Of Strokes, Defibrillators, Atrial Fibrillation, and the Pennsylvania Senate Race

Last week the skeptical cardiologist was contacted by Tom Avril, a science/health reporter for the Philadelphia Inquirer who wanted to discuss the stroke and cardiac problems that John Fetterman, the Democratic candidate for Senate in Pennsylvania, had suffered.

His article, entitled “John Fetterman got a defibrillator after his stroke. But doctors say the campaign’s story ‘doesn’t make sense” which includes some of my comments was published a week ago. Avril begins by giving the background of the case and the importance of the race:

It’s been more than a week since Lt. Gov. John Fetterman celebrated his win in Pennsylvania’s Democratic Senate primary from a Lancaster hospital, where he was recovering from a strokeand the implantation of a combination defibrillator-pacemaker. But the campaign’s explanation of his medical treatment doesn’t entirely make sense, according to cardiologists.

Fetterman’s campaign has said he’s on his way to a full recovery. Yet as that recovery continues at his home in Braddock, Fetterman hasn’t publicly answered questions himself about his health. And his campaign has refused multiple requests to interview his doctors, without giving any reason for that refusal. It’s left the full public picture of his health — and fitness for a six-year Senate term — unclear.

With Fetterman now the Democratic nominee in one of the most competitive and consequential Senate races in the country, the unanswered questions about his health have left some Democrats anxious — and cardiologists watching from the outside puzzled.

Indeed, even the skeptical cardiologist was puzzled.

Defibrillators Are Not Implanted for Atrial Fibrillation

We know that stroke is a common complication of atrial fibrillation, an arrhythmia that Fetterman had been diagnosed, with, but an implantable or internal defibrillator is not a treatment for atrial fibrillation.

It is quite natural to think that an implantable device that “defibrillates” would be the logical cure for atria that are “fibrillating.” Alas, these devices are only inserted for electrically cardioverting ventricular tachyardia (VT) or fibrillation (VF.)

We only electrically cardiovert atrial fibrillation (or flutter) using external pads (although when an ICD shocks a patient for VT or VF it typically converts atrial fibrillation back to normal rhythm.) Cardioversion of AF requires meticulous attention and planning (something an ICD is incapable of) in order to prevent any associated atrial clots from being dislodged and causing a stroke (the presumed mechanism of Fetterman’s stroke.)

Heart Failure and Defibrillators

If you read Avril’s outstanding Inquirer article in detail some potential clues as to why the ICD was implanted can be spotted:

Fetterman’s medical woes began in 2017, the campaign said, when his feet suddenly began to swell — a possible sign of A-fib. He went to a hospital for tests, and doctors diagnosed him with the irregular heart rhythm, Gisele Fetterman told The Inquirer. She said his father and grandmother also had the heart condition, which can be hereditary. Fetterman, who once weighed more than 400 pounds, announced in 2018 that he’d lost almost 150 pounds.

Swelling in the feet is not a typical sign of AFIB. It is, however, a typical sign of heart failure, that not uncommonly develops in patients who have silently slipped into AFIB. Such patients are totally unaware that their heart is beating very rapidly , sometimes up to 150 beats per minute. This rapid AFIB over a period of weeks to months can lead to a cardiomyopathy and heart failure.

I’ve had a number of patients who have presented with heart failure in this fashion. They are typically very similar to Fetterman; male, obese, and in their fifties. I usually treat them by loading on amiodarone and electrical cardioversion to regain the normal sinus rhythm. We also start medications appropriate for heart failure with reduced ejection fraction. Within a few 3 to 6 months these patients have typically regained normal cardiac function and are free of symptoms.

Treatment of Heart Failure Due to Atrial Fibrillation

I do not recommend defibrillators as initial therapy for these heart failure patients. Avril’s article has a good discussion on the indications. These should not be implanted and are not indicated until a heart failure patient has been on optimal medical therapy for 3 months without an improvement in ejection fraction or cardiac pump function.

In addition, every effort should be made in these types of patients (heart failure due to persistent AFIB) to maintain normal rhythm for at least 3 months before implanting a defibrillator.

Fetterman’s Prognosis: Can He Serve as Senator?

I don’t have enough information to speculate on Fetterman’s long-term prognosis or fitness to serve in the Senate.

I do know that a minor stroke would not be an impediment to serving brilliantly.

Atrial fibrillation, whether permanent, persistent or paroxysmal would not be an impediment: patients with these conditions can live totally normal lives with appropriate medical therapy. (A side note: My message to my patients with AFIB is to adhere to the 8 lifestyle modifications which reduce onset and recurrence of the arrhythmia.)

Finally, if Fetterman has heart failure (which is entirely speculation) or another type of cardiomyopathy we now have wonderfully effective medications which have the potential to restore cardiac function to normal or near normal. Thus, heart failure, would not be an impediment to a long and fruitful Senate service.

Even with all 3 of these cardiac conditions, I have numerous patients who are enjoying normal lives and operating at high intellectual and physical levels.

Antifibrillatorily Yours,

-ACP

N.B.

For information on my “Enlightened Medical Management of Atrial fibrillation” go here.

For information on stroke and AFIB go here

For information on Dr. Oz go here. I’ve written multiple times on my blog (dating back to 2013, long before he became a Republican PA Senate candidate) that he is a medical charlatan and snake oil salesman.