning on two new diabetes drugs, the future of cardiac devices and physicians’ view of electronic health records.

In This Week in Cardiology for April 10th, I discussed cooling after cardiac arrest, sports-related cardiac arrest, young adults and statins (ouch), antidotes for Factor Xa anticoagulant drugs and Staci’s letter to cardiologists on palliative care.

Great read of the week:

The best medical writing of the week came from my colleague and fellow writer Dr. Melissa Walton-Shirley. Trust me. Read her stirring essay A Death Well Lived. 


P.S. I rode 80 miles Saturday. It felt great.

6 replies on “Update: Social justice of AF care, NOAC monitoring, population health and two new podcasts”

Bravo Dr. M!
As an AF patient in the peanut gallery, now vastly improved by weight loss, magnesium, GABA, daily three mile walks, and CPAP, I applaud your efforts to change AF orthodoxy
If I had followed my EP’s advice, my insurance company would have had to absorb astronomical (and unnecessary) costs, which would ultimately be paid for by the rest of us in ever-increasing insurance premiums.
Keep making waves and speaking truth!

You rode 80 miles on Saturday and it felt great. I rode 65 miles on Saturday and – likewise – it felt great. But I would not have been able to ride 2 miles were it not for the PVI ablation I had back in 2011.

I like to read your stuff, but I find the social justice comment a little naive and offensive. I had two ablations last year. I paid into health insurance for 30 plus years, many years never going to any health care provider at all, and I was glad it was there when I needed it (I also paid a hefty co-pay, travel costs and lost work time for the two procedures). And it is not like you could just take the 200k from blue cross and give it to a homeless shelter. If you outlawed ablations, or made the qualifying criteria more onerous, it would only mean the insurance carriers would charge a few pennies less on premiums, or just pay their shareholders a few pennies more in dividends. And other than weight loss, how do you mandate lifestyle changes? I was a trial lawyer for 30 years, often defending doctors and hospitals. Hugely stressful. Do you just get rid of those professions so you can give more money to the homeless? I guess you have to ban triathlons and long distance cycling events (which I also did for years). And what happens to all the techs in the ablation labs, or the people who make the equipment used in the procedure? I guess they could work at Walmart for $15 and hour. Sorry, but I just don’t get your “social justice” comment. But keep writing, because for the most part you are spot on. Jeff

“…in most cases, lifestyle changes…” ??
46% of the LEGACY patients who lost 10% body weight sustained a normal rhythm without the use of antiarrhythmic drugs or ablation.
Good – for those included in the study.
But, 46% is not quite most.
Then, consider that LEGACY initially saw 1,415 AF patients.
590 of these patients were eliminated from consideration for LEGACY purposes.
They had BMIs lower than 27. Include them. Do math.

Not most.

I had a BMI of 19. My lipid panel numbers were eerily good. I also had two ectopic atrial tachycardias that were making my life hell. Mountain biking or road biking WERE my triggers. Without cryoablation, I would have ended up on the couch, avoiding rapid changes in heart rate. It pisses me off some that you’re suggesting that I should not have had the procedure in the name of social justice.

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