MYTHS & FACTS ABOUT AF MYTH: Patients with AF generally have poor quality of life and bad prognosis. FACT: AF is a common condition, especially in olderpeople. It is a generally benign and manageable clinical problem. MYTH: Onset of AF poses a medical emergency requiring hospital admission. FACT: Most AF episodes and the vast majority of AF patients can be treated safely and effectively as outpatients. MYTH: AF is generally life threatening. FACT: Proper anticoagulation (blood thinning) is effective for stroke prevention, and control of heart rate alleviates symptoms and prevents potential complications. MYTH: Procedures such as ablation are frequently necessary. FACT: AF ablation may benefit carefully selected patients but in our experience this is infrequently necessary. historic introduction, in the early 1960s, of direct current electrical cardioversion, which remains a primary intervention to restore normal rhythm in AF patients. The physicians at the Lown Center have managed thousands of patients with AF. With more than 40 years of experience, we have developed a unique approach to this condition, emphasizing medical therapy tailored to the individual patient, which produces excellent outcomes and good quality of life in the majority of patients with AF. Individualized treatment We don’t treat AF, but the patient with AF. An effective AF management plan takes into consideration many factors unique to each patient, including underlying heart disease, severity of symptoms, degree of physical activity, emotional state, compliance with medications and possible side effects, and, importantly, each patient’s preferences. For example, patients with infrequent AF episodes may require only intermittent treatment. By providing therapy on an as-needed basis, we avoid unnecessarily exposing them to potential side effects. Education and reassurance Being diagnosed with a cardiac condition can be alarming and stressful. We take time to help our patients under- stand their heart health, reassure them that AF is generally a benign and manageable condition, and affirm that most people with AF are able to lead full and normal lives. Maximize non-invasive therapies Through careful listening and examination, we identify and address issues that may co-exist with a person's AF, such as other medical conditions that can influence its course. A core principle of the Lown Center's model of cardiac care is to utilize invasive procedures, such as ablation, only as a last resort and only in symptomatic patients for whom other medical alternatives have failed or are not feasible. In our extensive experience, this is infrequently necessary. Read the Lown Center patient guide: Atrial fibrillation on page 4. Atrial fibrillation (AF), an irregular pulse originating in the upper chambers of the heart (the atria), is the most common sustained heart rhythm abnormality (arrhythmia). Increasingly prevalent, AF is a significant health issue, currently affecting 2.5 million adults in the US at an estimated cost of $6.65 billion annually. About 20% of strokes are due to AF. Most patients with AF can be treated effectively with medications. In recent years, however, invasive procedures for treating AF have been heavily marketed by specialized AF centers and related industries. The Lown Cardiovascular Center has been a pioneer in researching and treating patients with AF since Dr. Lown’s Atrial fibrillation: The importance of individualized treatment Shmuel Ravid, MD, MPH Lown Forum 2009 NUMBER 3 T H E LOWN CARDIOVASCULAR RESEARCH FOUNDATION 2 Foundation news President's message 3 Heart Hero Award: Uganda 4 Guide to atrial fibrillation 5 Patient profile: Living with AF I N S I D E 5 LCRF anxiety research 6 Question from a patient Lown CenterNewsbeat 7 Donors celebrate a Lown Center Golden Anniversary 8 Consumer beware: Mobile vascular screenings
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President’s messageVikas Saini, MD, President, Lown Cardiovascular Research Foundation
During a recent presentation in Tokyo, I made the casethat the key to cost containment is reimbursement ofphysicians for spending more time talking with patients,thus reducing premature ordering of multiple procedures
This approach is the core of the Lown Center’s practicestyle and key to its effectiveness. We have completed afirst-phase statistical analysis of our coronary arterydisease project. Results show a mean follow-up time of 13.2years for enrolled patients, and an annualized mortality of3.7%. For those under 80 years, the rate was 3.2%.
Many among this cohort of people originally came to theLown Center for a second opinion. As reported previously(1), our cardiologists determined that most of them did
not require surgery. Our results compare favorably withpeople who undergo bypass surgery: recent Medicareresults indicated that long-term survival after bypasssurgery in northern New England was 4.2% in those under 80 years old.
We have also found other interesting and importantassociations. Exercise duration on treadmill testing wasan important prognostic indicator, reaffirming the valueof maintaining fitness. As discussed by Dr. Blatt on page4, initial anxiety levels were a significant variable inoutcomes, reinforcing our interest in exploring ways toinfluence nontraditional risk factors.
Our next goal is to develop statistical techniques that willallow comparison of our outcomes to those of thegeneral population of patients. This is part of a broad areaof emerging research called “comparative effectiveness,”which has understandably drawn keen interest frompolicy makers in Washington as everyone struggles todelivery quality at affordable cost. Stay tuned.
(1) Long-Term Outcomes of Optimized Medical Management of Outpatients With Stable Coronary Artery Disease (Am J Cardiol2004;93:294–299). Read it on the LCRF website:http://www.lowncenter.org/articles/CAD.pdf
2 L O W N F O R U M
Newpatientappointmentsavailable
Patients of the Lown Cardiovascular Center frequently ask whether--and how--they canrefer friends or relatives to the Center. Newpatient appointments are currently available.Individuals who would like to make anappointment with one of the Lown Center cardiologists should contact Maura Emery,Appointment Coordinator, 617-732-1318 x3315.
moderate amounts in sensitive patients), and ingestion of
various stimulants. AF is occasionally triggered by
emotional or physical stress in susceptible individuals.
Adverse outcomes of AFThe most serious complication of AF is stroke, which is
caused by blood clots that originate in the atria and travel
through the circulatory system to the brain (arterial
embolism). Infrequently, embolism from AF blocks other
arteries, potentially causing a heart attack, intestinal
ischemia, or kidney malfunction. Annual incidence of
stroke is about 3-5% in patients older than 70. Weakeningof the heart muscle (cardiomyopathy) and heart failure
due to rapid AF for extended periods of time may occur.
Occasionally, fainting spells result due to slow AF.
TreatmentsTreatment goals for AF are to prevent serious
complications, minimize symptoms, and improve quality
of life. Treatment should be individualized and determined
by medical considerations as well as patients’ preferences
and expectations. Although complications occasionally
occur, AF is generally a benign, non-life threatening
condition, if treated properly with blood thinners and
either restoring normal rhythm (rhythm control) or
slowing the heart rate response to AF (rate control).
Intensive treatment of all coexisting cardiac conditions
and risk factors (high blood pressure, heart failure,
diabetes, etc.) is necessary to reduce recurrence and
complications of AF.
Treatment with Coumadin (warfarin) for patients at high
risk for stroke, especially the elderly and those with heart
failure and/or high blood pressure, effectively lowers the
annual risk of stroke from 3-5% to about 1%. Coumadin
therapy is inconvenient, requiring frequent blood testing
and patient compliance. Patients younger than 75 years
without overt heart disease or high blood pressure may
be safely treated with 325 mg aspirin. Both drugs increase
the risk of bleeding complications, but the benefit of
blood thinning in AF patients is well documented and
outweighs the risks.
Meticulous heart rate control with medications like beta
blockers, calcium channel blockers, or digoxin is a
mainstay for alleviating AF symptoms. Intermittent anti-
arrhythmic drug therapy is effective in restoring normal
rhythm in some patients with infrequent episodes of AF
(“cocktail therapy”), or as long-term treatment for
maintaining normal rhythm in others. However, such
drugs should be used cautiously because of potentiallysignificant side effects.
Electrical cardioversion remains the procedure of choice
to restore normal (sinus) rhythm for persistent AF.
Performed under short-term anesthesia, this outpatient
procedure is effective and safe, and is generally
attempted in most AF patients at least once.
Non-medical interventionsOver the past two decades, various techniques for a
"quick fix" of AF have been developed and promoted by
the industrial medical complex. Radiofrequency ablationof AF is currently the most popular invasive intervention.
While a viable option for a select minority of AF patients,
especially younger patients with symptomatic paroxysma
AF, we prefer to use it only as last resort. The procedure is
imperfect, and neither innocuous (about a 1-2% serious
complication rate) nor inexpensive, and in our experience,
is frequently unnecessary.
This Lown Center patient guide summarizes the latest medicalinformation and the Lown Center's unique approach to keycardiovascular issues. We encourage you to contact your cardiologist if you have any questions or concerns.
Lown Center patient guide: Atrial fibrillationShmuel Ravid, MD, MPH
Seventeen years after we started workon a major research study called "TheCoronary Artery Disease (CAD) Project,"new results offering further insight into
the impact of the psychological state on the the prognosisof patients with CAD have emerged.
As clinicians, every day we see the impact ofanxiety on how a patient will fare. Now wehave solid data to show that the psychologicalstate of anxiety may be as powerful as high
blood pressure, high cholesterol, or even smoking on theoutcome of patients with CAD.
Of course, the question that begs to be answered is: Willtreatment of anxiety with medication, therapy, or both atsome point during the progression of the coronary arterydisease (or, perhaps best, before CAD becomes evident)alter the course of the disease process--perhaps preventinga heart attack or slowing the progression of the disease sobypass surgery, stroke, or even death are avoided?
One might ask, "Why has this study not been done?" Thesimple answer is : It is not as easy as it sounds. A study of
PATIENT PROFILE
Getting my life back with AF
Karen W. was in the middle of preparing for the holidaysin December 2004 when she realized something waswrong. “I was so tired I could barely get through the
shopping," she recalls. "I went to the local walk-in clinicone evening; my problem was diagnosed as ‘stress’ and Iwas given a prescription for Valium.”
But on Christmas Day, she had difficulty preparing dinner.
"I couldn’t lean over to take the food out of the oven. I
was short of breath and coughing. My family was
worried, so I went back to the clinic. They told me I had
atrial fibrillation and to see a cardiologist 'right away.'"
"This was one of the darkest moments in my life," Karen
acknowledges. She has been in the real estate business
for more than 40 years. “Now I couldn’t climb stairs—
imagine a realtor who can’t climb stairs!"
A friend suggested she call the Lown Center. “The day I
met Dr. Ravid was one of the most fortunate days of my
life. He gave me my life back,” she says. "It took a while
to get everything under control, but I could see that he
was confident he was going to get me through this, and I
had complete confidence in him. He started me on
several medications and kept adjusting them. He did a
cardioversion in March 2005 but it only lasted two days.
He performed another cardioversion the following June,
and all of my other miserable symptoms began to
disappear. I was able to climb stairs again and since then I
have been doing well."
Karen encourages other AF patients to follow their
physician’s recommendations. “When Dr. Ravid speaks, I
listen. When he told me to lose 20 pounds, I thought,
‘Okay…' and I did it. I just put food portions I normally
would eat on the plate, and then took half of it off again.
I lost the 20 pounds.” She wishes to impress upon other
patients that “when a physician prescribes medications,
diagnostic testing, or lifestyle changes, the advice is for
your benefit and well being. By following Dr. Ravid’s
advice, I have been able to resume my career."
During busy periods, it is not unusual for Karen to work
more than 60 hours a week, most of which are spent on
her feet. Younger associates envy her energy. "Now
when I am showing a property and reach the top of a
flight or two of stairs without being short of breath," she
concludes, “I silently thank Dr. Ravid.”
this nature is full of pitfalls, and attempts by other institutions to create a cost-effective study design have notbeen fruitful. The Lown Foundation, however, continues toexplore the biology that links a patient's psychologicalstate, and the health of that patient's coronary arteries. Weknow that depression, for example, is associated withinflammation that may give rise to coronary blockage,
angina, and heart attack. We now also note an associationbetween inflammation, the psychological state, and thepropensity to develop atrial fibrillation (AF). Indeed, themore we learn, the more complex, interactive, andmysterious the human biology underlying heart diseaseappears to be.
The long-term nature of our study provides a uniquelyvaluable perspective. Although the importance of theemotional state to good cardiac health is obvious on thesurface, we will continue to explore beneath the surface inan effort to find more effective means of caring for patientswth heart disease.
LCRF data offers insight into effects of anxiety on the heartCharles M. Blatt, MD
Drs.BrianBilchikand VikasSainiare co-authors ofMadurai Area Physicians Cardiovascular Health EvaluationSurvey (MAPCHES)--an alarming status, published in theCanadian Journal of Cardiology (Vol 25, No 5, May 2009).The study demonstrated an alarmingly high incidence ofCVD risk factors and stroke among a cohort of 4000physicians in southern Tamilnadu, India.
Dr.BernardLown delivered thecommencement address and received anhonorary degree at the University of NewEngland College of OsteopathicMedicine's graduation on June 6, 2009 inPortland, Maine.
Dr.FredMamuya co-authored SCCT guidelines for performance of coronary computed tomographicangiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee, published inthe Journal of Cardiovascular Computed Tomography(2009; 3:190-24). He also chaired two sessions at theAnnual Scientific Meeting of the Society of Cardiovascular Computed Tomography in Florida on July 16-17, 2009.
Dr.TomGraboys, President Emeritus ofthe Lown Foundation, and his wife,Vicki, discussed his memoir, Life in theBalance, for an audience of nearly 500
physicians, medical students, and thepublic at the Semel Institute for Neuroscience and Human Behavior at
UCLA on June 2, 2009....Dr. Graboys spoke about hispersonal journey from cardiologist to patient with Lewybody dementia with Parkinson's disease on WRNI in May2009. The interview is available online:http://www.wrni.org/content/doctor-becomes-patient
Dr.BrianBilchik was appointed to theChronic and Cardiovascular DiseasesWorking Group of Harvard Institute ofGlobal Health (HIGH), which organized
a conference, "Cardiovascular Diseasein Developing Countries--MovingForward," on July 22, 2009.
Dr.VikasSaini participated in the 7th Teikyo-HarvardSymposium in Tokyo, Japan from June 26-28,2009. Hispresentation, "Hospitals, workers, and communities: timefor a new paradigm," focused on the relevance of theLown Center's recent research findings to health caresystem reform, particularly costs of overtreatment andthe role of the doctor-patient relationship in creatingviable solutions.
Question from a patientVikas Saini, MD
Should I take fish oil capsules?
The evidence suggests that omega 3 fatty acids
are good for heart health. In prehistoric times,we consumed many times more of these
essential fats than we do now. Since researchers first
noticed the seeming benefits of omega-3 fatty acids in
studies of diet and heart disease in large populations, the
evidence has grown enormously.
Omega-3s are a distinct group of dietary fats which are
part of the larger class of polyunsaturated fatty acids
(PUFAs). Omega-3s are found in fish in the form of
docosahexaenoic acid (DHA) and eicosapentaenoic acid
(EPA), and in vegetable sources in the form of alpha-
linolenic acid (ALA).
If your diet is rich in omega-3s, you probably don’t need to
take supplements.
It is well-known that fish contains these oils--but not all
fish. The best fish sources are cold-water fish, such as
sardines, mackerel, salmon, and tuna. Cod and haddock
have much less, while tilapia has very little. There are
vegetarian sources as well. The highest content is in flax
oil. Cooking with canola, soy, peanut, or mustard oil will
also contribute. Walnuts and pumpkin seeds are good
snack sources of omega-3s.
How does this translate into real life? Use canola oil for
cooking as much as possible. Try to eat 2-3 servings of the
fish mentioned above each week, and two or more
servings per week of a vegetable source like walnuts,
pumpkin seeds, or crushed flax seeds.
If your diet doesn’t contain enough omega-3, then taking
supplements is a good idea.
• Fishoil: 1200 mg /day of the combination of EPA and
DHA is a reasonable dose. Some preparations have a
slightly fishy odor. Others, especially "pharmaceutical
grade," have been processed to remove the smell and
are even available with lemon or orange flavorings.
• Flaxoil: 5-7 gms (1-2 tablespoons) should be enough.
However, unlike fish oil, the benefit of flax oil can be
blocked if you are eating too much other fat, even if it is
a healthy fat like safflower or corn oil.
Send your suggestions for the Lown Forum's "Question from apatient" column to Catherine Coleman, Editor, at 617-732-1318x3332 or [email protected].
Foundation donors celebrate their LownCenter "Golden Anniversary"Fifty years ago, James Bickman was unable to find a
cardiologist who could diagnose and treat his heart
condition, so he consulted the "up and coming" Dr.
Bernard Lown. Since then, "Through all these years,through thick and thin, from here to the other end of the
earth, the Lown Center's physicians have been there for
us," notes his wife, Ada. "We call this our Golden
Anniversary with the Lown Center."
Mr. and Mrs. Bickman are among the Lown Cardiovascular
Research Foundation's longest-standing supporters. "The
Foundation's research is constantly looking for new ways to
help people with cardiovascular disease," Mrs. Bickman
explains.
Mr. Bickman is committed to supporting the style of
cardiac care that is the cornerstone of the Lown Center.
"These days, everything is measured by seconds and
minutes. But life isn't that measurable," he notes. "We
support the idea of passing along to young physicians theimportance of listening to patients, asking a lot of good
questions, taking time, and making patients feel at home.
It will do younger doctors a lot of good to learn these
methods. I wish the Lown Center's approach would
expand across the health care industry."
Gifts to the Lown Foundation are vital in order to continue our cardiovascular research, patient care, medical education, andglobal outreach. Donations may be made online atwww.lownfoundation.org or may be mailed to LownFoundation, 21 Longwood Avenue, Brookline MA 02446.
L O W N F O R U M
BoardofDirectors
Nassib ChamounChairman of the Board
Vikas Saini, MDPresident
Bernard Lown, MDChairman Emeritus
Thomas B. Graboys, MDPresident Emeritus
Patricia AslanisCharles M. Blatt, MDJoseph Brain, SDJanet Johnson Bullard
Carole Anne McLeodC. Bruce Metzler Barbara H. Roberts, MDRonald ShaichRobert F. Weis
AdvisoryBoardMartha CrowninshieldHerbert EngelhardtEdward FinkelsteinWilliam E. FordRenee Gelman, MDGeorge GraboysBarbara GreenbergMilton LownJohn R. MonskyJeffrey I. Sussman
David L. Weltman
"In an ever-changing healthcare system that is
in desperate need of reform, I will forever
value the philosophy of the Lown Center to
treat each patient holistically as an individual,
taking into equal account a patient’sexpectations, environment, and goals of care.
During a recent hospital rotation, I often
thought of my training experience at the
Lown Center and asked myself how a
diagnostic test or procedure would change a
patient's care and management. I witnessed
first-hand the ways in which the side effects of
too many, often gratuitous, interventions
adversely affected patient outcomes. A morethorough history taking could readily have
eliminated the need for many of those tests.
Thank you!" Fatima Akrouh, 4th year Harvard
Medical School student
TheLownCardiovascularResearchFoundation
promotesahumaneandcost-effectivemodelof
cardiaccarethatadvocatespreventionover
costly,invasivetreatmentsandrestoresthe
relationshipbetweendoctorandpatient.CONTACTUS
LownCardiovascularResearchFoundation21 Longwood AvenueBrookline MA 02446(617) 732-1318info@lownfoundation.orgwww.lownfoundation.orgwww.procor.org
LownCardiovascularCenter
Brian Z. Bilchik, MD
Charles M. Blatt, MDWilfred Mamuya, MD, PhDShmuel Ravid, MD, MPHVikas Saini, MDCraig S. Vinch, MD
LownForum
EditorCatherine Coleman
EditorialsupportClaudia KenneyJessica Gottsegen
c2009 Lown FoundationPrinted on recycled paper with soy-
based ink.
"We support the idea of passing along toyoung physicians the importance of listening to patients," say James and AdaBickman, longstanding supporters of the