Tag Archives: atrial fibrillation

Domhnall MacAuleyDomhnall MacAuley is a CMAJ Associate Editor and professor of primary care in Northern Ireland, UK

Simon Griffin (Cambridge) was the headliner at the Association of University Departments of General Practice in Ireland (AUDGPI) Conference. Through his keynote address and workshop, he gave a scholarly and comprehensive insight into his team’s work both on promoting physical activity and exploring the evidence on routine health checks. It was clear that to examine a major research question means a long-term commitment, building multiple layers into a study, and testing different hypotheses as the work progresses. Success is incremental rather than through any single dramatic breakthrough. He described the different components of each programme of work and their sequential publication in peer reviewed journals. His views on the difficulty of promoting physical activity and the limitations of routine health checks carry considerable weight, formed on such a robust body of quality evidence. ...continue reading

Rich-Roberts preferredRichard Roberts is Professor and past Head of the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health. He is immediate past president of the World Organization of Family Doctors (WONCA) 2013-2016. He is a family physician and an attorney.

During my term as President of WONCA, I toured hundreds of hospitals and clinics in more than 70 countries. I never expected to be a patient in one.

In June 2012, I was excited to be attending another national conference of the Spanish Society of Family and Community Doctors (semFYC). I looked forward to reconnecting with good friends and mingling with the several thousand family doctors in attendance . My three flights from Wisconsin, USA to Bilbao, Spain were uneventful. The real excitement began as I was settling in to my hotel room.

About 7 pm, I had the sudden onset of several fleeting episodes of lightheadedness. There were no other symptoms and I felt well between episodes. With a regular rhythm and heart rate in the 60s, I concluded that I had jet lag and dehydration. I pushed fluids and rested the remainder of the first evening.

Although I felt well the next day, I was determined not to be the stereotypical physician trying to be his own doctor. I sought the advice of the semFYC President. Within moments, I was ushered to a nearby health center where my exam and electrocardiogram were normal.

The following day, I had several more episodes while touring another health center. A quick electrocardiogram revealed atrial fibrillation with a controlled ventricular response of 92 beats per minute. My rhythm converted spontaneously to sinus in a few minutes. Even so, my hosts insisted on driving me to a major teaching hospital. Their faces betrayed a mix of sincere concern and worry that an esteemed guest would die on their watch.

My memories of my experience in the Bilbao hospital remain vivid. The 4 hours I spent there seemed an eternity, and yet passed by in a flash. I remember the 40 minute registration process, for someone with an acute cardiac condition! Bureaucracies are the same everywhere. The bright ceiling lights all seemed positioned strategically to make it impossible to keep one’s eyes open while supine. These minor annoyances were much less memorable than the people who looked after me.

Mostly I remember the nurses. The emergency physician breezed by me several times, but it was the nurses who made certain that I knew that someone cared, that I was in good hands. Perhaps that is why I found myself humming the Leonard Cohen song “Sisters of Mercy.” I did so quietly, not wanting to add to the suffering of those around me.

My exam, blood tests, chest x-ray, and electrocardiogram were all normal. The hours of waiting enabled me to call my wife, my family doctor, and a cardiologist back home to inform and to seek advice. Even before I left the hospital, they made arrangements for a more extensive evaluation on my return home.

I later reflected on the miracle of modern telecommunications and on the privilege of being a physician. Mobile telephony instantly connected me across the world to those at home, where I really wanted to be. My colleagues at home made certain that my eventual treatment was swift and skillful. The paroxysmal atrial fibrillation resolved after catheter ablation. Yet, it did not feel right that the system moved faster for me than I was able to make it move for my own patients.

Writing this blog prompted me to look back on the lessons learned and on the priorities I reset for myself as I went through the first major health episode of my life. As a physician, I understood well my condition and the murky state of the science that guided therapy. I was annoyed at the interruption in my busy life and anxious about the risks and possible failure of treatment. As a patient, I assumed and received clinical competence and technical prowess. Better communication and empathy were the two qualities that were sometimes lacking.

As a result of this experience, I resolved to work harder to spend more time with my family and to listen longer, and better, to my patients. A candid self-assessment confirms that I remain a work in progress.

 

* This blog is part of a series that CMAJBlogs is publishing in the lead up to the International Conference on Physician Health #ICPH2014 to be hosted by the British Medical Association September 15-17 in London, UK

Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK

Atrial fibrillation makes me nervous. In the distant past there was only digoxin. Later, we debated the merits of focusing on rhythm vs. rate and we checked digoxin levels but, for the most part, it was a hospital topic. Yet as evidence mounted on the risks of stroke, the responsibility for managing atrial fibrillation began to migrate into primary care. Detecting, treating and anticoagulating became more important. Checking the pulse was much more than a ritual - it could be a life saver.

Anticoagulation also makes me nervous. Warfarin is straightforward in theory but patients don’t tend to follow textbook models. There is always debate about the optimal starting regime and strategies for monitoring. Computer programmes make it easier but there are always rogue results, patients with odd INR patterns and, even more worrying, those who don’t turn up for testing.

Doctors and patients may have been even more concerned by reports in the New York Times citing two recent papers from the NEJM indicating that many strokes of unknown aetiology may be due to undetected atrial fibrillation. One of the these studies was the Embrace trial, based on the Canadian Stroke Network, with collaborating centres across Canada. They found that, in those with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Their findings, that “noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring” has suddenly made follow up more complex. This is backed up by a study from Italy suggesting longer post stroke monitoring. By this time, of course, most of these patients should be back in the community under the care of their family doctors. On a more positive note, however, the UK National Institute of Clinical Excellence (NICE) recently recommended more frequent use of the newer anticoagulants that don’t require regular monitoring.

In this context, the recent CMAJ “Five things” article gives helpful advice on exercise for those with atrial fibrillation. However, as if to complicate matters for those who are already active, a 2013 paper in a study of healthy athletes who had completed the Swedish Vasaloppet cross country ski marathon, found those who were fittest and fastest, were more prone to atrial fibrillation.

No wonder, anticoagulation and atrial fibrillation make me nervous.