inflammation

Recap of 2017 in Cardiology

December 22, 2017 By Dr John

Hi all.

TheHeart.org | Medscape Cardiology published my picks for the top stories of 2017. Here is the link:Â Mandrola’s Top 10 Cardiology Stories of 2017

I called it the year of the medical reversal. Medical reversals occur when a superior study contradicts current practice.

I love medical reversals. First, they make you think about history. History teaches us a lot. Second, reversals reduce hubris–always a good thing. Finally, writers must have controversy. Controversy is our canvas. Reversals and doctors’ delay in accepting the new practice is fun to watch and write about.

Some highlights from 2017:

Doctors were shocked to the core that stenting a major blockage did not relieve chest pain any better than a sham procedure. That’s shocking because we already knew stents used in patients with stable disease don’t reduce the odds of a heart attack or death. Now, if they don’t even relieve chest pain. OMG. Billions are spent looking for and fixing blockages.

Another reversal of recent years was the failure of a special kind of stent, called the BVS. The name is not important. The idea was that the cage would disappear over time. Vanishing stents promised to make the artery healthier in the long run. BVS failed. Miserably. But we knew this in 2016. The story in 2017 was that experts denied to accept the failure. When key leaders don’t admit error and they keep promoting a treatment that harms people, that breaks our trust. The medical profession needs trust.

One of the biggest reversals of our lifetime may be the revelations on fat intake. I discussed the issues in point 3 of the piece.

Sucking clots out of blood vessels seems like a good idea. Nope. Studies showed it doesn’t work any better than standard care. Yet here is the thing: doctors keep doing it because “they know” it works.

Since I began cardiology, we have tried to prevent kidney injury from contrast agents given to show blood vessels. This year, two studies found that three common practices to protect the kidneys did not work. Yet, you guessed it. Doctors still do it. Even crazier: one of the practices shown not to work is considered a marker of healthcare quality.

(Imagine that: a practice used to grade doctors and hospitals on quality was proven useless and actually slightly more harmful than doing nothing. My friends, here is a pro-tip: most quality measures, star ratings and the like are a total farce. I have never been more convinced that many quality measures reduce quality.)

Speaking of farces, that we say patients with pacemakers and defibrillators must have special devices (called MR-conditional) to undergo MRI scans is also utter nonsense. This year, a major study, and an expert consensus statement from Heart Rhythm Society (I was an author on it), showed that old thinking needs revision. Another truth: almost any cardiac device is safe in an MRI if the scan is done with a protocol and supervision.

Opioids made the top-ten. Tragic is the best word to describe what’s happening to youngsters afflicted with infections in the heart from IV heroin.

Inflammation made the list. So did a possible (emphasis on possible) new way of ablating heart tissue without invading the body.

Finally, there was no big news in atrial fibrillation in 2017. We still don’t understand the condition. We still ablate in the same inelegant way. I still see tons of overuse and misuse of AF treatments.

JMM

Inflammation, Ablation, Fats, LDL, etc .. My review of ESC 2017

September 6, 2017 By Dr John

The European Cardiology Congress, ESC as it is called, has grown into the largest medical meeting in the world. This year, more than 31,000 attendees from 153 countries came to Barcelona.

I was busy. Here is an update of the big stories:

Inflammation:Â

Experts agree that inflammation associates with heart disease. One of the keys to showing inflammation causes heart disease would be to show a reduction of cardiac events with a drug that blocks inflammation.

The CANTOS trial tested the ability of a drug called canukinumab, which is already approved for rare causes of inflammatory diseases, to reduce cardiac events. Canukinumab exerts its anti-inflammation action by blocking a key signaling chemical in the inflammation cascade.

CANTOS turned out positive–well, sort of. Patients who took canukinumab had a 15% reduction of cardiac events. That sounds like a lot but translates to an absolute reduction of 0.64%. Researchers noted two other important observations: one was that blocking inflammation led to a small rise in fatal infections. The other nifty observation was that patients on canukinumab died from cancer at a lower rate than those on placebo. This anti-cancer effect will be explored further.

My post on CANTOS is here:Â Quick Thoughts on the CANTOS Trial

AF Ablation:Â

The CASTLE-AF trial studied the effect of AF ablation in patients with advanced heart failure–patients had low ejection fraction and ICDs. Does ablation in these patients reduce death rates or hospital admissions? The preliminary answer was yes. (Preliminary because the trial has not yet been published.)

Investigators reported a lowering of death rate by 47%. That’s massive. Many drugs and ICDs have been shown to lower death rates in patients with heart failure, but the reductions range from 15-35%.

The published results of this trial will be novel and could change the view of AF ablation. Novel because, to date, AF ablation has only been shown to improve quality of life–not outcomes. One strong warning is that patients included in CASTLE-AF were highly selected, most had previously failed antiarrhythmic drugs and the centers doing the ablation were highly experienced. I worry that irrational exuberance at the time of trial publication will add to the overuse of AF ablation that already exists.

My Post on Castle AF is here: Â CASTLE-AF: Does It Change the World of AF Ablation?

New Use of Rivaroxaban (Xarelto):

The drug rivaroxaban (Xarelto) has become well-established for prevention of stroke in patients with AF. At ESC, a huge trial called COMPASS tested lower doses of rivaroxaban for the prevention of cardiac events (heart attack, stroke, death) in patients with established heart disease. We call this secondary prevention.

Showing improvement in secondary prevention in 2017 is hard because we have so many good treatments already.

The COMPASS trial showed that the combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin lowered the event rate by a mere 1.3%. And this gain was countered by a 1.2% rise in major bleeding. Though this sounds like a wash, experts from around mainstream cardiology lauded the results. The king of cardiology, Dr. Eugene Braunwald, from Harvard, provided the discussion in the main auditorium after the trial was presented. He embraced the results as a breakthrough.

I was not so embracing. My post on COMPASS is here: The COMPASS Trial: Time for Clear Heads, Not Celebration

Extremely Low Cholesterol Levels:

You may have heard about the new cholesterol-lowering drugs calledÂ proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor drugs. These 14,000$ per year injections cause dramatic drops in LDL–the bad cholesterol. In the previously published FOURIER trial, patients on PCSK9i drugs had a lower rate of cardiac events, but surprisingly, the reduction in nonfatal events did not translate to improved death rates.

At ESC, the authors of FOURIER presented a sub-analysis of the results looking specifically at the association of LDL and cardiac events as well as safety. (Extremely low levels of cholesterol raise concern about other bodily functions.)

Three findings emerged: one is that many patients in the trial achieved crazy-low LDL levels, some in the single digits! The second finding was that the lower the LDL, the lower the event rate. The third finding was that despite crazy-low levels of LDL, the investigators noted no safety issues.

One popular narrative from these observations is that LDL in the blood is toxic and should be removed. In my post, titled,Â FOURIER: Very Low LDL-C Post Hoc Analysis Doesn’t Move the Needle, I make the case that this evidence is not enough to change our thinking about these expensive drugs. And, since the trial was truncated after only 2 years, it’s hard to say much about safety. Remember, people don’t take cholesterol-drugs for only two years.

The Healthiest Diet?Â

The debate on which diet and which percentage of nutrients, say fat, carbohydrates, plants, etc rages on. At ESC, results of massive observational study of more than 130,000 people across Earth, found that carbohydrates to be a villain, and fat intake, even saturated fat, associated with better outcomes. The PURE study, which included not one but three papers, was published in the Lancet.

One aspect of PURE is that it flies in the face of recommendations from our American Heart Association.Â My colleague Sue Hughes has great coverage of this story here:Â PURE Shakes Up Nutritional Field: Finds High Fat Intake Beneficial

Sue’s story includes this beautiful quote from senior researcher Dr. Salim Yusuf:

My hope is that our results will stop the whole population from feeling guilty if they eat fat in moderation. While very high fat intakeâ€”when it accounts for 40% or more of your dietary intakeâ€”may be bad, the average fat intake is about 30% and that’s okay. We’re all afraid of saturated fat, but actually we shouldn’t be. Saturated fat in moderation actually appears good for you.

Miscellaneous:Â

I recapped these stories in my weekly podcast called This Week in Cardiology.Â

I also gave my Watchman debate. I think I did pretty well as the antagonist. My opponent, Prof Horst Sievert was strong. He made mention that my case against Watchman came from a blog–but I countered that it has, in fact, been peer-reviewed and accepted for publication in a major journal. Stay tuned for more. Readers … stay suspicious of left atrial appendage closure.

Only a week after the terror tragedy, Barcelona felt like the safest city I have been in. If anything, given the tone at the meeting and on the streets, the terror event seemed to create greater cohesiveness of the people.

JMM

A new way to discuss statin drugs

March 21, 2016 By Dr John

A new study published last week in an open heart journal changes the conversation about how patients and doctors think about and discuss preventive therapies–such as statins.

Dr. Richard Lehman may be the smartest doctor on Twitter. This is what he said:

This is a game-changer https://t.co/WgGdLlodbL

— Richard Lehman (@RichardLehman1) March 20, 2016

Most discussions about using statin drugs focus on a 5-10 year period. That’s not the right way to discuss these drugs. When we take a statin drug (or screen for cancer, or any other preventive intervention) we do it to live longer–not just 5-10 years.

Here is a link to the (free) study. The editorial is here.

Researchers from the UK used national registries to calculate death rates. They then devised a mathematical model to calculate the probability distribution of lifespan gains from statin interventions. They used the well-accepted relative (CV) benefits of statins of 20-30%. In the third part of the study, they surveyed random people in train stations, asking how they would judge potential benefit from the drugs.

Before I tell you the results, let’s consider how we currently explain statin benefits. In primary prevention, the absolute benefit from a statin drug (or cancer screening) is small. How small is a matter of debate, but what opponents to these therapies rightly say is that most people who take these drugs get no benefit. (If the NNT is 50, 49 get no benefit.)

The problem with that strategy is we use average estimates of benefit and translate them to everyone who would take a statin. You know that is not how life works. You could start on a statin, and come down with cancer, or get hit by a bus, or die from pneumonia the next year. Then the protective effects of statins never helped you.

The researchers sought to figure out the probability that statins (or any other prevention strategies) would help you over a lifetime. They used what’s called a Monte Carlo simulation. The model gives a range of probabilities for life-expectancy gains for each individual on primary prevention. “MCS is like throwing multiple dices at the same time â€“ it is astrology with a dice.” The Monte Carlo simulation is explained well in this blog post. (Credit to Dr. Saurabh Jha, @roguerad on Twitter.)

The findings of this study changes everything.

Lifespan gains are concentrated within an unpredictable minority. For example, men aged 50â€…years with national average cardiovascular risk have mean lifespan gain of 7â€…months. However, 93% of these identical individuals gain no lifespan, while the remaining 7% gain a mean of 99â€…months. See Figure to the right> Screen Shot 2016-03-20 at 8.14.46 AM

Another finding was that younger people benefit more from statins. That’s because, even though they are lower risk, they have longer to accumulate gains. Likewise, an older person has a higher risk of death from a heart attack, and in the old way of thinking, would benefit more from statins. This new model, however, predicts that an older person’s benefit would be lower because of competing causes of death.

Here is a nice quote from the editorial:

The study highlights the problem of focusing on disease-specific mortality rather than total mortality in the evidence used to recommend various medical interventions. The two measures are taken as similar but they do not necessarily follow each other as well as researchers would sometimes like to think.

The third finding from the study was that when people were asked what they preferred, they chose the lottery approach to lifespan gains. “Our survey illustrates that people often prefer a small chance of a large benefit over the certainty of a small benefit, even when the mathematical average gain from the former is smaller.”

This is my first crack at translating this important study. I learned of it this weekend. This changes the way we will talk with patients, and among other doctors.

Look at that graph: 93% of this group gets no benefit but the 7% gets tremendous benefit. It’s like a lottery to see if you will be the one who benefits.

One important weakness of this model, which was discussed in the paper, is that it only counts benefits of intervention. Statin drugs and cancer screening clearly have possible harms.

Stay tuned.

JMM

Right Care Action Week — rational care

October 19, 2015 By Dr John

I wrote yesterday about how a broken healthcare system favors overuse of procedures.

Today I will discuss rational care. Remember the goals of the Lown Institute: We think healthcare should be affordable, effective, rational and available to all.

Rational means in accordance with reason or logic.

Hardly a day goes by that I don’t see irrational care. Why it happens is complicated. Patients may expect irrational care. Doctors and nurses can get pushed into delivering it. Then, insidiously, unreasonable and illogical care become normal; and rational care stands out as an outlier.

Some examples:

It’s not rational to perform (or offer) CPR to frail emaciated elders. CPR is an intervention–similar to surgery or chemotherapy. We don’t feel compelled to offer drugs or surgery that won’t help. If a patient would get no benefit from CPR, it’s not rational to do it.

It’s not rational to avoid asking patients about their end-of-life goals. As medical experts, we understand that death is normal. In taking the oath of Maimonides, we promised to look after the life and death of our patients.

The best way to help our patients avoid a bad death (death by ICU, death alone or death in pain) is to 1) ask patients what is important to them, and 2) be rational about how we frame the trade-offs. And there are always trade-offs.

We should stand against all who oppose recent the CMS’ proposal to reimburse end-of-life discussions. We let the death-panel trope squash rational reform in the past, let’s not let it happen again. Advance directives should be as normal as Time-Outs.

In general cardiology:

It’s not rational to routinely prescribe the new PCSk9 drugs. The FDA recently approved these drugs on the basis of their cholesterol-lowering properties. Costs will be huge, about $14,500 per year. That’s outlandish because there is not a shred of evidence that the drugs improve outcomes. The trials looking at this question will report in 2016-2017. Two facts to remember: 1) high cholesterol is not a disease. 2) Not all drugs that lower cholesterol reduce the risk of heart disease. Lilly just gave up on a potent cholesterol lowering drug, Evacetrapib.

Two examples in electrophysiology:

It’s not rational to offer primary-prevention defibrillators (ICDs) to patients with life-limiting illnesses, especially those on dialysis. The clinical trials demonstrating benefits from ICDs were performed in mostly young male patients with heart disease as their primary problem. Too often, the benefits of these expensive invasive devices are wrongly extended to those who do not stand to benefit.

It’s not rational to offer ablation of AF to patients who have not been tried on conservative measures. AF ablation is risky and expensive, and the disease AF is not immediately life-threatening. We learned in medical school that when AF occurred with high thyroid levels, we should treat the thyroid problem and the AF would resolve. Now we know most AF stems from typical lifestyle issues, such as obesity, sleep apnea, alcohol excess and high blood pressure. Hospitals and doctors make big money burning the heart for AF, but the rational thing to do is treat the problems that cause the disease first.

Then there is oncology: (I have personal experiences here.)

It’s irrational to offer chemotherapy and radiation to patients with late-stage disease who are debilitated. It defies logic to think people who can’t walk to the bathroom or eat a decent meal will tolerate and benefit from chemo. When my mom died a few years ago from rapidly progressive stage-4 GI cancer, a respected oncologist recommended chemo only 2 days before she died. A brave hospitalist helped my family understand the irrationality of “palliative” chemo. Oncology as a field has done amazing things, but this outside observer thinks it would benefit from a hefty dose of reason and logic.

Rational care needs a following. Many are the caregivers who want it to become normal. If you do, say so. Head over to Right Care Alliance and sign-up. Tweet, blog, write letters, make noise. Feel free to add other examples of irrational care in the comments.

JMM

The cardiac dangers of excess exercise

July 30, 2015 By Dr John

Regular exercise is essential for health. I’ve taken to prescribing daily exercise as a drug. I’ve even written it on a prescription pad for effect.

I see exercise as medicine, a safe medicine, an effective medicine.

That means, like all drugs, exercise can be overdosed. The challenge is knowing the upper limit. How much is too much?

Recently, I helped Chris Case, a writer at VeloNews, put together a magazine-length article on the cardiac effects of extreme exercise. He did a great job with an immense topic.

It’s worth a read: Cycling to Extremes

Two other reads:

This February, I wrote a review article on AF and endurance athletes. Athletes and AF: Connecting the Lifestyle Dots

Another review comes from the Lisa Rosenbaum, writing in the New Yorker: Extreme Exercise and the Heart. Lisa is a friend and a talented writer. She is now the national correspondent for the New England Journal of Medicine.

If you are curious, you will be drawn to this paradox. Athletes should not get heart disease. They are fit and lean. They don’t smoke or drink alcohol excessively (usually). They don’t have high blood pressure or diabetes. The only risk factor most athletes with heart disease have is athletics.

JMM

Recap of 2015 European Heart Rhythm Association Meeting — Milan

June 28, 2015 By Dr John

I recently returned home from Milan, Italy. I was covering the 2015 European Heart Rhythm Association (EHRA) sessions.

Selfie at the MiCo convention site

My favorite part of the congress, as it always is with medical meetings, was connecting with old friends, and making new friends. I had coffee, lunch or dinner with colleagues from Australia, Netherlands, France, Italy, Belgium, Frankfurt, Hamburg, Leipzig, Milan and the US.

You learn a lot from colleagues. Even after 20 years, it never gets old listening to others explain how they do this or that. I hope the Internet and social media does not render medical meetings extinct. In real life is different–better.

Here are the topics I wrote about for theHeart.org on Medscape.

FIRM ablation for AF:

Focal Impulse and Rotor Modulation (FIRM) is a novel way to approach AF ablation. The idea is to find and burn the rotors (think eye of a hurricane) that cause AF. The doctor places a basket catheter in the atria during AF. This basket has many electrodes, which record the waves of electricity. These signals are fed into a computer, and voila, the computer tells the operator, “burn here.”

The European perspective on FIRM ablation is one of strong skepticism. More than half of the EHRA program dealt with AF, but there were only a handful of presentations on FIRM. No Euro doctor I spoke with used a Topera rotor-finding system, or were they looking into getting one. That’s quite different from the US.

Here is my post on the stark differences of opinion:

FIRM Ablation for Atrial Fibrillation on Unfirm Ground

The CARDIOFIT Trial:

The CARDIOFIT study, which was presented as a late-breaking clinical trial and simultaneously published in the Journal of the American College of Cardiology, was, by far, the most important study from EHRA.

In CARDIOFIT, the University of Adelaide research team studied whether fitness (or gains in fitness) would reduce AF burden or possibly add to the benefits of weight loss. More than 300 patients in their study group had before and after exercise stress tests–which are a fast and easy way to gauge fitness.

The results were remarkable (below are only a few highlights):

Two-thirds of patients with high baseline fitness remained free of AF without drugs or ablation, while only 12% of patients with low fitness remained free of AF.
With both weight loss and fitness gain, the odds of AF-free survival without drugs or ablation was 76%, vs only 13% in those with neither weight loss nor fitness gain.
With AF drugs or ablation, the weight-loss and fitness-gained group had a 94% chance of being free of AF, while only 34% of those who did not lose weight or gain fitness were free of AF.

I was not the only one excited about this data. Trial discussant, Dr. Claudia Siklody (Germany), called the results “spectacular.”

You can read my entire commentary here:

New Antiarrhythmic Drug for AF: No FDA Approval Required

Cryo v RF Ablation for AF:

Most every one agrees that electrical isolation of the muscle sleeves in and around the pulmonary veins is essential for AF ablation. The question is how best to accomplish this. The original way is to do point-to-point RF ablation. Another way to isolate the PVs is to use a cryoballoon. One freeze of a well-placed balloon makes a circular lesion around the veins.

Cryoballoon ablation began in Europe well before it did in the US. I can’t cite the statistics, but it seems cryo is more commonly done in Europe. All the European doctors I talked with did cryo. You see lots of cryo-related abstracts at EHRA–much more so than at American meetings, especially lately.

Right now, no one knows which technique is superior. All we have for evidence comparing the two strategies are single-center studies and non-randomized registries. The Fire and Ice trial is a multi-center randomized comparison of RF v Cryo. That study is finished recruiting patients and is currently in follow-up. It will be a biggie.

The young investigators award at EHRA went to an abstract that looked into how operator experience figures in the results of both cryo and RF ablation. The results were intriguing. The teaser is that operator experience plays a much more important role in one technique. From a patient perspective, the findings have important implications.

My full commentary is here:Â Fire or Ice for AF Ablation? Operator Experience Counts

ICD generator change:

An implantable cardiac defibrillator (ICD) battery lasts between 5-8 years. These days, ICD generator change procedures nearly outnumber new implants. The reason for that trend is, in large part, good news. Good news because people with heart disease are living longer. The bad news is longevity often comes with age-related organ dysfunction and chronic diseases.

My favorite slide from the meeting — Love Osler

Recall that when we implanted an ICD the first time, we gambled. We took the risk that future device benefits would outweigh harms. That gamble changesâ€”often for the worseâ€”at the time of generator change. ICDs only prevent death from arrhythmia. When we age, biology dictates that organ function declines. When organ function declines, chronic diseases develop. In medical speak, we call this law of nature, “competing causes of mortality,” which lessons the benefit of an ICD. What’s more, the surgery to change an ICD generator is as high (or higher) a risk as putting in a new one.

You see the problem: older patients, more diseases, and significant surgical risks. A number of studies on this topic were presented at EHRA.

Here is my coverage of this important and growing dilemma.

ICD Generator Change: No Easy Answers at EHRA

Deborah Brauser is a new journalist at theheart.org on Medscape. She was also in Milan and has filed some nice reports from EHRA. There is an especially cool study on test-driving a pacemaker before getting a permanent one.

JMM

P.S.: Finally, if you ever visit Milan, the B and B Hello Milano provided outstanding accommodations. Perhaps the best I have had in Europe. Note that I grew up with an Italian grandmother next door–so I consider myself highly qualified to make that statement. It was lovely. Thanks Lorenza and Mary!

Good health does not require an Apple Watch

May 10, 2015 By Dr John

Social media is awash in news about digital health.

I am a skeptic. Health is much simpler. I like this rendering from a kindergarten class.

"Kindergarten teacher asked class to create rules for living healthy. Here's what they came up with" via @rickplus3 pic.twitter.com/cRmHfcfjrf

— Brad Stulberg (@BStulberg) May 9, 2015

When I was a trainee in electrophysiology, I spent oodles of time learning the underpinnings of the heart and its rhythm. I studied molecules, then cells, and then the physics (vectors) of how it all worked together. Catheter ablation of focal circuits or implantation of pacemakers for aging pacemaker cells are the appendectomies of EP. Curative. Clean. Easy.

Heart rhythm care has changed. It is much harder. The majority of my patients now suffer not from fluky imperfections, but from the sequelae of deviations from the kindergarten rules of health.

It’s weird; although I am a sub-subspecialist, a techie-doctor of sorts, most of my clinic days are spent teaching kindergarten health lessons.

For fun, let’s make brief comment on each of these beautiful rules:

1. Eat good food — Nothing to add here.

2. Exercise every day — that you eat.

3. Drink water — not sugary drinks.

4. Brush teeth — so you look good smiling.

5. Milk — No guideline or set of rules are perfect.

6. Don’t watch too much TV — or Internet.

7. Sleep well — It’s easier if you follow the previous rule.

8. Listen to the teacher — just listen more.

9. Remember stuff — See the previous three rules.

10. Dream — but don’t forget to work some as well.

11. Play with friends — Maybe modify this to: play nicely with friends.

12. Talk to people — I think they mean talk with people.

13. Ask people to play — I love a great group bike ride or run.

14. Calm down — It’s easier if you follow the above rules, especially numbers 1,2, and 7.

15. Express your feelings — Abscesses heal only when they are drained. Be careful though; pus comes out under pressure.

16. Make peace — and enjoy lower inflammation.

I’d put these rules up against any mobile sensor, blood test, DNA swab, medication, or surgical procedure.

If only there was a way to more easily hold on to the mastery of the obvious that we once had as children. Then there would surely be less AF (and PVCs) out there.

JMM

H/t to @rickplus3 and Brad Stulberg

A new way to think about curing atrial fibrillation

February 22, 2015 By Dr John

The problem with AF treatment is that we do not (really) understand the underlying causes of the disease.

Why does the heart fibrillate? What gets those pesky premature beats started? Why do intermittent episodes persist? Why does AF come back after shocks or ablation?

AF has been thought of as its own disease. You have high blood pressure and AF, diabetes and AF, depression and AF. And when there are no other obvious diseases, we used to say “lone” AF, which wrongly assumed that AF was its own disease.*

Atrial fibrillation was just another problem on a list of things to address. It was in a silo–cardiac.

That mindset is changing. And it is a good news/bad news thing.

The good news is that we are finding answers to the basic questions of AF. We are closer to a cure. Really, we are. I have seen cure happen.

The bad news is that there will be no single pill or procedural cure. That is because atrial fibrillation is (most often) an effect not a cause. The top chambers of the heart, with their thin walls and closeness to nerve endings and exposure to blood volume and pressure 100,000 times per day, are like a window onto overall health.

When we are well, our atria are well.

When the balance is perturbed, our atria will tell us. The nerve endings that connect the brain and heart fire. Premature beats begin. Initially, the premature beats are extinguished. They are just single beats, a thud and that is it.

Over weeks, months and years the premature beats wander out into the atria and find diseased cells and pockets of scar tissue (fibrosis). We name this process remodeling. Single premature beats can now start rotating around the sites of disease into rotors. (Picture an eye of the storm and hurricane.) AF starts.

The remodeling process is complex. It happens inside the atrial cells (ion channels), between the cells, in the scaffold surrounding the cells and in the nerve endings connected to the cells. It is so NOT one thing.

But why it occurs is not mysterious at all. Remodeling occurs because everything in our body is connected. The brain and the heart are connected. The lungs and the heart are connected. The immune system and the heart are connected. And so on.

Dr. Prash Sanders and his team of scientists are getting doctors to pay attention to the entire patient–not just her atria.

Listen to my friend explain this new way of thinking. In the Q & A after his lecture, the second question leads to a very disruptive thought for cardiologists.

JMM

* In very rare cases, AF can be its own disease, sort of like a fluky atrial tachycardia.

Can a song be anti-inflammatory?

February 8, 2015 By Dr John

I do not speak nor understand French. (I wish I did.) But it is not necessary to enjoy this song. I think it is as close to anti-inflammatory as a tune can get.

I discovered this beautiful voice from a blog–a cycling blog at that.

I have written often that success in social media comes when you offer value.

The In The Crosshairs cyclocross blog does this. The #Svenness (Sven Nys) and #LikeAVos (Marianne Vos) videos are montages of words, astute observations, compelling music and bike racing action. And they are free.

Here is perhaps the best 15-minute cyclocross video ever made. You need the sound. And watch it until the end. I realize you may not follow Belgian cyclocross as closely as I do, but if you like athleticism mixed with mitochondrial power, this contest between Niels and Sven is perfect. (Full disclosure: I met both these men, so I see them as humans not just athletes.)

Plus the music!

JMM

P.S. In electrophysiology, ERAF means early recurrence of AF after cardioversion. I suspect it means something different in Flemish.

Where is Cardiology in 2014? An AHA Review

November 24, 2014 By Dr John

Last week, I attended the American Heart Association (AHA) 2014 Scientific Sessions in Chicago. I was there as both a learner and physician-writer for theHeart.org.

Here are a few paragraphs on the meeting. The main purpose of this post is to introduce the five editorials I wrote. The links to the posts are at the end. A warning: I worked in the word asymptote. Grin.

I’m sorry to say the most-covered news of the meeting was hardly notable.

The IMPROVE-IT trial tested the combination of the statin drug simvastatin and ezetimibe (Vytorin) against simvastatin (Zocor) alone in patients who just suffered a heart-attack-like event. The results were headlined as moderate, but the number to needed to treat to prevent one cardiovascular event over 7 years was 50. That means 49 of 50 patients who took the drug got no benefit. The curves barely separated.

From Twitter stream at #aha14

My colleague Melissa Walton-Shirley wrote the best summary on the trial. She aptly named the post: What I’m Telling Patients About Ezetimibe on Monday Morning. It’s really good.

Perhaps the most important result from IMPROVE-IT was that it kept the LDL-lowering strategy alive. Big pharma appreciated that, as the next line of health-thru-chemicals–injections of monoclonal antibodies called PCSK9 inhibitors–are being developed by multiple companies. Gosh.

Speaking of drugs and heart health, check out this Tweet.

A lecture on drugs at #aha14. Overflowing. People taking pics. The session on exercise is near empty. #TheProblem pic.twitter.com/hOjI9tfhdx

— John Mandrola, MD (@drjohnm) November 16, 2014

I made the above observation right after leaving a lecture on making physical activity and fitness a vital sign. In 20-minutes, Dr. Carl (Chip) Lavie (Oschner Clinic) made a compelling case that exercise and fitness are indeed vital enough to be a vital sign. Sadly, this session was nearly empty. It was a different story a couple of doors down where a drug lecture overflowed with attendees. This pattern–drugs to supplant lifestyle choices–will be a problem for future cardiologists. I’ve been here before so let’s move on.

On the way to my hotel, the taxi driver and I talked about the convention. He said the size of medical meetings was decreasing. I confirmed that fewer doctors were traveling to big conventions. For many reasons: the Internet; the rising cost of travel and dwindling corporate sponsorship, among others. The taxi driver came back with a smart comment: “Isn’t there value in connecting with your peers in person?”

Perhaps my favorite moment of the congress was meeting with two stars of the medical world. Prash Sanders is a professor, scientist and clinician in Adelaide Australia. He and I have become friends thanks to social media. Lisa Rosenbaum is a physician writer. Her interests are in how humans, doctors especially, come to make decisions. Lisa just took a job as a national correspondent for the NEJM. We also first met and wrote to each other online.

It happened that I was supposed to meet with both of them at nearly the same time. So rather than choose which friend to meet with, I said, what the heck, I’ll introduce the two. Here is the Twitter pic:

Great visiting w/ 2 rock stars of the medical world. @PrashSanders of Adelaide and @LisaRosenbaum17 of @NEJM #aha14 pic.twitter.com/l8h4XfIeLM

— John Mandrola, MD (@drjohnm) November 17, 2014

We had a great conversation. Not only did Prash and Lisa get along well, but their field of interests intersect. Lisa writes about medical decision-making and Prash’s work is utterly disrupting the decision-making of AF.

I’ve told you about the work of the Adelaide researchers before. They are showing that risk factor modification, much of it through lifestyle changes, may render AF (mostly) unnecessary. If millions of people with AF can be treated through lifestyle choices, what, then, are the ethics of burning or freezing their atria? Are we doing too many AF ablations? How do we help AF patients make choices that best align with their risk tolerance and goals? And, how do we–as a society–justify doing $100,000 AF ablations for a disease that might be treated by simple lifestyle choices? (Not in all cases. Please, fibbers, go easy.)

Lisa, Prash and I talked about other things as well. We touched on left atrial appendage occlusion devices, industry support of cardiology and the conflicts therein, writing, doctoring and serving the greater the good in different ways–as a doctor, writer and researcher.

Ok. Enough chatting. Here are the essays I wrote for Trials and Fibrillations.

The first day of AHA offered two choices for topics: resuscitation science or early career sessions. I picked early career. These were lectures for youngers given by olders–and they did not disappoint. The senior professors waxed philosophically on their careers and what lies ahead in the field of electrophysiology. There were beautiful moments in the talks. I actually felt a wave of emotion come over me during a Powerpoint presentation. Here is my report: Day 1 AHA: The Future of EP Is Not Bleak

On the second day, I found an abstract that looked at the relationship of AF burden and stroke risk. In terms of stroke risk, current guidelines do not distinguish between intermittent short duration AF (PAF – paroxysmal) and long-standing persistent or permanent AF. But that’s always been counter-intuitive. Here is the post: In Terms of Stroke Risk, Not All Atrial Fibrillation Is Created Equal. It includes the AHA abstract, and two similar studies from the ESC meeting in Barcelona.

Day 3 was a day for Big Data. Do you recall the Framingham Heart Study? This was(is) a three-decade longitudinal cohort study–medical speak for following patients over decades and studying associations. Framingham has shed oodles of data on cardiovascular risk, but it is a bricks and mortar study. What if we could do this type of research digitally? Dr. Jeff Olgin (chair of cardiology at UCSF) is the principal investigator of the Health eHeart study. He and his colleagues plan to connect people (a million is their goal) digitally and follow their health parameters over decades. Olgin told me they want to use this Big Data to predict heart attacks and sudden death–the holy grail of cardiology. Here is the post: Day 3 AHA: The Health eHeart Study: A Digital Disruption of Clinical Research.

No. COI is not important in Cardiology.

My Day 4 post induced anxiety. It was a difficult essay to write because fear, marketing and corporate influence of medical leadership were central to the story. The specific issue involved the MagnaSafe registry, which studied 1500 MRI scans performed in patients with implantable cardiac devices, such as pacemakers and ICDs. MagnaSafe showed that nearly all cardiac devices, not just one company’s proprietary devices, are MRI safe. The post is Fear, Marketing, and Corporate Influence: Lessons of the MagnaSafe Registry.

On the plane home, I wrote a summary piece of the entire meeting. I talked about the incremental nature of cardiology in the current era. In a first draft of the essay, I included the word asymptote to describe modern cardiology and the limits of human biology. In other words, maybe we are approaching the limits of our humanity. If you read the post, AHA 2014: Inching Forward, you will note asymptote didn’t make the cut. This essay was a fun one to write because I was able to work in some less publicized but nifty studies.

That’s if for AHA. My next project is putting together a 2014 Top Ten Cardiology piece. I’ll be working on that in the next few weeks.

I’ll also get back to my What to expect after AF ablation list over on the DrJohnM Facebook page.

JMM

Public health is on the ballot this Election Day

November 4, 2014 By Dr John

The election I am going to watch today is in San Francisco. On the ballot there is Proposition E, an initiative to add a 2-cent tax for every once of sugary beverage. Choose Health SF, a group supporting the tax, estimates it would raise $54 million, which would go towards, get this: “funding active recreation and nutrition programs in San Francisco public schools, parks, and recreation centers; food access initiatives, drinking fountain and water bottle filling stations; and dental health services.”

The other side effect of this tax would be a decrease in consumption of sugary beverages. Some estimates say by up to 31%. That’s a lot fewer calories being ingested, and hence, a lot more public health.

I know taxes are a polarizing topic.

Credit: High Mark Foundation

But obesity is different. It is serious. Our fatness is killing us, literally.

Some argue such beverage taxes are regressive, eg, they hurt the poor more than the rich. To that I respond, obesity is hurting the poor more than the rich. Obesity in America is regressive.

I don’t get sugary beverages. The massive doses of sugar in these artificially-colored drinks causes spikes in insulin. Insulin then promotes fat storage and arterial disease. The NPR Salt blog recently ran a story about labeling high-calorie drinks by how much exercise it would take to neutralize the sugar. A 110-lb adolescent, for instance, would need to run 50 minutes to burn off a typical 250-calorie soft drink.

I see obese patients every day. I see their heart disease and atrial fibrillation. They tell me about their joint problems, their immobility and often about their complications from diabetes. What fatness does to the human body is nothing less than sad. Do fat men (or boys) actually know their fat cells are churning out estrogen, which has the effect of transforming them into women?

Racing bikes on the weekend provides a striking contrast. Cyclists, especially young ones, are beautiful to watch. I often think to myself: this is how a human body should be. Then I go to work on Monday and see the ravages of excess calories and immobility. Sad.

Of course I realize taxation is politically charged. Millions of dollars are lining up on both sides of the issue. Big corporations are behaving just as you would expect in a capitalist system–they are protecting their self-interest. Soda companies aren’t charged with public health; their job is to make money. This is normal. It’s our system.

We let government set rules about driving, alcohol, car seats and education. We do so for the greater good, to protect the children and the less fortunate.

I write in favor of this tax as a witness from the front lines of public health. It’s really bad here. The people need help.

JMM