Two gifts and a consolation prize

President Obama has a few good ideas.

He wants Americans to discuss healthcare this holiday season. That’s actually a really good idea.

This blog aims to do some good in the area of medicine and health. What follows are two incredibly important essays. The consolation prize is an excerpt from my recent Top Ten post. I chose this particular excerpt because in my view the most impactful cardiology study of 2013 involved two prominent themes of this blog–arrhythmia and the power of lifestyle choices.

On over-treatment and the collective inability to give peace a chance:

Dr. Rob Lamberts is a primary care doctor, accomplished writer and full-fledged master of the obvious. His November 20th essay, Gaia and Snake Oil, is an absolute gem. He hits upon the very essence of what’s wrong with the American culture of medicine. He calls it Medicine 101. I call it Medicine 101-through-404. (Staci first discovered this post on KevinMD.)

On the risks of denying death as a natural part of life:

I don’t know Dr. Craig Bowron, but that doesn’t diminish my admiration for his 2012 Washington Post essay, Our unrealistic attitudes about death, through a doctor’s eyes. I’ve tweeted that if I could change one thing about US healthcare, it would be to improve the care of the elderly and dying. End-of-life care is a great American tragedy. Neither the medical profession nor the general public has come to grips with death and dying.

Now for the consolation prize. I believe the most important cardiology study in 2013 involved atrial fibrillation. Here is an excerpt from my Medscape/Cardiology post:

#5. In Electrophysiology, Treat the Underlying Cause of AF

There are a few landmark studies I keep around the exam room for show-and-tell. 2013 brought another keeper. Dr. Prashanthan Sanders and colleagues (from Adelaide, Australia) are authors of the most significant study in all of cardiology in 2013. (Here is the link to the study– JAMA)

Here is the story: Atrial fibrillation is increasing exponentially. Electrophysiologists see patients at the end of the disease spectrum. Rate control, rhythm control, and anticoagulation are each important treatment strategies, but they don’t address the root cause of AF. In previous work in animal models, this group of researchers showed that obesity increases the susceptibility to AF.

The hypothesis was that weight loss (and aggressive attention to other cardiometabolic risk factors) would reduce AF burden. They randomly assigned patients on their waiting list for AF ablation to 2 groups: (1) a physician-led aggressive program that targeted primarily weight loss, but also hypertension, sleep apnea, glucose control, and alcohol reduction; or (2) standard care with lifestyle counseling.

The findings were striking. Compared with the group of patients receiving standard care, patients in the physician-directed program lost weight, reported less AF symptoms, and had fewer AF episodes recorded. Most impressive were the structural effects noted on echocardiograms. Patients in the intervention group had regression of left ventricular hypertrophy and reduction in left atrial size.

Though this is a small trial, it is practice-changing for cardiology. It shows that treating modifiable risk factors remodels the heart and in so doing reduces the burden of AF. In an interview in JAMA, Dr. Sanders says aggressive risk factor treatment should be a standard of care. I agree. Right now, AF ablation is too often thought of in terms of a supraventricular tachycardia ablation — a fix for a fluke of nature. It’s not that way. In the majority of AF cases, the same excesses that cause atherosclerosis also cause AF. Rather than make 50 burns in the atria, it makes much more sense to address the root cause.

JMM