CW: My Athlete’s Heart Podcast

Hi John. EXCELLENT 35-minute discussion on ERCast. It was easy from itunes to download this mp3 recording onto a CD that I could play in the car. A couple of thoughts I’d add to your insightful discussion:

i) The cost of an ECG in the office is not $25 anymore as you indicated. At the time I retired from academic primary care practice (July, 2010) – it was at least 3 times that amount (not to mention interpretation fees that are sometimes added on).

ii) Great points you make about various QT interval durations (that clearly anything over 500 msec should be investigated). At least in my primary care experience – it was rare indeed for me to see a QT anything close to that in an otherwise healthy, young athletic population not on meds (ergo, rare as a screening test in someone without positive family history that you’ll see a QT approaching that duration).

iii) Given the pros and cons for anticoagulating (or not) a young adult athlete who is otherwise healthy – Shouldn’t this be an informed consent decision that the athlete himself/herself makes once told of the pros and cons? I’m no longer in my 40’s – but I do not think I would opt for anticoagulation if I truly had “lone AFib” – given the hassles of becoming a “patient” (with need for frequent doctor visits) and the potential for not insignificant side effects from longterm anticoagulation. Newer anticoagulants (like Dabigatran) was extremely expensive (potentially an important issue- depending on one’s coverage) – and don’t have an “antidote” if bleeding does occur …

iv) Wouldn’t use of Echo be appropriate for that young athlete with AFib on the fence about anticoagulation or not – by providing another way to assess if the heart is truly “normal” (perhaps there was previously undetected cardiomyopathy or LA enlargement that would be enough to suggest definite need for anticoagulating that individual?)

v) In your experience – is intermittent (= paroxysmal = PAF) much more common than persistent AFib when AFib does occur in young adult athletes? My impression has always been that it is frequency and especially likely duration of AFib episodes in individuals with PAF that determines likelihood of stroke – so might not ambulatory monitoring in addition to Echo be yet another way to truly assess relative likelihood of stroke (and therefore the need for anticoagulation). If YOUR 2 AFib episodes were truly all you had – and if those 2 episodes were short and self-limiting – Wouldn’t your stroke risk be truly very, very low? (that said with full acknowledgement that the vast majority of AFib episodes are asymptomatic …. ergo my suggestion for additional ambulatory monitoring to assess this).

vi) You bring up an EXCELLENT point about Dabigatran – namely the inability of the medical provider to KNOW if the patient is taking the medication (since there is no way of monitoring drug levels). IF the new test you allude to for Dabigatran monitoring does come through – Won’t the addition of “Dabigatran monitoring” cancel out what was to have otherwise been one of the major “pros” for using that class of drugs (namely that monitoring would no longer be needed). Absence of monitoring of course makes it extremely difficult to know the “true event rate” on these new anticoagulating drugs, because investigators can’t be sure if the patient is truly taking the drugs?

vii) You ARE a “philosopher” – and I LOVE it!

viii) GREAT recording you made!!! It is a LUXURY for us to have ready access for tapping into your wonderful clinical insights! Keep up the superb work – : ) Ken