How dangerous are NSAIDs in patients with AF?
One of the most commonly asked questions in the office is the treatment of arthritis pain. This comes up because of the concern over taking NSAIDs (non steroidal anti-inflammatory drugs) in patients who are on anticoagulants (such as warfarin, or dabigatran, rivaroxaban, apixaban).
My views on this matter have changed.
But first, I want to mention a study published in JACC that addressed the issue of NSAID use in pts with AF who take an anticoagulant.
This was a sub-analysis of the RELY trial, which pitted dabigatran vs warfarin. Remember, in the original RELY trial, the 150mg dose of dabigatran did better than warfarin at...
Source: Dr John M - July 13, 2018 Category: Cardiology Authors: Dr John Source Type: blogs
Cardiology Podcast Every Friday
My editors at Medscape warned me years ago that many people, especially younger ones, read a lot less. This saddened me because I’ve spent a great deal of time learning to write.
One of America’s most accomplished writers, Malcolm Gladwell, began his podcast because he worried about not reaching younger people.
Each week, I spend a great deal of time putting together thoughts on the top 4-5 cardiology stories of the week. Most of the ‘stories’ are studies, but not always. I have been doing this podcast for a couple of years now, but haven’t promoted it because I was not sure it would stick. ...
Source: Dr John M - June 25, 2018 Category: Cardiology Authors: Dr John Source Type: blogs
Finding Truth: How Much Do We Need Experts?
I am planning a column on the role of experts in translating medical evidence. Evidence is important because it’s how doctors know they are helping not harming people.
It’s hardly news that the new (digital) democracy of information has changed the rules of influence in Medicine.
In the days of old, academic doctors generated, analyzed and translated evidence. We called these people key opinion leaders (KOLs). To become a KOL, you stayed in academics, published lots of studies, and crucially, you were not too critical of prevailing views.
If you did that, you could get invited to speak at meetings, write editor...
Source: Dr John M - June 10, 2018 Category: Cardiology Authors: Dr John Source Type: blogs
A Corrosive Force in Medical Care
It comes in a large white envelope each month. It’s marked confidential.
When I hold it up to the light, I can see through the envelope. I can’t see the details, but the colored graphs give it away.
It’s my monthly productivity report. Most employed doctors get these graphs.
These “dashboards” of value include your own productivity as well as many graphs on how you stack up with other doctors across the country. It shows your employer if you are a hard worker.
The measure of productivity we use is called the relative value unit or RVU.
Doing an ablation, cath, stent or valve replacement earns ...
Source: Dr John M - October 17, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
Left Atrial Appendage Closure Does Not Prevent Strokes
Our cautionary left atrial appendage occlusion (Watchman) editorial is now published in a prominent medical journal, called Heart Rhythm. My co-authors are Drs. Andrew Foy and Gerald Naccarelli from Penn State. It was a peer-reviewed version of my previous theheart.org | Medscape Cardiology column.
Watchman and other similar devices are plugs that occlude the left atrial appendage in an attempt to reduce the odds of stroke in patients with atrial fibrillation. It was a nice idea but it did NOT work.
The link is here> Percutaneous Left Atrial Appendage Closure is Not Ready for Routine Clinical Use
In the allotted 2500 ...
Source: Dr John M - October 12, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
The Nobel in Economics and Medicine?
Once again, the Nobel prize for economics–not science and medicine–has immense influence on the practice of medicine.
Every day, in fact.
This year, Richard Thaler, a behavioral economist at the University of Chicago, won for his work on human biases and temptations.
The famous writer Michael Lewis (Moneyball) has a nice essay on Thaler’s work here.
Along with Kahneman and Tvresky, the work of behavioral psychologists and economists directly relates to clinical medicine because it describes human decision making.
Thaler made lists of irrational decisions. For example, we often make choices that don’...
Source: Dr John M - October 11, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
We get what we tolerate…
Richard Fries, a cycling-safety advocate in Boston, uses the phrase we get what we tolerate to describe the dire situation of drivers killing cyclists and pedestrians. Many humans die from these collisions because we tolerate it. An inattentive driver kills a person on a bike; then nothing changes.
The phrase applies well to other dubious policies in the US. Before a gunman slaughtered 60 innocent people with a machine gun in Las Vegas Sunday night, I had planned to use the we get what we tolerate phrase in health care policy.
I was going to argue that US citizens pay too much for medication, navigate a morass of bureaucra...
Source: Dr John M - October 3, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
Medicare for All?
Maybe it’s sampling error, but I am seeing an increasing number of people who are being financially crushed by the US healthcare system.
One recent patient had a real rhythm problem, one that could or should be fixed with a procedure. But he could not afford it. He had insurance but could not afford to pay his allotted portion. I felt helpless–because although I could agree to do it for free, the hospital charges would be over $100,000.
Another patient suffers from stress-induced arrhythmia because her brother–whom she is close to– is hospitalized and she can’t be with him at the bedside. Why?...
Source: Dr John M - October 2, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
Young people, stroke and a hole in the heart (PFO)
(This post introduces my latest column on TheHeart.org | Medscape Cardiology. It’s about stroke in young people.)
***
We define stroke as the death of brain cells. The typical cause is a blocked blood vessel in the brain. Stroke usually occurs in older people who have established blood vessel disease. Stroke is bad; it may be the worst outcome in all of medicine. That’s because stroke can permanently remove basic functions of being human, things such as speech, thought, personality, movement, swallowing, and many others.
Stroke is not supposed to happen in young people. But sometimes it does. And in some of t...
Source: Dr John M - September 28, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
Inflammation, Ablation, Fats, LDL, etc .. My review of ESC 2017
The European Cardiology Congress, ESC as it is called, has grown into the largest medical meeting in the world. This year, about 38,000 attendees came to Barcelona.
I was busy. Here is an update of the big stories:
Inflammation:
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 ant...
Source: Dr John M - September 6, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
Big lessons from my error
I was furiously tapping on the computer when he asked: “Doc, what happens if I don’t have the procedure you are recommending?”
Glee spread through my body. I grinned and nearly jumped up from the stool to hug him. I enthusiastically answered.
Few patients ask this vital question.
I tweeted about the encounter:
An older pt asked me: "what happens if I don't have this procedure" / I nearly jumped up to hug him! <Please, people, ask your doc that
— John Mandrola, MD (@drjohnm) July 7, 2017
A number of people noted my error:
Why aren't docs telling their patients their options an...
Source: Dr John M - July 9, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
New Data Increase Caution on Left Atrial Appendage Occlusion
This study took data from more than 61 centers across the world.
The details of the studies are included in my column: Real-World Data on Left Atrial Appendage Closure Does Not Reassure
The gist of these studies was that clots on the device are not rare; potent clot-protecting drugs are likely required to prevent clots (at least for a period of weeks-months); the presence of clots increase the risk of stroke, and finally, major procedural complications are in the range of 4%.
These findings bolster my already cautions approach to this procedure.
Remember, left atrial appendage closure is a preventive procedure. Its benefi...
Source: Dr John M - June 27, 2017 Category: Cardiology Authors: Dr John Source Type: blogs
