A Visit To The Electrophysiologist

I have been waiting for today’s appointment since January 19^th of this year. At that time I saw a cardiologist who recommended that I see an electrophysiologist for atrial fibrillation.  I have had paroxysmal atrial fibrillation - just a few episodes per year for 10 years.  It didn't start out that way.  I was having frequent episodes until the dose of the antiarrhythmic was adjusted.   It all began while I was speedskating one night and my heart rate monitor began chirping uncontrollably.  Since then I have been seen by 4 cardiologists and 4 electrophysiologists.  The first one suggested that I hold off on any ablation procedures until “the technology improves”.  I was back to seeing that doctor today.  The first time I saw him he impressed my with detailed drawings and notes about atrial fibrillation and the time he took to explain it all.  He wrote out all of the details of CHADS-VASc Score for atrial fibrillation stroke risk and tried to convince me to start anticoagulation.  I was not impressed with the addition of one point to the score just based on age so I deferred. I did start apixaban 3 months ago when I realized the systems of medical care was fragmented and if for some reason I did not come out of one of these episodes in a reasonable period of time I might run out of luck and end up with a stroke. This time the visit was a bit different – it went something like this (not a transcript):

EP:  “We have seen each other before – what brings you back?”

Me:  “A few things – the cardiologist I saw in January recommended it, I have some concerns about the Holter results, can I expect a better result from medication changes, and to get your opinion about ablation.”

EP: “How often do you have episodes?

Me:  “This year so far I have had three – one for 2 hours, and 2 for 1 hour each in February, July, and August.  Triggers may be anxiety and nightmares. Exercise is not a trigger acutely but I did have an episode the next day after I increased my pushups from 100/day to 150/day.

EP:  “That is actually pretty good considering you are 10 years out.  We generally see this as a progressive process….

Me:  “ I have been having 2-3 episodes per year for the past 10 years.”

EP:  “Even so there may be progression there.”

Me:  “What about the Holter result?  I noticed there was a brief episode of trigeminy. When this all started I had a much longer episode of bigeminy and was advised it was a benign rhythm.  Is there a ventricular component?  Does something need to be done about that?

EP:  “No this is atrial bigeminy/trigeminy and you are right it is a benign rhythm.  Your Holter shows less than 1% isolated PACs and VPCs so there is nothing to be concerned about there and I don’t think changing any medication would be useful.”

Me:  “My primary care doc called one of your colleagues about increasing the flecainide to 200 mg/day and he said the arrhythmia risk increased at the higher dose.” 

EP:  “I just don’t think it will do much in terms of eliminating 3 episodes per year.  Are you using CPAP?”

Me:  “I don’t sleep without it – my AHI is typically less than 1.  I also my check BP twice a day in triplicate and the systolic is typically in the 100-110 range.  It always seems elevated when I come here.”

EP:  “Everybody’s BP is higher here. Do you drink alcohol?”

Me:  “No.  I had a question about NSAIDS.  I have gout but have not had an attack in a long time. I know what the package insert says about NSAIDs and apixaban – can I safely use them for a few days?”

EP:  “Well I can’t tell you it is OK to use them because it is listed as a contraindication – but you would probably be OK for a couple of days.” 

Me:  “What about an ablation?  The last time you and I talked you advised me to hold off because the technology was improving at the time. Has it improved to the point it is safer?”

EP:  “It improves every year.”  [ draws a diagram of rate versus rhythm control and on the rhythm control arm antiarrhythmics versus ablation].  About 70% of people respond to ablation but in 33% of those patients it requires multiple procedures.  There is a 5% complication rate across all procedures and that includes damage to the esophagus or phrenic nerve but we monitor to prevent that. [Another diagram to show proximity of esophagus and phrenic nerve to the structures to be ablated].   There is also a risk of stroke but you are anticoagulated during the procedure to prevent this.  It is done under general anesthesia. It takes about 3 hours.  At the end of that time, you spend 2 hours in recovery to monitor the catheter sites and if you are OK – you can go home.”

Me:  “I have also had two episodes where the afib converted to atrial flutter at a rate of 130 – I understand that takes a right sided procedure in addition to the pulmonary vein isolation on the left?”

EP:  “They can both be done at the same time [demonstrates lesion and current pathway on his drawing].”

Me:  “I have seen photographs of the radiofrequency ablations and they appear to be full thickness burns….”

EP:  “We use a cryo procedure for the pulmonary vein isolation.  Any other questions?”

Me:  “On the Eliquis – my initial concern with it was ’nuisance bleeding’ described in the package insert but I noticed that I am bleeding a lot less than with aspirin.  Is that common.”

EP: “Yes.”

Me:  “Well at this point – I guess it’s up to me to decide on the ablation.  Let me think about it and get back to you.”

EP:  “OK here is my direct number.  Either way let’s get back together in about 6 months.”

That was the approximate content of the encounter. I am used to memorizing these details and summarizing them from long and detailed discussion in a psychiatric context.  I also compared the process with the first time I met this physician.  We were both wearing masks and this was significant and of course he worked through the entire pandemic and I bailed out after the first 18 months.  Both of those factors seemed significant.  The first time I saw him I was probably wearing my white hospital coat because I worked in the same hospital and would never take time off for an appointment in the building.  This time, he either forgot I was a physician or possibly had the view that psychiatrists don’t know much about medicine. At any rate the interview seemed pressured and he was running 30 minutes late.  I had advised his nurse that I thought I had dysgeusia (altered taste) from the apixaban.  That was not passed on and I forgot to ask about it again. I also wanted to ask about exercise and resuming speedskating now that I am retired but I also forgot to ask that question. But every cardiologist I have asked that question to in the past 16 years says the same thing: “Exercise as much and ask vigorously as you want to.”  I have come to realize that is not necessarily the best advice.

The overriding goals never seem to make it into medical appointments.  There always seem to be the assumption that you address a medical problem separate from your overall life.  For example, my goal is to live as long as possible and be as active as possible.  Never touched on.  With any cardiology problem there is also the issue of cardiac neurosis – will I at some point consider myself disabled from cardiac symptoms when I am not? Is it possible to do something that will make my symptoms worse? It helps to have a clear answer to that problem.  The closest I ever get is the exercise advice (that I question) – although today it seems that the episode frequency is minor and stable and the Holter results are nothing to be concerned about.

There was potentially some controversy in the appointment that I could have brought up.  The progression of atrial fibrillation irrespective of frequency seemed new and may not have been consistent with a recent New England Journal of Medicine review.  In that review it seemed like paroxysmal atrial fibrillation was a stable phenotype compared with persistent atrial fibrillation.  On the other hand remodeling at the molecular level potentially occurs every time there is an episode and for that reason my goal is to do everything possible to minimize them.

Was there another reason to post this?  There are a couple of reasons that I use my own medical experiences for didactic purposes.  The first is to illustrate the uncertainty in all medical diagnosis and treatment. Psychiatry is constantly (and erroneously) criticized for not having a discoverable lesion or testable abnormality as a cause of most non-medical psychiatric disorders. In this case, I am talking about two conditions (atrial fibrillation and atrial flutter) that seem to have a clear medical cause or do they? There are several pathways (genetics, heart disease, excessive exercise) leading to atrial fibrillation.  What is the true etiology in my case? The excessive exercise is largely based on preclinical studies in animals and observing a higher incidence of atrial fibrillation in endurance athletes. If I opt for an ablation – the first part of that will be an electrophysiology study to detect the conduction problems to be ablated. It is not a specific treatment for a lesion – it isolates the lesion or interrupts the circuit pathway.  The medication is similarly non-specific.  As the electrophysiologist said today: “Of course the medication will not cure anything. I can’t say whether the ablation will work. We can’t be certain of anything.”  Just a few weeks ago I saw a debate saying the psychiatric medications don’t “cure” anything. Cardiology and the rest of medicine seems to be in the same boat.

The other reason to use my own data is that I don't have to worry about consent and I don't have to disguise anything - although I have deidentified the ECG with respect to the physician and hospital. 

Death was not discussed as a possible outcome and I know that it happens.  Within the past few years there was a case posted in the NEJM that showed airlock in the ventricles based on and injured esophagus and air entering the heart from that pathway. There was also a celebrity who died following an ablation for atrial fibrillation.  Like most procedures, people who do them a lot are probably more successful, but there are never any guarantees.  Henry Marsh the British neurosurgeon has written about his complications and states that even in procedures where everything seems to go right there can be a bad outcome. Over the course of my lifetime I have experienced good and problematic surgical outcomes. It is a far cry from a coin toss - but they happen.

The phenomenology of the episodes was basically irrelevant today. I have them correlated with nightmares, anxiety, and other stimuli leading to increased adrenergic input.  None of the seemed relevant.  There was no discussion of sleep or how to get rid of the nightmares. Most people may have the expectation that cardiologists don’t cover this area.  Psychiatrists do and that’s why I am trying to figure that part out myself. On the other hand – I spend a lot of time talking with people about their cardiac symptoms and often tell them to call their physician immediately at the end of my session.

The nurse who got me into the room was very pleasant and professional. She went out of her way to make me feel comfortable. Her efforts were appreciated.  She was also charged with getting an ECG done before I saw the electrophysiologist.  She did this expertly and then offered me a copy of the ECG.  The electrophysiologist gave me an additional copy!  I posted a copy here (it is unremarkable) but I will add that if this had happened in a primary care clinic within the same healthcare organization – it would have elicited eye rolls, the statement: “Let me ask my supervisor if I can do that.”, followed by a rejection of that request. Again this is all the same healthcare organization presumably schooling each clinic differently in the nuances of HIPAA.  There should be no reason why you can’t walk out of the clinic with test results and I appreciate the efforts of the Cardiology Clinic.

That is where things stand today. I am playing it by ear and tracking my blood pressure, heart rate and rhythm, sleep apnea, nightmares, anxiety level, neurosis, headaches, and long COVID symptoms. I have decisions to make and will probably get a second opinion on the ablation issue as well as where to have it done.  Should it be at my local health care organization or at a larger referral center where they do a lot more of them?

But that is another story….

 

George Dawson, MD, DFAPA

References:

1:  Michaud GF, Stevenson WG. Atrial Fibrillation. N Engl J Med. 2021 Jan 28;384(4):353-361. doi: 10.1056/NEJMcp2023658. PMID: 33503344.

2:  Thomson M, El Sakr F. Gas in the Left Atrium and Ventricle. N Engl J Med. 2017 Feb 16;376(7):683. doi: 10.1056/NEJMicm1604787. PMID: 28199804.

   

How To Ruin Your Life Without Being Dangerous

Changes in Personality and Decision-Making

The above table is really all that you need to know. You don't need to know anything about psychiatric diagnoses. You don't need to know anything about medications. That is typically how the problem is approached these days. What could have gone wrong? What kind of mental illness could account for what happened to this person? Let's get a panel of experts together, put them all on TV and have them speculate about what type of mental illness the person might have. I have never observed this to be a useful exercise. How could it be? There are just too many conflicts of interest and too much entertainment bias for anything of value to occur. The diagram is meant to illustrate the basic transitions associated with many mental illnesses and how the problems occur. It appears to be very simple and it is even more simple than depicted.

The top two zones - both Dangerousness and Altered State of Consciousness can be combined because Dangerousness has no medical or psychiatric meaning.  It is a legal and/or managed care definition.  From the legal side of things it determines grounds for civil commitment, guardianships and conservatorships. More importantly it determines when courts can dismiss these cases and not spend money on the people brought to their attention.  In the case of managed care companies, they view dangerousness as the only reason that somebody needs to be in a psychiatric hospital.  The diagram illustrates why they are wrong.  Rather than considering this process to be tabular a Venn diagram might be a better way to view things.  I constructed this one looking at some relative contributions of these conscious states.  Keep in mind that the dangerous conscious state here is an artificial legal and insurance company construct and that all of the demarcations here are permeable to indicate that transitions between states commonly occur.  A porous line might be better but I am limited by my software.  The diagram also illustrates that in these transition zones the difference between an altered and even dangerous state may be practically indistinguishable from the baseline state.

The simple 3 row table also describes what families have observed happening since ancient times.  It has only recently been modified to include the role of physicians, medications, insurance companies and local governments.   What do I mean about family observations?  Within the timeline of any family, the generations observe their members starting out as a vigorous young people and going through the expected developmental stages of adulthood.  The trajectory is predictable with some notable exceptions.  Some family members will get sick and die unexpectedly.  Some may get sick or injured and become disabled.  That is as true today as it was a hundred years ago.  It is also the case that the disabilities can be mental problems as well as physical health problems.  They can be something that you are born with or something that you acquire along the way.  Most families have stories about members who experienced some kind of transitional event and they were never the same afterwards.  That transitional event could have been a serious illness, an accident,  an episode of psychological trauma, exposure to combat,  excessive exposure to street drugs or alcohol, changes in interpersonal relationships, or losses of significant people in their life.  There is a consensus in the family.  They all see the person as changed.  That change is sometimes positive, but typically the person seems less well and less capable of handling life's everyday stressors.  The diagram attempts to illustrate what families observe in terms of personality characteristics and decision-making.

In the diagram, the diagnosis is really not the most important consideration.  All diagnoses and all problems for that matter are mediated by a conscious state.  All human beings have a unique conscious state that starts in the morning when we wake up and our feet hit the floor.  We have a stream of ideas and thoughts that occur in familiar ways every day and our behavior patterns and personalities are fairly predictable to our friends and family.   There are very limited discussions of conscious state in any discussion about psychiatric diagnosis or the ways that diagnosis impacts on a person's ability to function.  A further complicating factor is that most of the considerations about problems functioning suggest that there is a linear relationship between the mental illness and the inability to function.  For example, in the case of schizophrenia the diagnostic criteria may be met, but at some point a determination of the person's insight and judgment is made.  Problematic behavior is often taken as proof of a lack of insight.  Anosognosia or a form of neglect has been cited as one of the reasons for impaired insight in schizophrenia.  The actual sequence of events looks something like this:

Baseline -> Symptoms of schizophrenia ->  Diagnosis of schizophrenia ->  Problematic behavior

The real sequence of what happens is far from that linear.  Problems are often noted over a number of years.  Drug use and other behavior problems are often theories that families have before there are more clear cut symptoms allowing the diagnosis.  The concepts of pre-clinical, sub-clinical, and latent syndromes are described by some researchers.  But the main point I am trying to make here is that the pathway is not linear and there are associated changes in the person's conscious state.  There is rarely a sequential pathway to a significant mental illness.  There are starts and stops and often misdiagnosis along the way.  People can pass back and forth between an altered state of consciousness and their baseline mental status for a long time before any psychiatric diagnosis is declared.  

Psychotic depression is often a difficult illness to diagnose and treat.  Consider another common scenario.  An elderly woman walks into her kitchen and discovers her husband pointing a shotgun at himself.   She convinces him to put the gun down and go to see their doctor.  She is completely shocked about the suicidal behavior and did not see it coming.  They have been married for 40 years.   Her husband had no prior history of suicidal behavior or depression.  As they talk with his primary care physician, she corroborates that he seemed to have been sleeping well, but seemed less spontaneous and "happy".  She was shocked to find out that he had lost about 15 pounds.  He is sent to a local hospital where he talks with a psychiatrist and at one point says: "I just could not go on living anymore."  Further questioning leads to a discussion of an event that occurred when he was in high school (over 65 years ago) that he was guilty and embarrassed about.  His worries about the event continued to build until he got to the point that he saw suicide as his only means of relief.  He was too embarrassed to discuss it with his wife.  He had the original suicidal thought over 6 months ago and he observed it "come and go" over time.   This is a good illustration of how delusional guilt can be associated with transitions between baseline and then within the altered states model to one that is potentially dangerous.  It also illustrates how the individual life experience of the person is relevant. 

Manic and hypomanic patients often have transitions in their mood state.  Families members will call and say that the person needs to be in the hospital because they are keeping the whole family up all night and there have been some dangerous confrontations as a result of the sleep deprivation.  The patient can present very calmly and declare that the only problem is their family.  They may not acknowledge that they are spending money excessively, driving recklessly and starting to drink a lot.  Since they do not believe that there are any problems they will refuse crisis care, sleep hygiene advice or medication changes.  They are incapable of recognizing a change in their conscious state that puts their marriage, finances, and health at risk.  With many people this can be a self limited change, but in others it can lead to mania and psychosis or severe depression.  At the critical point where the altered conscious state could be treated, they are unable to process that information and make a decision in their best interest.  They may come back later and tell the psychiatrist who was trying to make an acute assessment that they were really out of it at the time but during the acute episode they were not able to see this reality.

Altered conscious states also occur in outpatient settings.  It is not uncommon to talk with professionals who need a specific medication that is prohibited by their licensing or regulatory body.  These are typically professions that regulators decide can inflict a significant amount of damage if they are compromised in some way by prescription or illicit drugs.  In the case of a person concerned about losing that profession, not reporting the medication or not taking it can happen.  That can occur as both a direct attempt to mislead regulators or as a result of impaired decision making from a substance use or mental disorder.

From what I have seen about the way that mental illness and substance use can alter conscious states, figuring out how to recover baseline conscious state is far from clear.  The first issue is that there is no real focus on the problem.  Psychiatric hospitalizations depend on a handful of yes-no questions about suicide and in some cases homicide.  I was recently told that a psychiatric hospital said that their admission criteria was: "You have to be suicidal and we have to be able to discharge you in less than a week."  That statement is so far from the reality of how mental disorders need to be treated it is stunning.  That statement shows a lack of regard for quality assessment and treatment.   There is no apparent interest in restoring a person to their baseline or even finding out what that baseline was.  On the other hand, I have had active discussions with psychiatrists who were interested and actively talked about these things to their patients each day.  If you are such a psychiatrist, patients will often say that in retrospect their very interested and compulsive psychiatrist missed the fact that they had significant suicidal thinking or that their were probably psychotic in a previous interview.  

The life ruining events discussed in this post and the possible mechanism illustrate that our lives are a complicated web of social interaction.  We make decisions based on that web every day and all day long.  Going into a hospital and being discharged based on whether or not the suicide question is endorsed or whether or not you are aggressive is a very low standard of social behavior and ability to function.  It takes a lot more than that to stay married, stay on the job and perform it safely, stay in the role of spouse and parent, and stay in a stable living situation.  Those are the real goals of assessment and treatment when it comes to recovery rather than ruin. The necessary decision making is linked to a conscious state that may be in a state of flux during an acute episode mental illness.

It is important to recover and recover completely.  Being familiar with baseline conscious state rather than a list of symptoms as being a good measure for this seems like a reasonable approach.  


George Dawson, MD, DFAPA