How Atrial Fibrillation Patients Can Get the Most From Their Doctors — Video of Robert Kowal, MD, PhD, FHRS
December 16, 2013
In this video from the Get in Rhythm. Stay in Rhythm.TM Atrial Fibrillation Patient Conference, Dr. Robert Kowal talked about getting the most from your doctors, including who to see and when to see them.
Video watching time is approximately 13 minutes.
About Robert Kowal, MD, PhD, FHRS
Dr. Robert Kowal graduated from Yale University and received his MD and PhD degrees from UT Southwestern Medical Center. He completed his medical internship, residency and cardiology fellowship at Harvard Medical School/Brigham and Women’s Hospital and went on to study cardiac electrophysiology.
He currently practices at Baylor Heart and Vascular Hospital. While performing a broad spectrum of device implantation procedures, from pacemakers to multi-lead defibrillators, his main focus is the management of complex arrhythmias such as atrial fibrillation and ventricular tachycardia. His approaches involve both non-invasive medical therapy and catheter-based ablation procedures. He has been and is currently involved in research on many cutting-edge technologies including cryoballoon ablation and FIRM mapping for atrial fibrillation, left atrial appendage closure and the role of renal denervation in the treatment of arrhythmia.
He has taken a national leadership role serving on the Board of Trustees at the Heart Rhythm Society and is on the editorial board of several scientific journals.
Knowing how important this information would be to those living with atrial fibrillation, we committed to do a two-camera video shoot of the entire conference—a very expensive undertaking—in hopes that you, the afib community, will be willing to help us defray those costs through a donation (instead of us charging you for these videos, which many of you said you were willing to pay for). You can make a secure tax-deductible donation here, or click on the red Donate Now button.
Mellanie: Our next presenter is Dr. Robert Kowal. He is on staff at Baylor Heart and Vascular Hospital performing ablation procedures for atrial fibrillation and other arrhythmias. He is the VP and Medical Director of the Baylor Quality Alliance, serves on the Heart Rhythm Society Board of Trustees— that’s the professional society for electrophysiologists. He has been on D Magazine’s list of Best of Electrophysiologists in Dallas and Texas Monthly’s list of Super Doctors. Dr. Kowal will speak about getting the most from your doctors – who to see and when do you see them. And then when he finishes, I will continue with the topic of communicating with your doctors.
Dr. Kowal: Thanks. I’m looking forward to when we tag team because I think that will be the most valuable. It’s great to be here—Mellanie and I talked about this meeting about a year ago—to finally get this going, so it’s great to see us here. I want to tell one quick anecdote about Dr. Prystowsky. He’s been a great mentor to me for many years, in several ways, both directly to me, and by the fact that he trained my direct mentor, Rick Page. My first day of fellowship, when I decided to go into electrophysiology, Rick Page produced a family tree of EPs because it’s a young specialty so there are not many of us. And you can trace who’s been trained by who very easily. Eric Prystowsky trained Rick Page. Rick Page says to me and a couple other fellows in our group, “you’re the next in line”. And so three weeks later, Eric comes to give a talk. This is 1999. One of the fellows comes up and says, “Dr. Prystowsky, you’re my grandfather”, and without missing a beat, he said, “You must be the mutant gene.” Do you remember that? But I’m indebted to Eric because he’s been a great mentor, teacher, advisor, and I owe a lot of what I am today to people like him.
[2:30] What I want to do is talk a little bit about something you don’t hear as a patient, which is how to navigate through some of this system of who you see and why you see them because, often times, you’re getting treated by a doctor, but you’re not sure what the next step should be or not. Just a couple of general points I want to make, and that will lead into the discussion with Mellanie, and that is that in terms of your atrial fibrillation, often times the doctor who is taking primary responsibility—and that’s the real issue in this day and age where it’s hard to communicate between doctors and patients and figure out who’s doing what—oftentimes it depends on how it was discovered, ironically, and nothing else. If you walk in to the office, and suddenly your doctor listens to you, and an EKG is done and they find that you’re in atrial fibrillation, your primary care doctor—GP is general practitioner, FP family practice—if they’re the ones who found it, often times they’ll be the one that manages it. But if you have enough symptoms that you’ve gone to the emergency room, or it was picked up after surgery, for example, in the hospital, often then a higher level specialist, a cardiologist, or even someone like me, will be called, and then suddenly we assume that care. Again, some of this is just plain luck as to who sees you first.
[3:53] The doctor who is then taking responsibility going forward will often base whether they’re going to be involved or not based on how you feel. This came up before. “Do I have symptoms? Do I not?” [4:13] If you have minimal symptoms where you don’t know you have atrial fibrillation, which is a good number of people ironically, your primary care doctor, the general practitioner, the family practitioner, may be the person who takes over and manages your stroke risk, etc., and that’s the only person you’ll see. Then the question is, “What prompts referral?” and “What prevents referral?”
But before we do that, I want to jump back into [4:45] why it is that how you feel is so important. And again, this is a little bit of repetition from what you heard in the last few talks, but the reason you’re hearing this over and over again is because they’re important. Again, you can tell who helped trained me from the slides. Care has three components: stroke prevention, rate management, and symptom, or rhythm, management. Most primary care providers will manage stroke prevention and rate control, but not rhythm management because most of them don’t give the specialized drugs and won’t do cardioversions.
[5:25] What prompts them to move you to the next level? This has been looked at and studied. If you’re young, if you’re kind of an outlier—most people with atrial fibrillation are in there 70s’, and even 80‘s, or older—but if you’re young, you show up with atrial fibrillation at age 50, like I’m about to be, you’re an outlier, and so most people feel uncomfortable not pushing you up the chain of specialization.
[5:50] If you have a lot of other medical problems, high blood pressure, sleep apnea, diabetes, you add all these things up, and particularly if you have other heart problems, if you have coronary artery disease, if you have aortic stenosis, you’re more likely to get moved to a cardiologist or an EP to get seen.
[6:09] If your rate is very difficult to control—so, regardless of how you feel—if your rate is always in the 110’s or 120’s, most people will push you on to a referral to get help with that. And then again, the biggest one is ongoing symptoms. If you continue to feel poorly despite attempts that your internist is doing, they’ll probably move on to a referral.
[6:33] I want to take a step back and reintroduce this concept of the AFFIRM trail, which again as Dr. Prystowsky pointed out, was this trial comparing people with atrial fibrillation and risk factors for stroke who are in their 60’s, and who had minimal symptoms, to randomizing them. Half got just rate control and half got a strategy attempting to maintain normal rhythm, and at the end of five years, there really wasn’t really that much difference in how many people were alive. The important take home message is that [7:10] AFFIRM does not tell us that AF patients do not do better in normal rhythm. All it did is tell us was that these two strategies in all patients who have very few symptoms were different. If you start hearing from someone, you go into your doctor and say, “Look I’m having a lot of symptoms from this,” and they say, “Well look, this trial says we don’t need to do anything else,” that’s a misinterpretation, and you need to look for someone else. The biggest mistake in medicine, in afib medicine, is misinterpreting this trial.
[7:47] What are the pieces? We’ve looked at the stroke prevention; I’m not going to reiterate all that. There are blood thinner drugs. Later in the morning, I’ll be talking a little bit about devices to replace drugs for stroke prevention; that’s coming in the future and there will be select patients. And again, I just want to reiterate that aspirin or the combination of aspirin and Plavix, if you have a lot of risk for stroke is not adequate. We all want to believe that it is, we all think it would be more convenient, but it’s not as good, and it’s probably not as safe either.
[8:23] Rate control, we talked about. There’s medications, and there’s also a procedure where you do a special type of ablation and put a pacemaker in. That’s pretty much a last ditch effort in a lot of people, and we’ll talk about that later.
[8:37] Rhythm management are issues you’ll talk about with your doctor and that can include more complex medications that need to be individualized because, with the higher demand of the medication to try to treat your atrial fibrillation and maintain normal rhythm, come more risks, and so you have to balance those.
[8:58] We’ll hear later this morning about catheter ablation, atrial fibrillation surgery, and combination approaches. And then the timing of everything, as you heard, can be critical. Depending on how long you’ve been in afib, it may impact what’s available. You can see, it may take several visits with the doctor to get through all this stuff and really understand it well. My nurse practitioner, Melanie Durham is here, and we tag team this when we see patients because it’s too much for one person to handle.
And then, what I didn’t even cover is if you have other medical conditions, those need to be managed or it doesn’t matter what you do with your atrial fibrillation. If you have high blood pressure and sleep apnea, and you’re not taking care of those, I can do everything I want about your atrial fibrillation—it’s not going to work. (9:47) It’s a combinatorial approach.
[9:51] When do you want to see a specialist? I think, in general terms, if you’re not sure your stroke risk is being properly addressed, you need to force your way up the chain to get someone who will manage that. I agree that the number one issue you have to deal with is stroke prevention, and if you’re not getting the answers on that, find answers for that.
[10:10] If you’re limited by your atrial fibrillation, and someone tells you there’s nothing else that can be done, get another opinion about it because there often is something that can be done; it just depends on how you look at it. When you don’t feel like you’re getting the answers to your questions and concerns, you have got to be able to get some answers. That’s where StopAfib.org is great because there’s a source for answers, when you can’t get into the doctor’s office, when you have more time. But, there is a balance.
[10:45] There are a lot of unknowns here; there are a lot of black boxes. People have been looking at atrial fibrillation—we just hit the 100-year anniversary of the discovery of atrial fibrillation—and there’s probably as much we don’t know as we know. [11:00] No doctor has all the answers, and you have to avoid the problem of perpetual dissatisfaction because the more specialists you see, the more likely it is that you’ll get something done that is complex and high risk whether you need it or not. Doctors love engaged patients, and then there’s sometimes too much engagement. And we could talk about that in a minute, [11:31] so it’s a balance of trying to get the best care for yourself without going to the point that you doctor shop to the point that someone does something that leads to harm. And I don’t have any hard and fast rules other than I see too much of this. [11:50] Be sure you’re armed with the most information possible, that your options are presented completely so you can make some good decisions, but understand that balance.
Mellanie: Thank you so much, Dr. Kowal.