Category Archives: Atrial Fibrillation

Please, Sir, May I Have My Gall Bladder Back?

Do we have property rights over our body parts?

Apparently not, as I and several thousand David Sedaris enthusiasts learned recently at the Peabody Opera House where he was promoting his new book, Let’s Explore Diabetes for Owls.

Sedaris related that he was unable to get a surgeon to remove his lipoma (a benign fatty tumor) and give it back to him. His goal was to feed his lipoma to a deformed snapping turtle that he had become obsessed with.

I had not previously thought about retrieving my body parts after surgery but was surprised to hear Sedaris say that it was “against federal law” to return to a patient, their amputated or excised body parts.

I’ve had my appendix and my gall bladder removed and I began wishing that I had asked for them back. Wouldn’t it be nice, I thought, to have a display in my basement of my removed body parts, pickled, and with their important components labeled.

Not only would the display serve as a conversation starter but it would help visiting, budding physicians understand the three-dimensional anatomy of some very interesting body parts.

Unfortunately (or is it fortunately), I have not yet had any of my cardiac structures removed but it is common practice now for surgeons to lop off the left atrial appendage during open heart surgery in patients with atrial fibrillation. This is done in an (perhaps misguided) attempt to reduce their risk of stroke from clots which like to form in the left atrial appendage.

I look at a lot of left atrial appendages by transesophageal echocardiography (learn more about transesophageal echo via this  link to the Amazon.com (this is not (entirely, unabashedly) shameless self promotion-you can’t really buy the book, it is out of print) description of my old textbook on transesophageal echocardiography) and am fascinated by their peculiar shapes.

I would really like to have a row of pickle jars containing left atrial appendices in my basement to invigorate lagging dinner parties and refine my understanding of their function or lack thereof.

Laws On Body Parts

Why would there be a federal law denying one access to one’s own body part?

It turns out there is no federal law but lots of state laws that do exactly that.

Removed body parts fall under the category of infectious waste or medical waste and their disposal is governed by a complex litany of regulations, most of which do not allow them to be given back to their original owner.

This EPA site gives a state by state breakdown of the laws governing medical waste. If you click on the Missouri link, you reach a document from the “Department of Natural Resources,” which defines “pathology wastes.” These wastes include tissues, organs, body parts and body fluids that are removed during surgery and autopsy.

David Mapow, MD has written an extensive treatise, entitled “Do People Have Ownership Over Their Body Parts And If So, Can The State Control Their Ultimate Disposition In The Interest Of Public Health And Safety?”

Mapow’s paper illuminates how far reaching this topic is. It touches on topics as diverse as abortion rights, organ transplantation, cell lines used in cancer research, religious and cultural practices and the public health  versus private interests.

Interestingly, the placenta seems to be the one body part that is getting a pass in some states since some religious and cultural practices encourage either eating or venerating the placenta in various ways.

The Sedaris Solution

Sadly, those of us who would like to possess our removed body parts for sentimental or educational reasons may have to resort to what I shall term “the Sedaris solution.”

At the book signing event after one of his book tour talks, a woman introduced herself as a physician and volunteered to remove his lipoma that night in her clinic. Fortunately, the subversive procedure was successful, the patient survived and the lipoma was thrown to the deformed snapping turtle.

In the end, the snapping turtle, however, showed remarkably good taste and snubbed his nose (beak?) at the Sedaris lipoma.

If you’d like to read the story Sedaris wrote for The New Yorker that introduces the deformed snapping turtle (“Did it help, I wondered, that my favorite turtle was the one with the over-sized tumor on his head and half of his front foot missing? Did that make me a friend of the sick and suffering, or just the kind of guy who wants both ice cream and whipped cream on his pie?”) it is available for free here. It’s a great example of his style, his humour and his oddness.

In Memoriam of my gall bladder,

-ACP

Addendum: Here are the opening paragraphs of Leviathan, the Sedaris New Yorker piece:

“As I grow older, I find that the people I know become crazy in one of two ways. The first is animal crazy—more specifically, dog crazy. They’re the ones who, when asked if they have children, are likely to answer, “A black lab and a sheltie-beagle mix named Tuckahoe.” Then they add—they always add—“They were rescues!”

The second way people go crazy is with their diet. My brother, Paul, for instance, has all but given up solid food, and at age forty-six eats much the way he did when he was nine months old. His nickname used to be the Rooster. Now we call him the Juicester. Everything goes into his Omega J8006: kale, carrots, celery, some kind of powder scraped off the knuckles of bees, and it all comes out dung-colored, and the texture of applesauce. He’s also taken to hanging upside down with a neti pot in his nose. “It’s for my sinuses,” he claims.

“If a vegan diet truly did cure cancer, don’t you think it would have at least made the front page of the New York Times Science section?” I ask. “Isn’t that a paper’s job, to tell you the things ‘they’ don’t want you to know?

Paul insists that apricot seeds prevent cancer but the cancer industry—Big Cancer—wants to suppress this information, and has quietly imprisoned those who have tried to enlighten us. He orders in bulk, and brought a jarful to our house at the beach, the Sea Section, in late May of last year. They’re horribly bitter, these things, and leave a definite aftertaste. “Jesus, that’s rough,” my father said, after mistaking one for an almond. “How many do you have in a day?”

Paul said four; any more could be dangerous, since they have cyanide in them. Then he juiced what I think was a tennis ball mixed with beets and four-leaf clovers.”

 

 

 

 

Stroke Risk Estimation in Atrial Fibrillation: Please Give Me Lip!

The best way we have of estimating a patient’s risk of stroke if they have atrial fibrillation (AF) is by the CHA2DS2-VASc scale.

Stroke Risk EstimationThis scale take the factors we know that increase the risk of stroke and assigns 1 or 2 points. The acronym comes from the first letter of the factors that are known to increase risk as listed to the left.

Most of the factors get 1 point, but prior stroke (S) and age>75 (A) get 2 points.

We then add up your points and use another chart (or app) to calculate the risk of stroke per year.

CHA2 stroke riskYour risk of stroke is very low if you have zero risk factor; it gets progressively higher as you reach the maximum number of 9.

Treatment with an oral anticoagulant (OAC),  either warfarin, or one of the four newer anticoagulant agents (NOACS), is recommended when the risk gets above 1-2% per year.

The higher the risk, the more the benefit of these blood thinners in preventing stroke.

In lower risk patients, the bleeding risk of OAC of 1% per year may outweigh the benefits conferred by stroke reduction.

Both European and American guidelines recommend using the CHA2DS2-VASc score for initial risk stratification. The European  guideline recommends OAC therapy for males with a CHA2DS2-VASc score ≥1 and for female patients with a score ≥2., whereas the American guideline recommends use of OAC if the CHA2DS2-VASc  score is ≥2 for men and women.

I’ve been using the CHA2DS2-VASc scale for several years in my AF patients. I try to review the patient’s risk of stroke and their risk of bleeding during every office visit, and decide whether they should be on or off an OAC.

Initially, it was helpful typing all those capital letters and number twos (although I never took the time to make the twos a subscript) because it helped remind me of the factors.

However, I now view this acronym as a big pain in the neck and I am sick of typing it into my electronic medical records. It is also, really hard to say. Do you say “chad -two-D-S-two-vasc?” That is six syllables! I could have told my patient that warfarin is rat poison during that time.

And, what is with the Sc? Sex category? Why not just an S?

An Easier Term For The Stroke Risk Estimator: The Lip Score

I would like to formally request that this be termed the Lip stroke risk score in honor of Dr. GregoryLip,Greg-Cropped-110x146 Y. H. Lip who developed it at the University of Birmingham (UK).

because (per his bio): 

“The CHA2DS2-VASc and HAS-BLED scores for assessing stroke and bleeding risk, respectively were first proposed and independently validated following his research, and are now incorporated into major international management guidelines.”

birminghamIf the Lip score should somehow be unacceptable, then let’s go with the Birmingham score (recognizing, of course, that this is Birmingham, England and not Birmingham, Alabama). After all, this is what the app I use terms itself and I can type Birmingham a lot faster than CHA2DS2-VASc (even without the subscripts).

The Lip Score will be a great advance in the world of stroke risk estimation for AF patients. It will make all of us doctors creating EMR notes much more efficient, shaving precious minutes off the work day. It will be easier to communicate to patients, medical students and other medical personnel.

Finally, it gives, credit where credit is due, to Dr. Lip, who, according to his bio: “In January 2014, was ranked by Expertscape as the world’s leading expert in the understanding and treatment of AF,”

(I have no knowledge of Expertscape but you can be sure I will be investigating them soon)

Giving Lip service to stroke and atrial fibrillation,

ACP

Why Does The TV Tell Me Xarelto is a BAD DRUG?

One of my patients called the office today concerned about a medication she was taking because she was “seeing about 4-5 commercials a day about how bad Xarelto is”.

She is the latest of many of my patients who have been inundated with ads like these which state in very strident tones that a drug is bad and that if “you or a loved one has had a serious bleeding problem” contact 1-800-BAD DRUG and see if you are eligible for compensation.

These drugs are not bad and the only reason these advertisements are being played is that tort lawyers sense an opportunity to make money.

To understand why they are flooding the TV market now I will have to give you some background on atrial fibrillation , stroke and the drugs available to reduce stroke risk.

Preventing Stroke Associated With Atrial Fibrillation

Patients with atrial fibrillation are at increased risk of stroke and since the 1950s the only drug available for doctors to reduce clot formation in the heart and susbsequent strokes was warfarin (brand name Coumadin). Warfarin is only effective and safe within a narrow window and its effects are strongly influenced by Vitamin K in the diet and most medications. Thus, frequent blood testing is needed, and close monitoring of diet and changes in medications. Even with this close monitoring, serious and sometimes fatal bleeding occurs frequently with warfarin.

Novel Anticoagulants

In recent years, three new drugs for reducing strokes in patients with atrial fibrillation which are much less influenced by diet and medications have gained approval from the FDA. These are generally referred to as “novel anticoagulants” reflecting their newness, different effects from warfarin or aspirin, and their blood thinning properties.  The first  (brand name Pradaxa) was released to much excitement and fanfare in October, 2010.  The press release for this approval read as follows:

PRADAXA, an oral direct thrombin inhibitor2 that was discovered and developed by Boehringer Ingelheim, is the first new oral anticoagulant approved in the U.S. in more than 50 years. As demonstrated in the RE-LY® trial, PRADAXA 150mg taken twice daily has been shown to significantly reduce stroke and systemic embolism by 35 percent beyond the reduction achieved with warfarin, the current standard of care for patients with non-valvular atrial fibrillation. PRADAXA 150mg taken twice daily significantly reduced both ischemic and hemorrhagic strokes compared to warfarin

Differences Between Warfarin and the Novel Anticoagulants

What was very clear from the study with Pradaxa  and stated very clearly in all publications and patient and doctor  information sources was that just like warfarin, patients could have severe bleeding complications, sometimes fatal. Overall serious bleeding complications were about the same (the rate of major bleeding in patients Pradaxa  in the RE-LY trial was 3.1% versus 3.4% in the warfarin group) but Pradaxa had about 50% more bleeding from the gastrointestinal tract and warfarin about 50% more bleeding into the brain.

Another big difference between the novel anticoagulants and warfarin is that we have antidotes (Vitamin K, fresh frozen plasma) that can reverse the anticoagulation state rapidly for warfarin but none for the newer drugs. This information also was made very clear to all doctors prescribing the medications in the package insert and educational talks. Despite this, in the major trials comparing these newer agents to warfarin, the newer agents were as safe or safer than warfarin.

The Pradaxa Bad Drug Ads

Beginning about a  year after Pradaxa was released advertisements paid for by law firms seeking “victims” of Pradaxa  identical to the ones we are now seeing for Xarelto began to appear.

The Pradaxa ads went away in mid 2014 when these lawsuits were settled and almost immediately the lawyers began paying for Xarelto ads. Xarelto was the second “novel anticoagulant) to be approved by the FDA and, similar to Pradaxa, was proven to as effective as warfarin in preventing strokes with a similar rate of serious bleeding complications.

As the Wall Street Journal noted (with the catchy title “The Clot Thickens” and opening line “Is a blood thinner causing lawyers to smell blood?”)

“Spending (on Xarelto ads)  jumped to $1.2 million in July from just $8,000 in June, according to The Silverstein Group Mass Tort Ad Watch, which noted the number of ads that ran in July exceeded 1,800. …

The spending increased shortly after Boehringer Ingelheim, which sells a rival blood thinner called Pradaxa, last May agreed to pay $650 million to settle about 4,000 lawsuits over claims the drug caused serious bleeding episodes. The settlement likely emboldened attorneys to turn their sights toward Xarelto which, like Pradaxa, is one of a relatively new batch of blood thinners.”

The third drug to be approved for preventing strokes in atrial fibrillation was Eliquis. Data from the large, randomized study comparing it to warfarin suggest that it is more effective at preventing stroke than warfarin and significantly less likely to have bleeding complications. However, I predict that within the year (especially if the Xarelto lawsuits also are settled by its manufacturer) we will start to see lots of TV ads telling us that Eliquis is a BAD DRUG.

It’s important to remember that all drugs have benefits and side effects. Seemingly harmless antibiotics can increase your risk of dying suddenly (see here), rupturing your achilles tendon or developing a life-threatening colitis.

Xarelto is not a BAD DRUG. When prescribed to appropriate patients with atrial fibrillation with  appropriate precautions it prevents strokes which are potentially life-threatening or disabling. All blood thinners are two-edged swords: they stop good clots and bad clots.

Ignore The Ads

Patients are better off ignoring both positive, direct to consumer, advertisements, promoting these newer anticoagulants and negative, greedy-lawyer sponsored advertisements, soliciting “victims”.

Hopefully when your doctor discusses the choices of blood thinners with you he will present to you a balanced discussion of the pros and cons both of whether or not to take  a blood thinner and whether to take the old standby warfarin or one of the newer agents. An interactive discussion should follow in which your particular issues and concerns factor into the final decision.

 

Take Your Pulse and Prevent A Stroke

Hopefully by now everyone has gotten the message that atrial fibrillation is associated with stroke (and, most importantly, that we have ways to prevent those associated strokes).

Atrial fibrillation occurs when the normal, regular, synchronous action of the upper chambers of the heart becomes chaotic, rapid and inefficient. Take a look at this video to get a good understanding of what happens in atrial fibrillation:.

How do you know if you have atrial fibrillation?

Some who go into atrial fibrillation know it right away because they feel bad-they feel what we doctors term palpitations:their heart beating rapidly or irregularly (fluttering).They may have other symptoms associated with this such as dizziness, chest pain or shortness of breath. Many, however, go into atrial fibrillation and are not aware of it.

The first symptom they feel may be a stroke due to a clot developing in the upper chambers of the heart dislodging and going down an artery to the brain, a process beautifully (seriously, this is really wonderful and the narrator has a great British accent) animated in this video: 

The diagnosis is often made when the patient’s pulse is felt, and an irregularity is noted, or if an ECG is done for some reason (not uncommonly prior to surgery).

Atrial Fibrillation Can Be Diagnosed By Taking Your Pulse

Taking the pulse is an easy, cheap, low-tech technique which is surprisingly good at detecting atrial fibrillation.

The European Society of Cardiology  recommends this as a screening technique for all patients over age 65 visiting their family doctor. This is based on a study published in the British Medical Journal in 2007, which compared systematic screening with an electrocardiogram (ECG) to screening by taking the pulse. If the pulse was irregular and ECG was then performed. The measurement of pulse was just as good as the systematic ECG technique.

Take a look at this great video featuring Archie Manning (former Saints great QB and father of Peyton and Eli) here which gives an excellent description of how to take your pulse and what to look for. Please ignore the bad accompanying music and the shameless hospital plug at the end.

Take 15 seconds out of your day, every day, and take your pulse.

Take your friends’ and relatives’ pulse when the opportunity presents itself.

You may help prevent a stroke in you or your loved ones.