Category Archives: Atrial Fibrillation

AliveCor Is Now Kardia and It Works Well At Identifying Atrial Fibrillation At Home And In Office

I’ve been using the AliveCor Mobile ECG App/Device to record my patients’ heart rhythm in my office for about 6 months now.

It has for the most part taken the place of the more elaborate, but cumbersome and time-consuming, 12-lead ECG in patients where heart rhythm is my only concern.

I’ve also convinced about a dozen of my patients who have intermitent atrial fibrillation to obtain the device and they are actively using it to monitor at home their heart rhythm. Through the AliveCor website, I can view their recordings and see what their heart rhythm is doing when they have symptoms.

Last week, a patient of mine (I’ll call her Suzy) who has had significant prolonged episodes of atrial fibrillation associated with heart failure (but cannot tell when she is in or out of rhythm) notified me that her device was interpreting her rhythm as atrial fibrillation. She had not had any symptoms, but was making  daily recordings for surveillance.

Suzy called our office and we brought her in the next day and confirmed with a 12-lead ECG that she was indeed in atrial fibrillation with a heart rate of 120 beats per minute.

It’s pretty amazing that this little, inexpensive device can now replace expensive and elaborate long term cardiac monitors for many of my patients.

AliveCor Rebrands Itself to Kardia


Screen Shot 2016-03-28 at 5.38.34 AM
I’ve noticed that AliveCor has rebranded itself as Kardia. If you go to www.alivecor.com now you see the fourth generation device along with promotion of a “Kardia band” which apparently works with an Apple Watch to record your ECG.

The Kardia band is not available for purchase at this time but if and when I can get one, it might motivate me to purchase an Apple watch.

When I purchased my AliveCor device in June, 2015 it cost $74.99 from Amazon.com. The newer version is priced at $99 at both AliveCor and Amazon websites. I’m told by Dr. David Albert of AliveCor that this “fourth generation” version is more accurate, so I have purchased it to see if it reduces the problem of occasional bad recordings.

Screen Shot 2016-03-28 at 5.38.10 AM

You can see in this picture from the website that the formerly flat metal electrodes now have bumps. Dr. Albert says these result in more surface area for better contact with skin. We will see.

The Value of Early Detection Of Atrial Fibrillation

Meanwhile, I will be doing an electrical cardioversion (shocking or resetting the heart) on Suzy to get her back to normal sinus rhythm.  If we had not detected the asymptomatic onset of her rapid atrial fibrillation using the AliveCor/Kardia device, chances are we wouldn’t have known about it until her heart muscle weakened again and she became short of breath from heart failure.

I have Suzy on blood thinners to lower her risk of stroke associated with her Afib but for my patients who are not on blood thinners, detection of silent or asymptomatic AFib is even more important.

-Affibly yours,

-ACP

p.s. The skeptician in me feels this post borders on infomercialese.

Let me make it clear that I have no connection with the company formerly known as AliveCor and have received nothing from them (not even free test devices or Apple Watch Kardia Bands!) but I’m just really excited about the device and how it can help my patients (oh, please excuse me, this really sounds like marketing) “empower” themselves to take control of their heart rhythm.

In the course of writing this, I’ve discovered an academic paper evaluating 13 ECG smart phone type ECG devices so there are other devices you could try. I haven’t had the time or resources to evaluate them.

The Perfect Christmas Gifts for the Palpitating or Hypertensive In Your Life

As December draws ever closer to the twenty-fifth you may find yourself  behind the wheel of a large automobile puzzling over the perfect gift for your loved ones.

Fear not, for the skeptical cardiologist has a few suggestions to help you.

The Omron 10 Blood Pressure Monitor

IMG_5618
EXTRA-LARGE digits with backlight!!

If your hypertensive friend or relative already has all the standard BP paraphernalia (pill splitter, basic BP cuff), owns a smart phone and has an engineer or scientist approach to data the Omron 10 (BP786, 59.99$ at Best buy.com) just might be the perfect gift.

The skeptical cardiologist recently purchased two (that’s right two) of these in anticipation of Christmas.

Christmas arrives with multiple stressors guaranteed to hike your blood pressure.

The Omron 10 offered three features not available on my basic Walgreen’s BP cuff that I felt were possibly useful:

  1. Averaging/automating three consecutive readings. After reading about the SPRINT BP trial which showed a benefit of aiming for SBP of 120 over 140,  I thought I should try to reproduce the method used in the trial. This involved measuring BP 3 times separated by 5 minutes and averaging the results. The Omron 10 can be set to make and average three BP readings separated by a variable time period.
  2. The ability to communicate with an iPhone or Android smartphone and record and display the data in an app.
  3. Works off both batteries and plug in electrical power.

I thought my dad (a retired chemist) would like the Omron 10’s features but, alas, he informed me that if he wanted to average three BP readings he could just write down the numbers and do the math.

IMG_5670If he had an iPhone he might really like the way the Omron sends its data to the free Omron app.

The app displays BP  and heart rate readings recorded for different time intervals.

You can take a screen shot like I did here or email it and share the data with your doctor through the doctor’s patient portal!

 

The AliveCor Mobile ECG

IMG_6936 copyI’ve mentioned this really cool device a few times (here and here).

It is now listed on Amazon.com for $57 (a significant drop from when I purchased it)  and can be attached to your smartphone case. It does a really good job of recording a single lead electrocardiogram (ECG) and diagnosing normality or atrial fibrillation.

If your friend or loved one  is experiencing periodic fluttering in their chest or a sensation of the heart skipping beats or racing (the general term for which is palpitations) then this could be the perfect gift.

A number of my patients have purchased these and have made ECG recordings which I can review online.

Primarily I have been recommending them to my patients who have atrial fibrillation periodically.

You may think this is too complicated a device to master but last week I saw in my office a 94 year old lady who had had an episode of atrial fibrillation earlier in the year.  Since her last visit she had purchased an AliveCor device and was able to show me the ECG recordings she had made on her iPhone.

May your holiday season be joyous, full of loved ones and free of stressors that raise your blood pressure and cause your heart to pound and race. But if it is not, consider purchasing one of these nifty devices.

Same as it ever was

-ACP

 

 

AliveCor Mobile ECG Misidentifies One Patient’s Heart Rhythm

The skeptical cardiologist has been evaluating the AliveCor mobile ECG device for use with a smartphone to detect atrial fibrillation.  In my initial post on this I found it to be accurate in identifying atrial fibrillation in my patients.

The AliveCor stuck (in a very crooked fashion) on the back of my (not particularly clean) iPhone 6 and ready to record YOUR heart rhythm.
The AliveCor stuck (in a very crooked fashion) on the back of my (smudgy) iPhone 6 and ready to record YOUR heart rhythm.

I’ve been using it in my office fairly regularly and encouraging my patients with intermittent AF to acquire the device and use it to monitor their heart rhythm.

When they make recordings they can be uploaded to me via internet for my review.

The other day I was examining a patient who I was seeing for syncope (passing out) and I noticed when listening to his heart that his pulse was very irregular.

I pulled out my iPhone with AliveCor stuck on the case and made the recording you see below. Screen Shot 2015-09-08 at 2.24.05 PM

Although the AliveCor app diagnosed it as “possible AF” it is very clearly normal sinus rhythm with frequent premature ventricular contractions (PVC), a totally different (and more benign) rhythm.

I’ll continue on with this evaluation and I’ll be particularly interested in how AliveCor performs in other patients with PVCs which are a common cause of palpitations in the general population.

If AliveCor cannot differentiate AF from PVCS it may lead a lot of users to become unduly concerned about their heart rhythm.

palpitatingly yours

-ACP

 

Can Ovine Obesity (Fat Sheep) Teach Us About Atrial Fibrillation?

Until the last year or so when patients asked me what they could do to help their atrial fibrillation (AF) I would tell them to avoid excessive alcohol consumption and take their medications as prescribed.

My response has changed because new data suggest that losing weight and exercising can significantly reduce the recurrent rate of atrial fibrillation. Now, in addition to my standard reasons for staying at ideal body weight and exercising regularly I can toss in the fact that atrial fibrillation will be less frequent and troublesome.

I had noted previously that the majority of my patient’s with AF were obese and sedentary (although there are definitely many AF patients who exercise regularly, eat a great diet and stay at their ideal body weight0 but data was lacking to suggest cause and effect.

LAAfat
View of the left atrial appendage (LAA) and posterior aspect of left atrium obtained in a 400 pound woman about to undergo  electrical cardioversion for her atrial fibrillation. The orange arrow points to extensive collection of fat in the walls of the atrium.

In addition, I had noted that when I looked at the left atrium of the vast majority of patients with AF using an imaging tool called trans-esophageal echocardiography they had evidence for fatty infiltration into the area between the atria (atrial septum)  and the wall of the left atrium.

I strongly suspected based on these observations that somehow the fat infiltrating into the walls of the left atrium was triggering AF but I had no way of proving it.  Isolated observations like these can only generate hypotheses on causality.

Science has many different approaches to solidifying or proving hypotheses and one such approach is to induce a disease in an animal similar to humans and make detailed analyses of the cause and consequences.

Australian researchers writing in JACC in July present their observations on the electrical, physiologic and structural changes that result when sheep get fat.

How Do You Make Sheep Fat?

Apparently you just let them eat as many pellets made of energy-dense soybean oil (2.2%) and molasses–fortified grain as they want.

After 36 weeks the 10 sheep given ad libitum pellets weighed twice as much as the sheep who were restricted and kept lean

After 36 more weeks of obesity the sheep were studied extensively. All sheep underwent “electrophysiological and electroanatomic mapping; hemodynamic and imaging assessment (echocardiography and dual-energy x-ray absorptiometry); and histology and molecular evaluation”.

The investigators found

“Sustained obesity results in global biatrial endocardial remodeling characterized by LA enlargement, conduction abnormalities, fractionated electrograms, increased profibrotic TGF-β1 expression, interstitial atrial fibrosis, and increased propensity for AF. Obesity was associated with reduced posterior LA endocardial voltage and infiltration of contiguous posterior LA muscle by epicardial fat, representing a unique substrate for AF”

The fat sheep developed AF and had multiple abnormalities in the left atrium, the source of AF, that made them more likely to develop atrial fibrillation.
Screen Shot 2015-09-01 at 4.32.32 PM In fact, the investigators believe it was fat collecting around the heart and specifically around the posterior left atrium that was triggering all these changes.

The pictures to the left show a heart from one of the fat sheep. The arrow points to the extensive amount of fat collecting posterior to the left atrium.

When the posterior left atrial wall was viewed microscopically, fat cells could be seen infiltrating between the muscle cells in the fat sheep (right, blue arrow) but not in the lean sheep. Screen Shot 2015-09-01 at 4.33.06 PM

In the fat sheep, fat cells (adipocytes)  were enlarged and infiltrated between the muscle cells of the left atrium, presumably disrupting the normal electrical activity and contributing to the development of atrial fibrillation.

More Reasons To Stay At Your Ideal Body Weight!

If you were previously unmotivated to avoid obesity perhaps this will motivate you.

Think about fat cells gathering around your heart and pouring their evil humours into the tissues of your left atrium and making it more likely that you will develop AF. With AF comes increase risk of stroke, heart failure and death.

-unadipocytically yours

-ACP

AliveCor Smartphone App Detects Atrial fibrillation: Potential for Stroke Prevention

Atrial fibrillation (AF)  is a common abnormal rhythm of the heart which causes 1 in 4 strokes. Those afflicted with AF may lack any symptoms or only have a vague sense of irregularity of their heartbeat and thus the first symptom of AF can be stroke.

The gold standard for diagnosing AF has long been the electrocardiogram (ECG or EKG) and typically the ECG involves placing 12 electrodes on the chest/arm/legs and recording the electrical activity of the heart on an expensive device.

I’ve been checking out a device made by Alive Cor which works with your smart phone to record a single channel ECG and is capable of accurately diagnosing if you are in the normal (sinus) rhythm or in AF.
Screen Shot 2015-07-12 at 8.45.49 AMYou can purchase the third generation (significantly smaller then earlier versions) AliveCor Mobile ECG from Amazon or from AliveCor directly for 74.99$ and it works with an app with both iOS and Android devices.

I used mine with my iPhone 6. At first I carried it separately, fearing the added bulk when stuck on to my iPhone case but after a while I realized that it was never with me when I wanted to use it and that there was a huge risk of losing it and so I used the backing adhesive to attach it to my case.

After pairing the device with the app you put two fingers on each of the metal pads and the smartphone screen displays the recording. After 30 seconds of recording it then interprets the rhythm.

Screen Shot 2015-07-12 at 8.56.47 AM
Typical recording in normal sinus rhythm. The red arrow indicates the small p waves which are the electrical signal of the upper chambers (the atria) depolarizing , the blue arrow indicates the electrical depolarization of the ventricles (QRS). The orange arrow indicates that the time interval between the QRS complexes is the nearly the same for each beat, indicating the regularity that we expect when in NSR compared to AF.

Above is a typical recording I made in my office on a patient who had a history of AF. The quality is good and I can clearly see that he is in normal sinus rhythm. The app correctly made the diagnosis of NSR and calculated his heart rate at 68 beats per minute.

One day I had most of my patients record their ECG’s using AliveCor and compared it to the standard 12-lead ECG we normally record. The device correctly identified the two patients with AF out of this group and correctly identified the normals.

Screen Shot 2015-07-12 at 9.26.42 AM
AliveCor recording of patient with AF with heart rate of 70 beats per minute. Note the absence of p waves before the QRS complexes and note the beat to beat variation in the RR interval (orange arrow)

This recording is from a patient with persistent AF which had recurred two weeks earlier. The device correctly identified AF.

Studies have documented that AliveCor Mobile ECG can accurately diagnose AF in a screening setting and the FDA approved the device for AF screening in 2014.

Given the high prevalence of silent AF, the strong association of AF with stroke and the availability of anticoagulants which reduce AF associated stroke by 70%, screening for AF with devices like AliveCor holds the promise of preventing large numbers of stroke.

(For my comments on taking the pulse and stroke prevention see here and on the inadvisability of a routine 12-lead ECG see here)

AliveCor allows physicians utilizing the Mobile APP and ECG to have a “dashboard” into which their patients can transmit their AliveCor ECG recordings.

I will be discussing this remarkable new device with my AF patients  who are smartphone enabled. I think it will advance our ability to more efficiently and quickly diagnose AF in them.

My standard approach if a patient with AF calls and says that they feel like they are out of rhythm is to have them come into the office for a full 12-lead ECG. If they are AliveCor enabled, they could make their own recording, and we could review that remotely and make a diagnosis without the office visit.

Let me know your thoughts on smartphone ECGs.

fibrillatorily yours,

-ACP

Foxglove Equipoise

I came across the word equipoise, used eight times, in a recent, brief editorial entitled “Digoxin: In the Cross Hairs Again.”

It’s not a word I hear outside of medical circles but it serves a great function in the clinical arena.

When used in medicine as in the phrase “clinical equipoise” it means that medical experts are uncertain as to whether a treatment for a disease is helpful.

Thus, for digoxin, a drug which has been utilized for patients with heart failure or atrial fibrillation for 240 years, we still don’t know if the benefits outweigh the risks.

foxgloveDigoxin is the major medicinally active chemical in the foxglove plant which was first described by Leonhart Fuchs (the plant and color fuchsia are named after him), a German botanist and physician in 1542. It was given the latin name digitalis purpurea, reflecting the plant’s purplish color and similarity to a thimble (German finger hut).

A vague understanding that the foxglove had medicinal and toxic properties existed in subsequent centuries, but it took a very observant physician from the West of England, William Withering, to give it a sold footing in the medical pharmacopeia.

Withering collected 10 years of his observations, using various preparations of foxglove to treat various diseases including the mysterious “dropsy” in the (now famous) An Account of the Foxglove and some of its Medical Uses.”

He writes of his rationale for beginning to give patients foxglove:

“In the year 1775, my opinion was asked concerning a family receipt for the cure of the dropsy. I was told that it had long been kept a secret by an old woman in Shropshire who had sometimes made cures after the more regular practitioners had failed. I was informed also, that the effects produced were violent vomiting and purging; for the diuretic effects seemed to have been overlooked. This medicine was composed of twenty or more different herbs; but it was not very difficult for one conversant in these subjects, to perceive, that the active herb could be no other than the Foxglove.”

(Excerpt From: William Withering. “An Account of the Foxglove and some of its Medical Uses.” iBooks. https://itun.es/us/ZeJDE.l)

Dropsy was that era’s term for edema: “The dropsy is a preternatural swelling of the whole body, or some part of it, occasioned by a collection of watery humour. It is distinguished by different names, according to the part affected, as the anasarca, or a collection of water under the skin; the ascites, or a collection of water in the belly; the hydrops pectoris, or dropsy of the breast; the hydrocephalus, or dropsy of the brain, &c. [Buchan1785].”

Foxglove was in clinical equipoise in 1775. When Withering started giving it to his patients with dropsy he did not know if it would help or harm them.

After trying various preparations of the foxglove in varying dosages in hundreds of patients he concluded that it was of a great benefit as long as it was carefully titrated to avoid the toxicities of overly slow pulse and vomiting.

With modern medicines that are proven to be safe and effective we demand evidence from randomized controlled trials in which the active drug is compared to a placebo. There are too many factors which affect the course of a disease to accept the kind of observational evidence that Withering collected.

Digitalis is currently utilized in heart failure and atrial fibrillation. Withering’s patients likely had one or both of these conditions.

A recent observational study found that digitalis usage in patients with newly diagnosed atrial fibrillation was associated with a 26% higher risk of dying.

The only large randomized trial of digoxin, the DIG (Digitalis Investigation Group) trial, showed no effect on mortality, but digoxin did reduce hospitalization among patients with heart failure and a reduced ejection fraction (HFrEF)

The DIG study was performed in the early 1990s, before current optimal treatment regiments for heart failure with reduced ejection fraction were developed and may no longer relevant. More recent observational studies suggest digoxin raises mortality in heart failure.

Thus, the foxglove or digitalis, although used for 240 years in hundreds of thousands of patients for both heart failure and atrial fibrillation remains in clinical equipoise.

Doctors must be very circumspect in prescribing this medicine. Personally, I do not use digoxin in heart failure patients.

I use digoxin in chronic atrial fibrillation only as a last resort when other agents do not allow adequate slowing of the heart rate and I carefully monitor levels and kidney function if a patient is on it.

jemimafoxglove
From The Tale of jemima Puddle-Duck. Jemima… rather fancied a tree-stump amongst some tall fox-gloves.

I have, however, decided to start growing foxglove in my garden. I will try to warn the ducks, rabbits and squirrels not to partake of its beautiful flowers as they might prove deadly.

I also plan to visit the grave of Withering on my upcoming trip to Europe, for upon his tombstone it is said, there is an engraving of the foxglove!

 

 

Digitally Yours,

-ACP

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.