The BVS Disappearing Stent: Promise, Hype and the Tension Between Progress and Safety
Medicine does not stand still. You want innovation; you want progress. But you also want safety.
Millions of patients have coronary stents placed in the arteries supplying blood to the heart. It’s big business.
Metal cages placed in the setting of a heart attack can be life saving. In other settings, however, the strongest quality evidence says metal cages perform no better than medicines.
One of the two* main reasons stents don’t improve long-term outcomes for patients with stable coronary disease are that they trade improved blood flow (good) for the presence of a metal cage in the artery (bad). The metal cag...
Source: Dr John M - July 22, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Should AF ablation require approval from a heart team?
A patient presents with atrial fibrillation (AF) and a rapid rate. He doesn’t know he is in AF; all he knows is that he is short of breath and weak.
The doctors do the normal stuff. He is treated with drugs to slow the rate and undergoes cardioversion. During the hospital stay, he receives a stress test and an implantable loop recorder.
He goes home on a couple of medications. The expensive implanted monitor shows rare episodes of short-lived AF, less than 1% of the time. The patient feels great.
But here’s the kicker: his doctor recommends an AF ablation.
This is nuts. The man has had one episode of AF. He has...
Source: Dr John M - July 13, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Is AF ablation a big placebo?
Turkish authors boldly raised this question in a recent editorial.
They likened AF ablation to renal denervation, a procedure in which RF ablation in the kidneys was felt to reduce BP. Many studies showed kidney ablation markedly lowered BP. Then a trial was done with a sham control (people got part of the procedure but did not have burns to the kidneys) and there was no difference.
Does AF ablation work the same way? Is it a big placebo? In over 5000 reports of AF ablation in the medical literature, not one is a true sham-controlled study.
People will argue AF ablation works; there are recordings before and after ablation...
Source: Dr John M - May 31, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Big news in AF ablation from HRS 2016
I have recently returned from the 2016 Heart Rhythm Society Sessions in San Francisco.
I wrote three articles for Medscape. I also did two podcasts from HRS. I will link these below. You need to sign up for Medscape (free) to read the essays and listen to the podcast.
In the first article, I discussed the good and bad of AF ablation. The good being the increase in quality of life seen in about two-thirds of patients who have ablation. The bad being a study from a Japanese registry which found 1 in 3 patients sustained post-procedural “sub-clinical cerebral ischemic” lesions on brain MRI scans. To translate, tha...
Source: Dr John M - May 15, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Wisdom…
…the quality of having experience, knowledge, and good judgment.
I read today a collection of words that exude wisdom. I share it with you because the purpose of this blog is to do create value through education.
Peggy Girshman was an award-winning health journalist. When ill with a life-limiting illness, she wrote her own eulogy. NPR published it today after her death.
Must-read is an overused phrase, but it modifies perfectly her words. Here are a few excerpts, with my thoughts.
Work-Life Balance: Though Girshman wished she could have worked longer, “to convince someone I was right,” she also wished she...
Source: Dr John M - May 9, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Right Care — There is always something to do
Some of my most poignant moments in medicine happen after the ablations and devices are finished. That’s when I go visit with patients up in the medical wards.
My legs are fried from standing all day. So I sit, a key move because then you are ready to listen. One good thing about computers in hospital rooms is they come with a stool, which is handy as a bedside chair.
This is slow time; a time for eye contact, an invitation. These are the moments when you hear things about a person. The connection goes way beyond the disease systems, the biomarkers, the CPT codes.
Maybe I am wrong, but it feels therapeutic. Sometimes...
Source: Dr John M - April 12, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Access to healthcare does not deliver health
Stanford economist Raj Chetty and coworkers published an important paper in the Journal of the American Medical Association this week. It’s free.
They looked at the association between income and longevity in the US.
The results will disrupt a lot of what you might have thought about healthcare.
The first finding was not surprising: higher income associated with longer life. The differences were immense–almost 15 years from lowest to highest income for men.
The second finding was that inequality in life expectancy increased over time. Between 2001 and 2014, life expectancy increased by 2.34 years for men and ...
Source: Dr John M - April 11, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Another thing to fear in healthcare: Getting an Xray
I head to Chicago this weekend for the 4th Annual Lown Institute Conference.
The Lown Institute seeks to catalyze grassroots movements for transforming healthcare systems and improving the health of communities.
For those of you who want to be on the right side of the street of history, Dr. Bernard Lown, a cardiologist, activist, and winner of the Nobel Peace Prize founded the Lown Institute.
The part of Lown that I am involved with is the Right Care Alliance. We are a group of people interested in curbing overdiagnosis and overtreatment. We believe that if there was less medicalization of normal, less waste, more RightCar...
Source: Dr John M - April 10, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
AF ablation still has a role
In this study, Prash Sanders and Rajeev Pathek and others showed that lifestyle measures before and after the an ablation procedure increases the odds of success 5-fold.
Given the modest success rates, costs, and risks of AF ablation, it’s imperative to improve the odds of the procedure.
JMM
Related posts:
AF Ablation Update – 2016
A cautionary note on AF ablation in 2015
Dabbling in ablation is not so good… (Source: Dr John M)
Source: Dr John M - April 7, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
More on the gambling decision to take statins
In my last post, I wrote my initial thoughts of an important new study on how the decision to take a medication or have a screening test in the name of prevention is similar to playing the lottery.
I promised to think and write about the study more carefully. My latest thoughts are now published over at theheart.org|Medscape Cardiology.
Here is the intro:
Medicine is easier when people are sick. In treating heart attack or stroke, certainty rules over uncertainty. The best outcome of a heart attack or stroke, however, is not to have had one.
Prevention is where medicine gets hard, very hard. To prevent something that may...
Source: Dr John M - March 30, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
A new way to discuss statin drugs
A new study published last week in an open heart journal changes the conversation about how patients and doctors think about and discuss preventive therapies–such as statins.
Dr. Richard Lehman may be the smartest doctor on Twitter. This is what he said:
This is a game-changer https://t.co/WgGdLlodbL
— Richard Lehman (@RichardLehman1) March 20, 2016
Most discussions about using statin drugs focus on a 5-10 year period. That’s not the right way to discuss these drugs. When we take a statin drug (or screen for cancer, or any other preventive intervention) we do it to live longer–not just 5-10 years.
...
Source: Dr John M - March 21, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Thoughts on Justice Scalia’s Death
When I heard Justice Antonin Scalia had died suddenly, presumably of cardiac causes, I spent time reading and thinking about the famous judge. Three themes seemed worth putting down in writing.
Read more here: Justice Scalia’s Death: Three Lessons for the Healthcare Community
JMM
Related posts:
New post up on theHeart.org — Dr Emanuel’s Death Wish Harms Rather Than Helps
Update: Social justice of AF care, NOAC monitoring, population health and two new podcasts
Death-denial is something doctors can change (Source: Dr John M)
Source: Dr John M - February 20, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Hospice and Palliative Care and Cardiology TweetChat Recap
Thanks to Dr Bernadette Keefe (@nxtstop1) last night’s Hospice and Palliative Medicine (#HPM) Tweet Chat has been “storified.”
Here you go>
[ (Source: Dr John M)
Source: Dr John M - February 18, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
Join us tonight for #HPM Palliative Care Tweet Chat
Tonight, February 17, at 2100 EST, Staci and I will host a Tweet Chat about cardiology and palliative care. It’s a great way for the general audience to learn from Staci. As a cardiologist married to a palliative care doctor, I get to know things that most cardiologists don’t know.
The one-hour session revolves around three questions that are outlined over at Pallimed.
****
Here are some of the details:
What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 2/17/2015 – 9p ET/ 6p PT
Host: Dr. Staci Mandrola and John Mandrola
Twitter Feeds to Follow:
Staci Mandrola @drstacim
John Mandrola @...
Source: Dr John M - February 17, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
VA hospitals do not deliver inferior care
This study shows that it delivers acute care similar to that seen in the private sector. That sends a big message about health care policy.
I work in the private sector of healthcare. It’s wasteful, costly, inefficient, unfair, and make no mistake, it denies and rations care. It’s a national embarrassment.
The VA system is not perfect, but US healthcare would do well to be more like the VA.
JMM
Related posts:
An important quality measure in hospitals
Another VA lesson — Healthcare needs to stop being like flying business class
Heart Attack Care: Your life may depend on which hospital you choose (Source: Dr John M)
Source: Dr John M - February 12, 2016 Category: Cardiology Authors: Dr John Source Type: blogs
