Electrophysiology 2nd opinion – implications for medical and psychiatric practice

 

Pandemic related inaccessibility prevented me from getting timely Cardiology appointments this year.  As a result, I ended up with my scheduled consultation and a second opinion consultation spaced just two weeks apart.  I talked with a 2nd electrophysiologist today. He had records about me dating back to 2009. I had consulted with a cardiologist who was an exercise physiologist and another electrophysiologist at that clinic. After reviewing the recent history of paroxysmal atrial fibrillation again we had a very interesting conversation.

He reviewed the issues of rate versus rhythm control again. The priority is reducing stroke risk and that is done by anticoagulation. When it comes down to trying to maintain a normal sinus rhythm and all the measures that involves the decision is based on "How much does the arrhythmia bother you". He gave many examples that I was familiar with including the person who is not aware of being in atrial fibrillation until you tell them. I have made the diagnosis many times by taking vital signs on people and noticing their irregularly irregular pulse and pulse deficit. Most of the time they have no awareness of the arrhythmia. In some cases, they have been advised of the arrhythmia but decided not to do anything about it. I am in the category of people with what I like to call "cardiac awareness". I know immediately if I am in atrial fibrillation or even having palpitations. I check my own vital signs 3 times a day-in triplicate. We had a discussion of my neurotic tendencies and how much this rhythm problem bothers me – even if I am in atrial fibrillation only a few times a year for a brief period.

This point is also critical when it comes to treating psychiatric conditions. A misrepresentation of medical and psychiatric treatment is that physicians are drumming up business and manipulating populations into unnecessary care. Either that - or the care is just automatic and dependent on a diagnosis or blood test.   One of the favorite fabrications is that the DSM is designed expand treatment and line the pockets of both psychiatrists and pharmaceutical companies. In fact, I have not seen a patient in outpatient practice that was not there because they were distressed, bothered by their current symptoms, and unable to get help anywhere else. In my conversation today with the electrophysiologist we are contemplating a 3-hour procedure under general anesthesia with significant potential complications including bleeding, stroke, the need for pacemaker placement, and death - all based on my subjective assessment of how much this arrhythmia bothers me. Based on level of risk – there are no equivalent decisions in psychiatry.

To reinforce that point, he said that cardiologists have been trying to show that rhythm control is superior to rate control for about 40 years and the evidence was very thin and possible non-existent. Based on the discussion of stroke prevention, that assumes that anticoagulation reduces stroke risk on the atrial fibrillation group to the same level as the normal sinus rhythm or rhythm group. I would give the edge to the rhythm control group on that parameter.  In terms of lifestyle measures rhythm control would potentially eliminate other nuisance rhythms like bigeminy and trigeminy if the origin was in the pulmonary veins.  Additional mapping occurs during the procedure to see if there is another focus for these rhythms.  The atrial flutter would need to be eliminated in a procedure on the right side of the heart. A concern that we did not discuss is a sudden worsening of the atrial fibrillation or atrial flutter to the point that a different antiarrhythmic would need to be used.  I have seen amiodarone added at that point and there are many complications with that medication – including death from pulmonary complications.

We got into a discussion about phenotypes based on the recent New England Journal of Medicine review. The focal point was whether a paroxysmal atrial fibrillation pattern like mine was easier to covert by an ablation procedure and remain in a normal sinus rhythm and remain in that rhythm.  He was aware of the review, but thought that not enough is currently known about phenotypes.  That seem to be a problem with a lot or intermediate or endophenotypes that are used in psychiatry and other fields like asthma or multiple sclerosis.  On the surface there appear to be a lot of easily described apparent subgroups, but the natural history of those groups and the underlying pathophysiology is essentially unknown and considerable heterogeneity in severity, course, and outcomes remains.   

There was a brief discussion of the athlete’s heart.  He had no reason to doubt that the slightly enlarged left atrium and aortic root on my echocardiogram was due to decades of intense athletic activity and knew that was also one of many potential factors leading to atrial fibrillation.

The question of early rather than late ablation was discussed and the idea that there is progressive remodeling in the heart due to atrial fibrillation even in the case of a few episodes per year. He thought that in general, ablation prior to persistent atrial fibrillation resulted in better outcomes and earlier ablation was better than late ablation.  He emphasized that these were across group comparisons and there was a heterogeneity factor at work.  All the ablation that he does is radiofrequency ablation and the result is anywhere from 75-90% effective depending on how well the pulmonary vein isolation goes.  That is balances against a 2-3% risk of adverse effects – largely in the form of bleeding and hematoma formation at the catheter sites.  Chest pain and migraine headaches are also common post procedure.  Very serious complications during the procedure including death and the need for pacemaker placement were at about 1%.  The only death he had seen during the procedure was unrelated to the ablation.

He had a different opinion about the dose of flecainide and moving on to other antiarrhythmics like sotalol.  He thought I could take twice as much flecainide as a standard trial dose 150 mg BID), but agreed that it might not make much difference in the low frequency of atrial fibrillation.  That is quite a difference in flecainide dosing compared to the other group of cardiologists that I consult with.

In terms of recovery time give my current workout schedule he thought it would take a month to get back up to speed.  At that point I could resume my usual activities. If I decided to do that soon it would mean putting speedskating on hold for another winter.

That is where I am at after the second opinion.  Assuming that my insurance is the same across facilities – I have two to choose from and two electrophysiologists willing to try the ablation. My choice is to weigh a moderately successful procedure against the low frequency but significant complications and make the decision. And I know at this point it is an elective procedure based on how disruptive this arrhythmia is to my life. It is possible that at some point due to worsening atrial fibrillation and/or flutter and associated worsening symptoms or cardiac function that it would be less elective.

In terms of comparison with psychiatric practice and the usual critiques – these are the same choices that people would have if they were seeing me in clinic with a few exceptions. I am not treating anyone with invasive procedures or general anesthesia.  The medications prescribed by psychiatrists are generally safer that antiarrhythmics. There is a long list of absurd complaints made by antipsychiatrists that could similarly be applied to this cardiology scenario. But most importantly – in either case the treatment decision by the patient is subjectively based on how much the symptom is bothering them. I do not know how to translate 4 hours of symptoms per year into what I have been told about daily anxiety and depression symptoms every week. Some of those symptoms are also cardiac in origin.  

But I think this highlights a completely neglected dimension of medical and psychiatric practice.  Treatment is based on more than a rational informed consent discussion and weighing the risks and benefits. It is based on more than a scientific diagnosis and confirmatory tests.

It is highly subjective and based on the personal experience of the patient that is rarely know to casual observers.

 

George Dawson, MD, DFAPA

 

 Supplementary:

I thought I would add some additional observations about my recent cardiology consults and how they compare with psychiatric practice. Putting these in the main body of the post would have increased the reading difficulty.

Categorial diagnosis versus something else:  It is fashionable these days to say that medically diagnosed syndromes are a thing of the past and we should be making dimensional diagnoses or systems diagnoses.  Of course, these have been tried in the past. Contrary to a standardized approach – the diagnostic and treatment approach is highly practice dependent as can be noted by comparing the recommendations of the last 2 posts.  In addition, there is a fine structure to categories that is so detailed that it cannot be listed as criteria. Diagnostic categories in medicine have been talked about as prototypes – but it is really an indexing system for each physician to catalogue everything they know about that disease especially in the populations they are treating.

There may be objections to this conceptualization of categorial diagnosis.  Shouldn’t all clinicians be making the same diagnosis based on some sort of standardization?  That is certainly the argument many people make – but it certainly is not realistic.  Experts have seen more cases, know more variations, and have seen more diagnostic errors in the conditions they are diagnosing and treating. They have studied those conditions more thoroughly than anyone else. To suggest that a non-expert can read criteria in a diagnostic manual or administer a checklist of symptoms from that manual and get the same results is a significant misunderstanding of the process.  

Any medical category can be parsed based on severity and using that metric will lead to different assessments and treatments within the same category That is as true for cardiac arrhythmias as well as categories of depression and psychosis. A related issue on the medical side is that all the associated symptoms that might be lumped into lifestyle effects or suggest a psychiatric disorder are basically ignored if they do not show up on a PHQ-3 that is given as part of a preregistration packet.

The good news here is that subjectivity is alive and well in medicine and psychiatry as it should be.  Our biology determines unique presentations of our illnesses as well as our reaction to them.  The physicians treating us have to understand that.