August 6, 2007

How Do You Treat Atrial Fibrillation?

It could be important...

Say you have a patient with a history of two heart attacks.  That's bad.  Now say he has atrial fibrillation.  That's worse.   Now let's say he is on no meds.

What do you do?  You'll treat two distinct problems: the history of ischemic heart disease gets a beta blocker, which has been shown to reduce mortality and improve quality of life.  A-fib gets amiodarone, the generally accepted treatment.   

Atrial fibrillation is a very fast but erratic twitching of the atrium.  While a-fib can be annoying-- palpitations, anxiety, etc-- it is a major cause of embolic stroke; the uncoordinated flapping of the atrium leads first to blood stasis in a less moving part, then flicking off of clots which happily go to your brain.  Hence, anticoagulants are common.

Beyond this, treatment of a-fib can be divided in two parts: rate control, with beta blockers, or rhythm control, with drugs like amiodarone.  The question is, which is better, and which is safer?  Traditionally, amiodarone was thought to be more efficacious.

Before I give you the answer, I want you to be aware of the form of the question. The question requires that you see a-fib as a distinct (disease) state, where risks and benefits of its treatment are considered.  It is, analogously, "what are we going to do about John's left arm?  It's a big jerk, always punching people.  Is what we do going to work?  Is it worth it?"

A study in the NEJM pitted sotalol, a beta blocker, against amiodarone for the effiacy and maintenance of a-fib.

What they found was, as expected, amiodarone was the best:


(The curves are read as "what are the chances you remain symptom free at x days?"  People are all symptom free on day 1, so the chances are 100%.  As time goes on, you get sicker.  So at day 600, you have a 10% chance of being symptom free on placebo, but a 70% chance on amiodarone. )

What was surprising is what's best if the patient has ischemic heart disease along with a-fib: 



If you have ischemic heart disease, sotalol was as good as amiodarone.  And, presumably, a beta blocker is less toxic than amiodarone (though the study did not show this.)

But there's a further point to be made here, about information bias.  Since beta blockers are already standard of care for any patient with ischemic heart disease, it doesn't actually matter whether they have chronic a-fib or not.    The history of ischemic heart disease is more important-- singularly more important-- than the a-fib.

So the guy above only gets a beta blocker.   Think about this. 

Whether he had "regular" ischemic heart disease, or ischemic disease and atrial fibrillation, the treatment is the same, single, drug. 

This is entirely the opposite of what happens in psychiatry.  In psychiatry, we pay lip service to a "disease state," but end up treating each disorder as if it was separate.  So a schizophrenic with negative symptoms (apathy, anhedonia, amotivation) gets an antipsychotic and an antidepressant, even though the antidepressant probably isn't necessary.  It may seem like both are necessary, but that's because you gave them both at the same time.  How can you know which was relevant med?  Bipolar is worse: a "mood stabilizer" and an antipsychotic and an antidepressant (or Lamictal)  each for a different symptom.  The nod to "disease state" however, is the dangerous one: all the meds are continued, even though each was started for a specific symptom that resolved.

And, this does not even begin to account for the overlapping pharmacology of many of the meds (like giving two antipsychotics for different "symptoms." )

In psychiatry, the incidental gets as much attention as the substantial.  But it is so hard for people to step outside themselves and say no to medication overkill.

This impulse towards polypharmacy- shotgun symptom management-- will never change unless there is a financial incentive, or, more accurately, negative reinforcement.  And I have one: give doctors a medication budget per day per person. 


Funny you should reference ... (Below threshold)

August 10, 2007 1:07 PM | Posted by Herb: | Reply

Funny you should reference “The Last Psychiatrist” recent posting. I commented and for whatever reason my post hasn’t made it to the board. What in particular caught my attention was his final statement to which I replied:

Dear Doc,

I had sent you a previous comment relating to this recent posting. Maybe it simply got lost in the ether of the Internet in front of or behind the credit person spammer.

Anyway, thanks for the information and even as a lay-person I understand your message.

But once again I’ll have to take exception to what I think is a convoluted resolution to correcting a problem.

“This impulse towards polypharmacy- shotgun symptom management-- will never change unless there is a financial incentive, or, more accurately, negative reinforcement. And I have one: give doctors a medication budget per day per person.” --- The Last Psychiatrist.

Why not simply better educate your colleagues and newer psych medicos?


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"Bipolar is worse: a "mo... (Below threshold)

August 10, 2007 7:00 PM | Posted by Stephany: | Reply

"Bipolar is worse: a "mood stabilizer" and an antipsychotic and an antidepressant (or Lamictal)"...being that we know Lamictal has antidepressant qualities, then should a patient increase the dose of Lamictal when depression increases, or for example, use a standard depressant, such as wine, or rum so it evens out in the end, and by the way is this the existentialist article?

Alone's response: You can increase Lamictal if depressed, sure, but what do you do after you're no longer depressed? Leave it on, under the assumption that depression is bubbling under the surface and you have to suppress it, or take it away, under the assumption that it's a state-dependent, flu-like problem, that comes and goes-- Tylenol when in pain, but no Tylenol when not in pain?

No, not the existentialist article yet. I'm getting there.

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alone said... Herb... (Below threshold)

August 11, 2007 11:25 AM | Posted by Herb: | Reply

alone said...

Herb-- sorry about your comment, it's not me, it's my insane overaggressive spam filter that I can't seem to get reined in.

"Educate my colleagues." Seriously? Have you seen my "colleagues?"

Also, in reference to Wyeth's abilify clone-- while it is, indeed, likely useless, Wyeth's future actually rests on its Alzheimer's drug. I don't own Wyeth (yet) but 46 for that potential blockbuster is an appealing price. It actually doesn't matter if it will work or not: if it gets approved, they will try it. And in a market with few alternatives-- Namenda and Aricept, and that's pretty much it-- it will be gigantic. Please note: for the purposes of Wyeth's stock price, it doesn't matter if it works or not. It will still get used.

Herb-- that's why educating my colleagues is impossible. At best, we can educate patients to keep their psychiatrists in line.

Friday, August 10, 2007 3:19:00 PM

Herb said...

The Last Psychiatrist,

"Educate my colleagues." Seriously? Have you seen my "colleagues?" --- The Last Psychiatrist

After 44 years as a support person to my spouse with numerous doctor appointments and a cadre of attending physicians as well as being a former facilitator for DBSA I am very familiar both hands on and indirectly with some of your medical colleagues and associates.

As a side-note to this commentary is a quick story of one of your fellow colleagues highly recommended to us when we were searching early on for a psychiatrist to tend to Joyce’s VNS Therapy. Joyce sat in this one physician’s office filling out his psych questionnaires for about ¾ of an hour. When we finally sat down with the good doctor I interviewed and questioned him whether he knew the company and/or anything about the VNS Therapy and I explained I was looking to have someone attend to Joyce and I would make arrangement to have the attending physician trained.

He replied he didn’t know the company. He vaguely heard about the therapy. He “was not interested in learning something new.” At which time, I said to Joyce, “Come on, let’s go.” That was the shortest meeting we’ve ever had with any medical professional. It was under 3 minutes. When I got to the car I told Joyce I appreciated the fact that he was forthright and upfront and didn’t waste our time but I also said that in a million years I would never recommend that individual to attend to anyone I knew. As a Psychiatrist one would have thought he might have enough intelligence and decorum to have at the very least explained he was swamped etc, etc and might look into the therapy later on.

Yup, I have had experience with some of those “colleagues” but as I often state, “There are doctors, good doctors and better doctors” and certainly it is incumbent upon the patient and/or their support people to ferret out the “better doctors” or at the least the “good doctors.” Joyce and I have been fortunate that in recent years we have, in my opinion, been associated with some of the better and caring doctors which may very well be a reason for her wellness currently.

This is not to preclude what I’ve stated previously and for my having to disagree with your thoughts and part of your additional statement.

“Herb-- that's why educating my colleagues is impossible. At best, we can educate patients to keep their psychiatrists in line.” --- The Last Psychiatrist

I have always advocated for educating the patient and/or his/her support persons while encouraging hope and persistence so we are much in agreement on that point. I am un-accepting of the word “impossible” as my spouse would never have achieved the reasonable success she has and at very least as it relates to this subject matter.

Then it is incumbent upon folks like you, CL PSYCH and others to change and better the system through education of your peers and own kind.

You also took the easy way out when you stated you’re against “Parity.” What you are missing is that patients like my spouse and others have no easy way out and we’re forced to struggle against difficult odds and if folks like you who work and earn a living from the system simply throw up their hands and surrender then while your sharing is interesting and informative you’re really no different than those you write about.

I’m sorry I may be harsh in my commentary but as I’ve stated early on, my wife and I have been battling a long time for her mental wellness and that of others and we’re not ready yet to give in or give up on our causes (i.e. VNS Therapy). I’ll presume there are others like you who still remain somewhat idealistic who can make a better effort to educate and challenge the system (colleagues).

I thank you for this opportunity to share my thoughts while not in agreement with all that you share.


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I was just saying last week... (Below threshold)

August 12, 2007 11:44 AM | Posted by TheShrink: | Reply

I was just saying last week how here in the UK we do much the opposite, thankfully!

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You are right. Depression i... (Below threshold)

August 18, 2007 11:37 PM | Posted by Stephany: | Reply

You are right. Depression is state-dependent symptom that comes and goes, as pain does and therefore does not need psychiatric medication adjustments.

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This isn't about how medici... (Below threshold)

October 19, 2007 11:38 AM | Posted by Nate: | Reply

This isn't about how medicine is smart and psychiatry is stupid.

Look at what we can do with afib. We get a patient that says, "I feel all funny in my chest, and I passed out and fell today." We hook them up to a bunch of wires, and see their heart rhythm. We start them on some drip, and watch their heart rate come down, watch their rhythm change. If its a beta blocker, we can raise the dosage, and watch their heart rate go down even further, too low, then reduce the dosage a bit and watch it reach an acceptable range. We have a good physiological explanation of their symptoms that we can test, and we can treat it, physiologically.

So compare to psych. Where are the wires? Where do we watch the drugs working? Where is the well-accepted physiologic explanation for something as well studied as schizophrenia-- nevermind PD, NOS! And how fast do the drugs work? Not in minutes, unless you're looking at drugs that would make anything approaching normal life impossible. How do you even objectively tell if they work? How do you quantify affect? "Please rate, on a scale from 0 to 10, how human you feel." I'm sure it's been asked in good faith.

So symptoms are treated. Everyone does their best to generalize, to figure out something that'll work for this person, that person. Mr X reminds me of somebody that had a really good response to SSRIs, but he needs something to keep him out of jail for the next three weeks. Who knows? Let's try this out, see what happens. It's bound to be better than nothing.

Ok, I follow you; you're saying, essentially, what's wrong with intuition based on clinical experience? Leaving aside a rigorous evaluation of the accuracy of clinical experience, I'm certainly all for experimenting and intuition. What I am against, and what is happening, is calling this science. In the absence of pharmacology, or even efficacy trials, psychiatrists can't say that this or that treatment is standard of care. But worse than this, is when there is science that directly contradicts a belief (e.g. low dose seroquel is a low dose antipsychotic) but "scientists" refuse to acknowledge it.

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