How does a cardiologist balance the benefits of invasive care with the patients' interest in non-invasive measures?
As great as improved care options—both medical and invasive—have been for patients with atrial fibrillation, their true value were unlocked with improved understanding of the patients’ treatment needs.
In an interview with MD Magazine®, Larry Chinitz, MD, director of Cardiac Electrophysiology and clinical director of Cardiology at NYU Langone Medical Center, explained how defining appropriate patients for either catheter care or a medical regimen has optimized the benefits of either option.
MD Mag: What does absolutely optimized care look like for a patient with atrial fibrillation?
Chinitz: We have learned that in a patient who is a good candidate for catheter-based therapy—meaning that they don't have very severe structural heart disease, left atrial size is not too large, they haven't been in persistent fibrillation for years and years, patients who have a chance to restore a normal sinus rhythm—the restoration of normal sinus
rhythm will lead to a better quality of life and possibly reduce risk.
So we feel that anybody who is amenable to that or, at least in my opinion and in many of the people that I work with, if they are amenable to catheter-based therapy, we should try that. Because medical therapy will not maintain normal sinus rhythm indefinitely, and medical therapy will require lifelong treatment with medications, and anticoagulants, and things like that. And if we need to go there, we'll go there.
And in patients who are not good candidates for catheter-based therapy we’ll not do that and go directly to medical therapy. But the intervention has the opportunity to change the course of their medical condition for the rest of their lives. So again, it's proper patient selection. I’m not sure if I'm answering your question, but it's proper patient selection, getting them through the
procedure safely, and then managing them over time.
How do you manage patients’ desires for non-invasive care?
You know, people say, “Well I don't want to go through the risk of a procedure.” But you have to balance that understanding that atrial fibrillation is not going away—you'll be on medical therapy and anticoagulants and deal with the morbidities associated with atrial fibrillation for the rest of your life.
So if the one-time risk of a procedure in appropriate patients is relatively low, then you're trading a relatively low-risk intervention for a lifelong risk you know that you're going to have to deal with. So I think that's the transition that people have to really understand more.
And I think in the primary care world, we need to make sure that the physicians who are seeing the patients for the first time really understand it. So that's what CABANA was about—the CABANA trial, it focused on primary care doctors, because they were the first contact. And emergency room doctors didn't want patients from guys like me who already see patients after they've been managed for years and years, they wanted people who present with atrial fibrillation and give them a choice, or randomize them as first-line therapy between drugs and medication.
And again CABANA didn't come out exactly as we wanted it to, but there are strong implications there that in the appropriate patients, catheter ablation is better.