Dr John M

cardiac electrophysiologist, cyclist, learner

New post up on Trials and Fibrillations over at theHeart.org: The changing role of AF medicines.

By

I cheated–a little. I promised to post on some of the ways I use rhythm-control medicines for AF.

I did indeed post about this topic–just not here.

As I wrote and edited and stewed about rhythm medicine for AF, it occurred to me that this would be a great topic to write about on Trials and Fibrillations over at theHeart.org. Here’s why: Electrophysiologists alone cannot care for the 3 million Americans and 5 million Europeans with AF. The fact of the matter is that most patients with AF get treated by non-electrophysiologists.

This is surely presumptive, but perhaps my colleagues might find a review of how old-fashioned heart rhythm medicine might fit into the new and changed landscape of AF treatment? Perhaps you might find it helpful too?

In the 900-word piece I focused on five reasons why I recommend these potent and somewhat scary chemicals. (Remember, theHeart.org audience is mostly a medical one. There is some medical speak. Sorry for that.)

Here’s an excerpt:

As an exercise, put yourself in the shoes of a patient safety advocate assigned to study the use of rhythm-control meds for atrial fibrillation. The first thing an outside observer would notice is how poorly these drugs work—in less than half the cases. Then they’d cringe when reading about pro-arrhythmia. A partially effective drug that slows the heart rate so much that a permanent indwelling vascular device must be implanted; this is acceptable? Or worse: AF drugs can perpetuate truly dangerous tachycardia like 1:1 atrial flutter or torsade de pointes. And if inefficacy and dangerous pro-arrhythmia were not enough, there’s also the side effects: metallic taste, fatigue, dyspnea, blurred vision, balance problems and stomach upset, among so many others. Ouch. How did these drugs get approved? What will we think twenty years from now?

Hopefully you will head over to Trials and Fibrillations to read more.

The link again: The changing role of rhythm-control medicines for AF

JMM

 

A Common Error in the Treatment of Atrial Fibrillation

By

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: “I have a patient on [AF-drug X] (guess) who has diarrhea.”

Me: “Stop the drug…It’s a typical adverse effect.”

PCP: “How do I keep him out of AF?”

Me: “Ha…That’s funny.”

PCP: “I’m serious.”

Me: “I know u r. If I could keep patients out of AF, I might make the big dollars.”

PCP: “K, I’ll get the patient an appointment with you.”

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. That’s not good. No further explanation is warranted. AF isn’t cancer; we should not expect patients to endure toxicity from treatment.

Next…

The other slightly more subtle issue here is that treating AF with rhythm-controlling drugs does not modify the disease or improve outcomes. It’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 pressure—not responsive to lifestyle changes–who develops an adverse effect with a BP-medicine. In this case, it’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 don’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, we’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-treating—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.

JMM

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.