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.

 

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.

   

My First Flu Shot

I got my very first flu shot on 12/3/2013.  Up until now I have depended on my coworkers being vaccinated and protecting me against the virus.  Very recently I have had Tamiflu and at the times I have used it thought that it worked very well.  I have asked repeatedly about getting the shot, including the Infectious Disease consultants who promoted the mass immunization of my fellow employees.  Over the years I have asked about 5 of them this question and they all said the same thing: "You can never take this flu vaccine."  My history was: "In 1975 I received two doses of anti-rabies duck embryo vaccine and had two episodes of anaphylaxis".  I was very interested in the new vaccine (Flucelvax) for people with egg allergies and when I asked about it, my primary care doc was initially enthusiastic, but then told me I had to be evaluated by Allergy and Immunology in order to get it.  That lead to a comprehensive evaluation that was nearly three hours long.

After the check in and doing some asthma tests, I met the Allergist.  He was about my age and the first thing I noticed was that he was gathering a history in nearly the same way I do.  It was detailed and comprehensive.  Not just the buzz words but what actually happened right down to what that duck embryo vaccine looked like in the syringe.  It was oily and it had particles in it.  Even in those days I was skeptical of the idea that all Peace Corps volunteers going into a specific country needed to take it.  There were about 50 of us and in the two years of service, I don't recall hearing that anyone was bitten by an animal.  The first time I got it, I broke out in hives and had a rash.  My friends took me down to a local Kenyan hospital where they gave me Polaramine (dexchlorpheniramine) and epinephrine.  When I got the second injection, I got intense abdominal cramping, hives, swelling of the face and lips, wheezing and lightheadedness.  At that  point they gave me Benadryl (diphenhydramine) and epinephrine.  Even though I can recall the antihistamine they were using in Kenya at the time, I can't recall why they gave me the second shot.   The Allergist wanted all of these details and more, like when was the first time anything like this happened.

That was 50 years ago.  The anchor point was the JFK assassination.  The day before his funeral I shot myself in the left eye with a BB gun and developed a hyphema.  I was hospitalized for a week and the hemorrhaging resolved completely.  In the follow up, I was in the ophthalmologist's office next to a fish tank.  My face started to swell of to the point that my eyes were swollen shut and my lips were extended.  I developed hives over much of my body.  I started to wheeze.  They moved me into a different room and talked with my mother who told me later that the diagnosis was "psychosomatic reaction".   Apparently the stress of not losing an eye or my vision was felt to be a more likely etiology than a moldy fish tank.  For the next 10 years or so, I start to wheeze when mowing the lawn.  I would get up in the middle of the night with hives or wheezing and drank Diet Pepsi until it went away and I could go back to sleep.  At some point one of the primary care docs in town gave me an epinephrine based inhaler.   I didn't see my first real allergist until I was about 25, after the Peace Corps and working at my first job cloning evergreen trees.

The skin testing began at that point.  96 patch tests up and down my back, all of them very positive.  I was given a long list of what to avoid and it was basically unavoidable.  I began a long series of immunotherapy injections, but gave up when they did not seem to do anything.  I remembered taking TheoDur the entire time I was in medical school and doing a rotation in Allergy and Immunology.  I gave a presentation about what was known about anaphylaxis at the time and at the end, one of the allergists seriously questioned me about why I was going into psychiatry rather than internal medicine.  During residency, I took my first course of prednisone for a flare up of asthma after a viral infection.  Since then, it has been random episodes of spontaneous anaphylaxis, corticosteroid inhalers and trying to minimize my exposure to them when possible, and using antihistamines and an Epi-Pen when the episodes of anaphylaxis seem particularly bad (that is infrequent).  The Allergist recorded this 50 year history of mostly inadequate treatment.

At the same time, I was marking where I would be in an interview with a person who had lifelong depression and anxiety.  Attempting to reconstruct the episodes of mood disorder and what the symptoms were.  Attempting to correlate it with major life events.  Attempting to determine in retrospect the exact nature of the symptoms and likely etiologies at the time.  Asking myself if the treatments received were appropriate or what it suggested.  Thinking about the resilience or vulnerabilities of the person I was talking with.  It is the same process I use in making diagnoses and treatment plans.  Were there differences?  Of course and the most noticeable were the objective measures for assessing asthma.  I did the usual assessments of FEV1.0 before and after bronchodilators.  There was also a new assessment of alveolar nitric oxide (NO) as a measure of asthma  control.  It would be extremely useful to have tests like that to objectively measure the distress, anxiety, or depression levels of the person sitting in front of me, especially if it involved something as simple as blowing into a tube.

But the most interesting part was that in the end, the Allergist addressed the question about whether I could take an egg cultured influenza vaccine by carefully synthesizing the data and correctly answering the question.  He did not need a test of any sort to answer the question.  He took a meticulous 50 year history of a guy with life-long allergies including asthma and anaphylaxis and correctly concluded that I could be given the shot, even though all of the experts with the same level of training had come to the opposite conclusion.  I got the shot, sat in the clinic for 30 minutes.  The information sheet said that delayed reactions for "up to several hours" could occur.  He told me that would not happen and I went home.  That was almost exactly 24 hours ago.

The lesson here is one that I have seen time and time again in the field of medicine.  The information content in the field is vast.  There may be only a certain physician or specialty capable of answering that question.  There is no better example than me getting a flu shot, but it also happens daily in the people I see who have had psychiatric disorders for the same length of time or less than I have been dealing with allergies and asthma.  No two people with asthma or depression are alike.  Meticulous history taking and pattern matching can get to the correct answer.  Suggestions that we can treat a population of people all in the same way will not.

People are biologically complex and as physicians we should celebrate that.  That also involves getting them to the person who can correctly answer their questions.

George Dawson, MD, DFAPA