Big Questions with Xarelto Study
The purpose of this post is to introduce my most recent column over at theHeart.org | Medscape Cardiology in which I address recent concerns about the drug rivaroxaban (Xarelto). — In 2014, Rivaroxaban (Xarelto) was the most prescribed new oral anticoagulant (NOAC). Millions of patients have atrial fibrillation, so it’s fair to call it a blockbuster drug. Recently, however, concerns have arisen about the validity of the results of the pivotal trial, called ROCKET-AF, that led to FDA approval. Recall that in the 14,000-patient-strong multicenter ROCKET-AF trial, rivaroxaban was found to be noninferior to warfari...
Source: Dr John M - February 10, 2016 Category: Cardiology Authors: Dr John Source Type: blogs

Science Needs Data Sharing Like Sports Needs Doping Controls
I’ve got a good story for you. One that goes back to the early days of this blog, a time when I wrote about cycling. It turns out that the biggest medical news thus far in 2016 has a connection, albeit slight, to the recent doping news out of Belgium. You’ve heard the news from Cyclocross Worlds: an under-23 year-old woman was caught with a motor in her bike. Although the mainstream media was surprised, this Italian journalist called it “old-stuff.” How does cheating in sports relate to medical science? The connection is trust and confidence–the ability to believe. Medical science is in the mi...
Source: Dr John M - February 3, 2016 Category: Cardiology Authors: Dr John Source Type: blogs

AF Ablation Update – 2016
I do AF ablation. But, similar to my 2015 update, I continue to do fewer of these procedures. What is new in 2016 is more confidence that this is the right approach. My technique for ablating AF has not changed. I do pulmonary vein isolation (PVI) with point-to-point RF. Each burn takes 10-30 seconds, and at the end, the machine counts about 60-80 burns. If the patient has had atrial flutter, or previous heart surgery, or if I can induce atrial flutter, I will do a CTI ablation for flutter in the right atrium during the 45-min period of waiting to see if the veins reconnect. (CTI = cavotriscupid isthmus). I then check for ...
Source: Dr John M - January 23, 2016 Category: Cardiology Authors: Dr John Source Type: blogs

Overdiagnosis and Overtreatment
I’ve never been more concerned about the harms of healthcare. Any exposure to the health care system can get you in trouble. It’s especially scary when healthy people enter the system–often in the name of prevention. Remember that the most likely outcome of a medical intervention in a person without complaints is harm. How can we make a person who says he is well any better? The newest scourge is the treatment of risk factors–not diseases. It’s routine for me to see people admitted to the hospital because of side effects from drugs or procedures used to treat risk factors. This morning, thanks...
Source: Dr John M - January 15, 2016 Category: Cardiology Authors: Dr John Source Type: blogs

Rethinking Cancer Screening
The purpose of this post is to introduce my latest column on Medscape, which is linked at the end. You might wonder why an electrophysiologist is interested in cancer screening. I am interested because it may be one of Medicine’s largest reversals. A reversal happens when something (testing or treatment) doctors did, and patients accepted, turned out to be non-beneficial. My friend Vinay Prasad wrote a book on medical reversals. It’s called Ending Medical Reversals, and it’s an important read. Think about cancer screening as it is today. Millions of healthy people are told they should have mammograms, PSA...
Source: Dr John M - January 13, 2016 Category: Cardiology Authors: Dr John Source Type: blogs

Alzheimer’s disease and macular degeneration concerns with Entresto
Three academic physicians, writing in an editorial in the Journal of the American Medical Association, raised serious (but theoretical) concerns about the risk of Alzheimer’s disease and macular degeneration with long-term use of the new heart failure drug, valsartan/sacubitril (Entresto, Novartis). Here is the translation: Sacubitril is a drug that inhibits neprilysin, which is an enzyme (protein) responsible for breaking down things called natriuretic peptides (other proteins). This is good for heart failure patients because having more natriuretic peptides may prevent worsening heart muscle weakness. The problem i...
Source: Dr John M - January 7, 2016 Category: Cardiology Authors: Dr John Source Type: blogs

A short take of the big stories in cardiology in 2015
Here is my most recent column on theHeart.org | Medscape Cardiology: Mandrola’s Top 10 Cardiology Stories 2015 What follows below is a short-writing summary of my ten picks. The hyperlinks go to earlier columns I wrote on the topic. 1. FDA approved two new (injectable) cholesterol drugs. The problem with the PCSK9-inhibitors: the study to determine whether or not the $14,500-per-year drugs prevent heart attack or death finishes in 2017. I wished the FDA had waited. 2.  The Sprint Trial studied the effects of lowering BP to 120 versus 140 in high-risk adults. The lower-BP target won. The differences were small, a...
Source: Dr John M - December 20, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

Despair not opioids is killing poor white American men
The news this morning is sobering. Poor, white, middle-aged American men are dying at increasing rates. The report, published in a prestigious medical journal by a recent Nobel Prize winner, has shocked the public health community. It should shock you. NPR covered the story. So did the NY Times. Twitter is abuzz with the news. One of the authors of the paper likened this trend to HIV/AIDs in the 1990s. Deeper looks into the data revealed suicide, drug addiction and alcohol-related liver disease were the likely reasons for the rise in deaths. This is bad. I talk often with emergency room doctors. They have been telling me t...
Source: Dr John M - November 3, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

We must inject more care into healthcare
A frail elderly women has a leaky heart valve. It caused her legs to swell and increased her work of breathing when she pushed her walker around the house. One doctor wanted to relieve her suffering. She suggested palliative care; she wanted to make her disease less severe but without removing the cause. Other doctors said no, the answer was to cut the bad valve out and fix the disease. It’s America; you know what happened. After heart surgery, which was successful in relieving the leaky valve, her health deteriorated. (My wife Staci talks often of the elderly and the house-of-cards analogy.) A prolonged post-op cour...
Source: Dr John M - October 25, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

Right Care Action Week — Change what we fear
Last night I talked with one of my partners about a few terrible cases of medical harm from unnecessary procedures. He said, “John, people get this stuff done to them because they fear not being healthy. People are scared.” My answer was that people should fear healthcare more than they do disease. That sounds like hyperbole, but it is not. When you are sick, medicine is beautiful. It’s never been better. But when you are well, you should fear getting stuck on the healthcare train. It moves fast. It’s hard to get off. I’ve never been more frightened to order a test. Any test, even an echo can ...
Source: Dr John M - October 23, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

Right Care Action Week — Let’s make the invisible visible
Seven out of eight patients in his clinic one afternoon had unnecessary care. This from Dr. Atul Gawande, who may be the most respected physician in the world. And he works at Harvard. Overuse wastes resources. Overuse causes harm. Overuse fosters underuse. We must make it visible. The public needs to know. Here you go: In supporting RightCare, I’ve never felt more sure of myself. If I only could tell you the details of what I know. It’s terrible. This nonsense has to stop. JMM Related posts: Right Care Action Week — Be skeptical Right Care Action Week — rational care Right Care Action Week R...
Source: Dr John M - October 22, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

Right Care Action Week — Be skeptical
Right Care seeks to be smart care. In the first part of my career, I rarely looked critically at the evidence. I was too busy; and I was more trusting of the vertical hierarchy of medicine. Eminence-based medicine seemed normal. Listen to the experts, for they are experts, went my mindset. Then something happened. When internal cardiac defibrillators (ICDs) came to be around the turn of the century, someone asked me to do a talk on ICDs. This forced me to study the actual data. I’ve never forgotten what I learned–not merely about the studies, but also how device companies used key opinion leaders, free food, ju...
Source: Dr John M - October 21, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

Right Care Action Week – Un-informed Consent
The current state of informed consent in the US is best described as un-informed consent. A study this May reported that only 3% of patients with coronary artery disease received full informed consent before having an invasive procedure. Findings like these, and there are many other similar studies, reflect the ill-health of the medical decision in US healthcare. It’s hardly a stretch to say most patients falsely believe stenting blockages is a fix for heart disease. Too many patients who receive cardiac defibrillators misunderstand the gamble they made. And don’t get me started on the LifeVest. Patient-center...
Source: Dr John M - October 20, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

Right Care Action Week — rational care
I wrote yesterday about how a broken healthcare system favors overuse of procedures. Today I will discuss rational care. Remember the goals of the Lown Institute: We think healthcare should be affordable, effective, rational and available to all. Rational means in accordance with reason or logic. Hardly a day goes by that I don’t see irrational care. Why it happens is complicated. Patients may expect irrational care. Doctors and nurses can get pushed into delivering it. Then, insidiously, unreasonable and illogical care become normal; and rational care stands out as an outlier. Some examples: It’s not rational ...
Source: Dr John M - October 19, 2015 Category: Cardiology Authors: Dr John Source Type: blogs

RightCare Action Week — a broken healthcare system
I am proud to be part of the Lown Institute. Founded by Bernard Lown, a cardiologist, mentor, activist, and winner of the Nobel Peace Prize, the Lown Institute is an organization committed to making things right in the US healthcare system. In case you wondered, yes, there is right and wrong in healthcare. At this point in my career, more than anything, I need to be on the right side of history. The Lown Institute seeks the basics in a healthcare system. We think healthcare should be affordable, effective, rational and available to all. This is hardly the case now in America. Today, October 18th, begins Right Care Action W...
Source: Dr John M - October 18, 2015 Category: Cardiology Authors: Dr John Source Type: blogs