Cardiac pacemaker interrogation reports-who does it and how well?

This is a revision  of an earlier posting on this subject, redone and reposted because I believe this is an important topic about which very little seems to be said. 

In the first 4 years of living with a cardiac  pacemaker (PM) implanted, the following instances of misinformation,lack of proper oversight,delayed reports and/or  misdiagnosis occurred.I did not need that stress after having a titanium foreign body containing a 3 V battery  crammed under my left chest wall muscle attached to wires going to various parts of my heart  which was quite enough to ramp up my anxiety level to at least sub-panic attack levels.

1)In October 2015 I had a pacemaker implanted- one  which is designed for bi-ventricular pacing  the most common form of CRT (cardiac resynchronization therapy).This has 3 leads, right atrium,right ventricle (actually mine is in the His Bundle position) and a Left ventricular lead (in a vein along the wall of the left ventricle)

 2)The technician who assisted and provided technical advice to the EP cardiologist at the time of the implantation told me on the following day that my home -bedside PM communication device  would send a recording every night to the manufacturer's web site  and then to the hospital PM center.

Only 6 months later was I informed by him , in reply to a question from me, that no -that was not true and that arrangement was only for devices with a defibrillator  which I did not have.  So for six months I made a effort  to be near  near by communication device device each night that in fact did nothing at all.Someone apparently had not read the manual.

2.In October of 2016 my device recorded several episodes designed as AF/AT  (atrial fibrillation/atrial tachycardia) Episodes of AF are thought to be common  ( at least 30% by three years in patients with a PM- according to one data base).This lead to to my fairly extensive literature review of the issue of AHRE ( atria high rate episode). I learned that the topic is controversial and opinion varies as to what if any threshold there is for "signficiant volume of AF" to justify anticoagulation. (There are 2 randomized clinical tarials underway that are designed to try and answer that question).So it was an opportunity to research a medical topic-fear being a great motivator.

Also, all AHREs so designated by the PM's algorithms are  not in fact AF. The phenomenon of far field r wave sensing (FFS) and  and a less common and more obscure PM rhythm disturbance known as  recurrent, non reentrant ventricular atrial synchrony (RNRVAS)  are capable of mimicking AF.The technician at the hospital PM center  who is tasked with screening the remote interrogation report had not recognized that the rhythm was FFS and apparently did not feel that the issue required calling the matter to the attention of the EP cardiologist.

I send an email to my EP cardiologist  and I was  told  the issue of short episodes of possible AF are very controversial and I  did not need to come any sooner or consider taking anticoagulants. He apparently did not address the possible issue of FFS or RNRVAS or actually review my interrogation report until months later even though I has asked in my email if the data really indicated AF.

 However three months later, at routine office followup a  Medtronic technician said  that the earlier interrogation did not actually show AF but rather FFS  the reoccurrence of which he intended to prevent  by increasing the sensitivity threshold(i.e making detection less sensitive) on the atrial lead. The EP cardiologist  agreed, and I later leaned that FFS is not an uncommon cause of AHREs particularly so in the type of lead placement that I have. (Placement in the Bundle of His which in my case is higher up in the ventricle than the standard apical placement of the RV lead-sometimes the His Bundle Lead is in the atrium)

3)At an August 2018 in office PM interrogation, the technician and I entered into a conversation about battery life estimation  and she wondered if the estimate of battery life was disproportionately shorter than what may have  been expected on the basis of the settings .She forwarded the data to the home office and the engineers found nothing to do to improve the settings.Her concern and interest was appreciated but ..

In talking to her I quoted the section of  the device manual that discussedto the device powering down a bit with several settings once three months has passed after the recommended replacement time ( RRT date). She said no that was not the case with my particular model However, I contacted the pacemaker company  technical support and they confirmed the manual's description was correct. 

4)Issue of high left ventricular (LV)  threshold occurring on multiple of the every three month reports.It was not until October 2017 (2 years after implantation ) that the left ventricular management system was switched to "monitor". I can only speculate as to the degree to which battery life was shortened by  what seems to be the less than prompt attention to that issue. 

The interrogation report is fairly long and reviewing it requires considerable technical knowledge about  cardiology,PMs in general as well as certain details regarding the specific brand,various programmable settings and particular model and various lead placement configurations and at least a little knowledge about electricity  and cardiac physiology.

 The device clinic technicians review reports from  various pace maker brands and also the more involved and complicated reports from ICDs (cardiac defibrillators) .Being a retired physician I have had the time and interest to spend a fairly large amount of time and effort into learning about PM lore and in particular the interrogation reports. My  shaken confidence in the folks monitoring  how well the wires  in my heart are performing has certainly provided incentive to learn how  to read the basics of device interrogation reports. 

5)By the summer of 4th year following implantation the   device clinic  services  had deteriorated to the point that I wrote the head of the EP section.They no longer directly  answered the phone and the messages left were only replied to days later and my complaints to them was met by curt replies that they were too busy. Reports that were typically available the same day took a week or more and required multiple phone calls . The section head  said  those issues were being addressed and apparently they hired a company that does device monitoring and were now also available 24/7 while their own in-house clinic also did some or all of their review work.How well that arrangement works remains to be seen. and I have not ben able to learn how the hosptial device clinic and the contract device monitoring company divide or duplicate the work.

coronary calcifications and the paradoxes of statins and endurance exercise

Coronary artery calcification is by definition coronary artery disease

Calcification can occur in the intima and in the media with possible different pathological implications.

All coronary artery calcifications (CAC) are not created equally. Dense calcification can occur in fibrous,stable plaques which carry little risk of rupture but can narrow the coronary arteries causing angina and ischemia on exercise. Spotty calcification can occur on unstable plaques which can rupture causing an acute coronary events and yet not be detectable on stress testing.

The is more than adequate epidemiologic evidence that statins can decrease the risk of coronary artery events- certainty when used in secondary prevention.So it seems paradoxical that more intense statin therapy as with the more potent statins  and for longer periods of time is associated with more CAC.The standard answer to this apparent paradox is that statins are able to stabilize plaques making them less at risk of rupture and that in part the putative stabilization involves dense calcification.

There is also more than adequate epidemiologic evidence that endurance exercise decreases the risk of coronary artery disease and cardiac vascular mortality.so it seems paradoxical that studies (at least some) have shown increase coronary artery calcifications with increasing levels of exercise. Might a reasonable answer to this paradox be that endurance exercise helps stabilize plaques by calcifying them. In fact some of the authors who have reported increased CAC with increased exercise have suggest that mechanism.

Merghani et al (1)reported on a study of  152 men who had logged an average of 31 years of endurance exercise type activities. All had echocardiograms,24 hour Holter, stress ECG,CT coronary angiograms (CAC) and cardiac MRs with gadolinium as did 92 age matched controls with similar Framingham Risk scores.

15  athletes and none of the controls had late gadolinium enhancement (LGE) on the MRs, 7 of which had a coronary artery pattern.(The LGE issue will need to be written about at a later date.,for now  the focus is on the  calcification.)

60% of the athletes and 63% of controls had a normal CAC score but only athletes (11.3%) has a CAC score of 300 or greater. So the incidence of any calcification was about the same in athletes and controls but the athletes had more calcium and more demonstrable luminal stenosis ( greater than 50%) in 7.5% of the athletes and in none of the controls.

So does this mean that long time endurance exercise increased the risk of coronary artery disease?
Maybe an answer to that is related to another question-does the increase in calcium scores noted in patients taking statins mean that statins increase the risk of coronary artery disease which is , of course, a conclusion contrary to realms of clinical trial results demonstrating the value of statins, at least in secondary prevention.

In regard to the second question there is a great deal of data regarding what could be called the statin plaque paradox-statins increase coronary artery calcium even as they shrike the plaques.A person's calcium score could increase even as the plaques regress because of the increased density of calcification bought about by the statins.

For long term endurance athletes who might be worrying that their ill spent youth and/or middle age and /or early old age was in fact ill spent might get some sense of relief from these comments from Dr  Benjamin Levine.


1)Merghani,A Prevalence of subclinical Coronary artery Disease in Masters endurance theleres with a low atherosclerotic risk profile. Circ. 2017, 136, p 137

Just a reminder from Maimonides

Recently I came across comments from a retiring Critical care doc who said that the 1978 novel by Samual Shem entitled "The House of God" no longer seemed so hilarious to him. The attitudes and behind the scene comments of the young house staff reflected a view of patients and medical care far different from what Maimonides had in mine. 

 Maimonides: "May I never see in the patients anything but a fellow creature in pain."

Not as someone who deserves his dyspnea because of cigarette use defying years of advice to quit, not as someone whose ascites is his just due from profligate use of alcohol, not as someone who should not be in this country at all, not as someone who would not be having the myocardial infarction at all if he had done what his doctors told him to do and not as someone who is taking "scarce medical resources" from someone who deserves them more or for whom the treatment could be more cost effective but as a fellow human whose is in need of what physicians spent so many years of their lives preparing themselves to be able to offer.(Not as the "gomers" Shem depicted)

The oath ( Maimonides) should remind us that being face to face with a fellow human in need

..makes judgment beyond the biomedical not only unnecessary but inappropriate.

More very important insights regarding how hospitals make money-by not getting paid

Dr. G. Keith Smith's website is a great source of important insightful information about how not for profit hospitals operate and how insurance companies make money by having higher billed amounts from hospitals. The name non-profit hospital is analogous to dry cleaning.Dry cleaning uses liquids soit is not really dry and if non-profit hospitals did not generate receipts greater than costs they would not be a hospital at all for very long.

See here for details from Dr. Smith regarding some of the ways hospital make money.

A few years ago  years ago a not for profit hospital sent me the following bill for a colonoscopy I had . This does not include physician's fee.

Total charge was $2527 and CMS and my Medicare supplemental carrier paid $ 589 leaving $1938 as "uncompensated" So why send me a bill for any amount that they knew would not be paid in its entirety? Thanks to Dr. Smith we have an explanation.


Smith calls it the "uncompensated care scam" which seems like an accurate characterization. To make up for the money that hospital "looses" in uncompensated care ( the difference between what they bill and what they receive) the federal government ( and I believe state governments may have a similar program for Medicaid) has a program known as DSH (Disproportionate Share Hospitals ). Using some arcade formula CMS computes a value that the hospitals will receive for this bookkeeping loss.

The medical insurance companies have their own scam,known as "repricing" in which they receive a percent of the "saving" they obtain for their employer clients by contracting fees for various procedures and hospital charges. The trick seems to be a mark up on the price the insurance company and hospital agree on so that the alleged savings and the reward for the insurance company is higher,

So the more the hospital losses the more they get paid by CMS and the higher the bills the hospitals charge the more the insurance companies make.

Is it time to stop primary prophylaxis with low dose aspirin

Well, it might be if one construes broadly-perhaps too broadly- the results of a  systematic review published in the Lancet. See here for summary- registration needed for full text) Also see here for a good discussion and some details of the study.

The authors meta-analyzed some six studies with mega numbers of patient years on the table and basically concluded that in secondary prophylaxis the beneficial reduction in heart attack trumps the risk of bleeding while in those individuals without established diagnosis of coronary disease the bleeding risk appeared greater than the heart attack risk reduction.This study is said to be more informative than an earlier meta-analysis of the same six studies because of access to some individual patient data.

The NCEP formula for heart attack risk estimate is based on data from The Framingham study.The current version of that formula cranks out a ten year risk of 24% for a 70 year old,non-smoking male, with a BP of 140 on blood pressure meds,a total cholesterol of 230 and an HDL of 40. Widely quoted guidelines would all agree that one should recommend low dose aspirin for such a patient. Does the new meta-analysis have sufficiently fine grained subgroup data to alter that recommendation?

An important insight to the data is the following.(quote is from the second link mentioned above)My bolding

This proportional reduction in serious vascular events did not depend significantly on age, sex, smoking history, blood pressure, total cholesterol, body-mass index, history of diabetes, or predicted risk of coronary heart disease. The authors point out that there was not even a significant trend in the proportional effects of aspirin in people at very low, low, moderate, and high estimated risk of coronary heart disease. "If the proportional risk reductions in these different subgroups really are similar, then the absolute risk reductions will depend chiefly on an individual's absolute risk without treatment," the authors comment.

I don't think this is anything new or surprising but the following could be:
They also say that their analysis suggests that the same factors that determine risk of heart disease also determine the risk of bleeding with aspirin, so that, even for people at moderately increased risk of coronary heart disease, the major absolute benefits and hazards of adding aspirin to a statin-based primary-prevention regimen could still be approximately evenly balanced.
So apparently not only heart attack risk increases with increased risk factors but so does the risk of bleeding.

There is an argument that since we now have statins as an arrow in the preventive medicine quiver and they seem so effective and also seem to do; God- only- knows how many other beneficial things maybe aspirin with its precarious and ambiguous balancing of thrombosis prevention and bleeding may not be for everybody in regards to primary prophylaxis.

The meta-analysis was published in May 2009 so the most recent guidelines from the U.S. Preventive Services Task Force could not have taken its findings into consideration. This version of their recommendations give different advice for men and women. For men they say:

Men aged 45 to 79 with heart risk factors should take aspirin if the preventive benefits outweigh the risk of bleeding. The trick is , of course, to somehow discern if the benefits outweigh the risk.

Even the practice of using low dose aspirin for primary prophylaxis in diabetes has come under attack. This article in the BMJ makes the argument that evidence supporting aspirin use is weak even though their analysis did show a 43% decrease in myocardial infarction men, but not women.

Doctor, were you wrong then or are you wrong now?

"Population Medicine" is not just intellectually empty it is dangerous

Over twenty years ago my partner, who was a very good physician, would occasionally say somethng that puzzled me. He would say  we probably should not  do such and so for a given patient because of the cost to the society or the system. Sometimes he used one word sometimes the other. I let it- go we had a great working relationship which I did not want to damage it  with philosophical discussion in which we would each probably talk past the other.

He was ahead of curve of the philosophy of population medicine- a philosophy that places importance of the health of a group or a collective as opposed to the individual's health which had been the emphasis and the polar star for the physician in the centuries old  physician-patient relationship.

But the health of a group had never been the role of the physician-it was the health or well being of the person acrosss from him in the examining room. The fundamental ethic of the medical profession stood in oppostiton to the notions of population medicine. For the notion of population medicne, which included reference to social justice,and a utilitarian calculus to prevail medical ethics had to be chosen.

Leading the charge for change were a group of leaders of the American College of Physicians  and some like thinking European  internists.

Population Medicine is much worse than just a very bad idea

Here are the comments of Apu,owner of the Kwik e Mart after Homer Simpson quite his job there:

"He slept,he stole,he was rude to the customers.Still, there goes the best damned employee a convenience store ever had. "

In a way a free market based society is something like that. With freedom and capitalism there are booms and busts, there are demonstrable inequalities  among various parameters,there is information asymmetry, externalties, and apparent market failures.Still it is the best damned economic, social system a country ever had.


Quoting Deirdre McCloskey speaking on why freedom and markets are better than central planning:.

"How do I know that my narrative is better than yours?  The experiments of the 20^th century told me so.  It would have been hard to know the wisdom of Friedrich Hayek or Milton Friedman or Matt Ridley or Deirdre McCloskey in August of 1914, before the experiments in large government were well begun.  But anyone who after the 20^th century still thinks that thoroughgoing socialism, nationalism, imperialism, mobilization, central planning, regulation, zoning, price controls, tax policy, labor unions, business cartels, government spending, intrusive policing, adventurism in foreign policy, faith in entangling religion and politics, or most of the other thoroughgoing 19^th-century proposals for governmental action are still neat, harmless ideas for improving our lives is not paying attention."

 Those medical progressives who champion the medical collectivism euphemistically referred to  to as population medicine have not been paying attention.

The 20th century made it crystal clear that collectivism does not work.Marx et al promised prosperity and equality by doing away with private property and individual liberty and delivered mass murder and starvation. The greatest welfare program in the history of the world was when Communist China did away with collective farming.

And astonishingly there is a faction of the medical leadership in this country who would institute a system of collective planning in regard to everyone's health  replete with acceptance of sacrifice of the individual to some purported calculable greater health metric for the group.

The very old wine in new bottle is labelled population medicine.


Population medicine is wrong on so many levels.It is antithetical to not only traditlonal medical ethics but also to classical liberal thought as well as Rawlian ethical precepts. It is something that both Robert Nozik and John Rawls would oppose.

His Bundle pacing is no longer the lastest thing in EP,Left bundle branch pacing may be

His Bundle pacing (HBP) is no longer the latest thing in cardiac electrophysiology (EP).Now direct pacing of the left bundle branch seems to be.

HBP is increasing recognized as a safe and more physiological alternative to right ventricular apical pacing. HBP is now part of the latest AHA/ACC/HRA guidelines. (2018).

HBP has been shown to be capable of normalizing the QRS duration and  the ejection fraction in as many as  80% of cases of nonischemic cardiomyopathy with left bundle branch block (LBBB). However, in 20% of cases HBP cannot correct the abnormal conduction pattern at a capture threshold suitable for long term pacing or is not effective because of distal His Purkinje disease.

There have been several case reports of  successful pacing in the left bundle branch in such cases. More recently Dr. Pugazhendhi Vijayaraman from Geisinger Clinc discussed his experience with Left bundle branch area pacing(LBBAP) in 100 cases at the 2019 Heart Rhythm Society meeting. See here.

He reported early success but emphasized the many yet to be answered question and concerns with this new technique. The electrode screw is inserted much deeper ( a centimeter or more) into the heart than with typical HBP pacing and the long term consequences of that are yet to be determined. Early report are encouraging ( lower capture thresholds and good r wave sensing )and hopefully better implantation tools will be developed to improve the process and more long term followup will help define what role LBBAP will have.

Medical scribes may help a bit but will not fix the EHR mare's nest

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Some developments have appeared on freeing the physicians from a bit  hegemony of the computer mandates . Back in the old days physicians would often see a patient and  do an exam and then dictate a note, in other words they used a scribe. Enter the computers and the reason for scribes was somehow forgotten and it was thought to be appropriate for physicians to transcribe their own notes  using the computer keyboard.

 The reason for scribes to begin with is explained by the economics 101 notion of opportunity cost. Simply put, the physician's time was worth more seeing the next patient than typing. This would be true even in the unusual case in which  the doc was a better typist that the scribes he uses.The opportunity cost of a physician doing her own typing is too high. Now it looks like the scribes are coming back. My eye doctor has been doing that for years. See here for details on the new scribe resurgence. Of course, this fix  does not alleviate the problem of "meaningful use".Scribes may decrease the amount of time wasted by physicians but the issue of the  mandated or quasi-mandated use of computers not  designed to facilitate physicians' work  is not fixed by this.

Why would physicians advocate replacing Hippocratic medicine with Platonic Medicine?

The notion of a fiduciary duty of the physician to his patient is long standing . In the era in which I grew up medically  ( now over fifty years ago) the idea that a physician should be obligated to care for the group of which his patient is a member was not talked about.

I first read about the Platonic notion of the physician as one obligated to provide the best care for a group as opposed to an individual in a series of articles in the Journal of the American Medical Association (JAMA). I make no claim that this was the earliest advocacy but only the first of which I became aware.


A series of articles was published  in 1995 authored by Dr. David Eddy that championed the  merits of decision analysis which he hailed to be a mechanism to increase the quality of medical care while reducing costs. Eddy defined quality as the greatest medical good for the greatest number within some economic medical collective. Eddy discussed the merits of decision analysis but the purpose of his version of medical decision analysis was to bring about a utilitarian outcome, namely the greatest medical outcome for the greatest number. Eddy admitted that there would be winners and losers in such an approach and implied that the group benefits trumped any individual loss or losses.


Dr. Robert Berenson  carried forward the plea for Platonic medicine  in the Annals of Internal Medicine  in 1998  in which he proposes that physicians should be devoted to  the health of the collective rather than the individual patient.

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group .This represents a sea change in medical ethics.

Outside of the HMO setting (or now the ACO) to what group would a physician owe his allegiance ?(Would a retainer physician strive to maximize the health of the city or states in which he practices or the country or what? Berenson's ethical proposal seemed to be aimed  primarily at HMO physicians as in the late 1990s the role of physicians in HMO settings was of concern and the topic for much discussion.


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I'll pretend to be your doctor,Medicare will pretend to pay me

Has it really gotten that bad? Are things devolving to the point where an application of a version of the following Russian joke is applicable to the changes in medical practice? Russians would say " we pretend to work and they pretend to pay us"?

This off-the-wall thought emerged from two of us perhaps catalyzed by dinner wine, as three retired internists gathered for a meal and pointless complaining session.

One of the three played several roles in my life; partner in an internal medicine practice,consultant when I left that practice, my personal physician until his group practice faced bankruptcy.It was he who remarked about his recent annual check up with a younger general internist who had been his former partner. He was irritarted how brief and perfunctory his physical exam had been. I was able to top that.

My recent annual exam with another former partner from that same clinic was interesting.He had me strip to shorts and put on a open-in-the-back paper gown. He then auscultated my posterior chest and that was it. I could have had an alien creature bulging from my anterior chest or abdomen and it would have gone unnoticed.

Contracting out post operative wound care-economic opportunity and what effect on patient care

I have been out of the game so long that I did not realize that apparently post operative op wound care,at least those with infected wounds,are often  contracted to wound care practices.

Wound care centers treat more than post operative wounds,including skin ulcers from venous or arterial disease,radiation burns,trauma etc.

What I found interesting was that  in regard to post op wounds t,hat this was something historically managed by the surgeon and post op followup was considered paid for by the surgical fee. ( if anyone can correct me on that please do)

So this was  a situation in which medical care that could be carved out and now compensated for.Someone found a new income stream. Is it sensible to think of this as a win-win situation as the surgeon is relieved of frequently being reminded of his complication and someone else can take care of problem and be compensated for it. Further, to the extent that a wound care facility is good at what they do ( maybe better than the surgeon) it is a win-win-win situation.

This is another example of the increasing fragmentation of medical care. Internists have morphed into outpatient doctors and hospitalists and many procedures traditionally done by various varieties of internists have been handed off to the  interventional radiologists,

Lactate threshold and summer time running

Endurance exercise is traditionally considered to be a function of three factors.

1. Cardiac output which is , according to the Fick equation, the product of cardiac output and a-v oxygen difference. Cardiac output is  the product of stroke volume and heart rate.
2.Ability to perform at a high percentage of the O2 Max for prolonged periods.This can be measured or approximated by measurement of the lactate threshold.
3.Running efficiency.

 The lactate threshold is lowered during exercise in hot and humid conditions.

Pappadopoulos  et al (1) demonstrated in healthy young men that exercise at a temperature of 98 degrees  the lactate threshold was increased at a lower oxygen uptake ( from 2.86 +/- 0.13 to 2.38 +/- 0.09) while hypohydration was not shown to alter the lactate threshold.


Tanaka and Seals (2) state that there is evidence that the lactate threshold is lowered in older athletes but not when expressed relative to te percentage of 02 max.This suggests that decreases in lactate threshold may be secondary to decreases in 02 max. but however you look at it is lower.

)Pappadopoulos,c et al "Effect of hypohydration on the lactate threshold in a hot and humid environment." J Sports Med Phys Fitness. 2008 48 (3) 293-298

2)Tanaka,H and Seals,DR "Endurance exercise performance in Masters athletes:age associated changes and underlying physiological mechanisms. J Physiol 2008, 586 55-63

Ed Whitlock's marathon record for age 70 has been broken-well sort of

Gene Dykes, age 70, a retired computer programmer , ran a marathon time time of 2:54 23 at the 2018 Jacksonville Florida marathon . This  is faster than the previous accepted "record" of 2: 54 48 set by legendary Ed Whitlock for runners age 70 and over.

But the time may not be   "official" record time  according to the US Track and Field Association who said that the race was certified by them but was not "sanctioned"  which includes a fee paid by the race organizers to the USTFA  as well as a requirement to buy insurance from them .As of  July 10 2019 Wikipedia lists Dykes as holder of the age 70 record.

According to the USTFA a race must be sanctioned by them for any record setting times to be counted .

So far Whitlock still holds undisputed records for the marathon for ages 75,80 and 85 as well as numerous other age records.

Both  Whitlock and Dykes have had their maximal oxygen uptake measured.

Dykes had a 02 max that was surprisingly low for a very accomplished marathoner , 46.9 ml/kilo/min. But he could run at 93% of his 02 max before reaching his lactate threshold.

For comparison, Whitlock's 02 max at age 70 was 52.8 and 54 at age 82.

Pacemakers,ICD -too many too few? need newc guidelines?

About 200,000 pacemakers (PMs) are implanted annually for slow heart rate reasons  ("brady" indications) in the U.S. as are about 100,00 ICD (intracardiac defibrillators).A smaller number of PMs are implanted for CRT (cardiac resynchronization therapy). Data from 2012 quoted about 35,000 for that indication.

A big increase in ICD use occured after randomized trials showed a morality benefit for ICD in heart failure patients .There were two primary prevention trials- previously ICD were for secondary prevention , i.e patients who had survived a SCD event ( sudden cardiac death)

John Mandrola , writing in Medscape ,makes an interesting case for less use of ICD as does a series of excellent comments by his readers. See here.

Is the integrity of the doctor-patient relationship still a topic?

When I published the essay found below in 2015,there was considerable chatter in the medical blog space about the dangers posed to the traditional physician-patient relationship. Now little is written about that topic. The dogs bark and the caravan moves on.

The following was originally posted on 3/24/2015 and a lightly edited version appears below in the hope that there  may be some physicians who still care .

H.L. Mencken defined Puritanism as that haunting fear that someone,somewhere may be happy.

The Medical Progressive Elite's haunting fear is that someone,somewhere is making their own medical decisions with input from their private physician.This fear is shared by the third party payers. In recent years,there appears to be considerable progress in alleviating their fear.

The last thing that the third party payers and the medical progressive elite want is that medical decisions be made  a physician- patient "dyad".This situation is ripe for a classic Baptists and Bootleggers scenario,some of the  medical elite sincerely believing that medicine is too complex and expensive to be left to the judgment of patients with advice from their physicians and the third party payers striving to decrease the cost of doing business and increasing profits share holder value.

This medicine-is-too important-to-be left-patients-and-their- physicians view  is made crystal clear in the following quote from the book,"New Rules"  written by Drs. Don Berwick and Troyen Brennan:

"Today, this isolated relationship[ they are speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making."

Dr.Berwick went on the be the  head of CMS for a while and Dr. Brennan went on to be the chief medical office of Aetna insurance company and then CVS Caremark.Sometimes the line between the Baptists and the Bootleggers gets a bit blurry.

Destroying the physician patient "dyad" or relationship  has been a strategic goal of the progressive elite for years and a major initiative to that end was the 2002 publication "Medical Professionalism in the New Millennium:A physician charter".That was a joint effort by the ACP Foundation,the ABIM Foundation and the European Federation of Internal Medicine. The project chair was Troy Brennan and, in my opinion, importantly in terms of future funding and  promotion of the "charter" a member of the project was  Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation.The RWJF has been a major source of funds for the ad campaign for the Professionalism project.   CEO and . Dr. Harry Kimball ,president of ABIM from 1991 to 2003, was also a project participant.

The Professionalism 's theme is to downplay the fiduciary role of the physician to the patient and insert a nebulous co-duty of  the physician to be a steward of society's limited medical resources and to work for social justice. A particular political agenda was inserted into medical ethics. For physicians who wondered how that role was to be played out, later the ABIMF clarified  things by explaining that one could be a steward of the [collectively owned] medical resources  and social justice would be achieved by providing efficient health care.In one document the authors changed the nature of traditional medical ethics and  also rewrote the meaning of social justice which was now efficient care as opposed to the widely accepted meaning of social justice as redistribution.  In a bait and switch move they have redefined social justice as efficient health care attempting to aggregate the values that individuals might place on a treatment with some collective metric allegedly representing the greatest good to the greatest number.They then further simplified things for the practicing internists (actually all physicians) by gratuitously asserting that following guidelines would be the road to social justice.

Disappointingly, the AMA went along with this flim flam sophistry of the physicians as stewards of society's collectively owned medical resources.See here.

In the ACP-ABIM world no longer would the patient and the physician  be the primary determiners of a test or treatment value but value would be designated as high or low  primarily on a cost effectiveness calculus.Rather than treating each patient as an independent moral agent an aggregate utilitarian metric would be imposed  in which "high value care" is not in the eye of the patient but rather defined by a third party and expressed in  quality adjusted life years per dollar spent The only or at least determinate value is economic efficiency.

Of course, the medical professional elite is a subset of the larger progressive community whose operational credo is that most things are too complex and complicated  to be left to average people and if they will not listen to the delivered wisdom they should be compelled  while the progressive's polar star and major talking point is  to fight against inequality. The poster child for the stick approach has be the comments of Dr. Robert Benson Jr.,the emeritus president of ABIMF,writing on the blog of the ABIMF:

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC." (This would seem to be a rather severe penalty for not complying with a "recommendation" which Benson thinks should be an edict.)

Consider how important the Choosing Wisely rules would be if  Benson's wishes were enacted.Consider how much of a target the Choosing Wisely decisions would be to various lobbying groups.Third party payers would relish such a situation.

If you want to know what the ABIM and its foundation are about, just read  the ABIMF blog.

The combination of mega hubris and libido domini spells trouble in health care as it does pretty much everywhere.

Why a non-cardiologist thinks generally ablation is bettter than medication for rhythm control

Of course the teaser tittle is misleading.You should ask "better for what".Remember the old auto ad that claimed Fords (or some brand) are better,again better than what and for what.

A  better,more focused claim is that ablation is better than drugs to convert atrial fibrillation to normal sinus rhythm.That issue arises only after the decision of rate versus rhythm control has been made.There is convincing evidence to that point that ablation works better. There is also general agreement that patients feel better with a sinus rhythm than when their atria are fibrillating.Atrial fibrillation is a bad method of running a cardiac pump.

What has not been proven with randomized clinical trials is that ablation results in longer lives and fewer strokes.

The recently presented CABANA trial (https://www.acc.org/latest-in-cardiology/clinical-trials/2018/05/10/15/57/cabana) was long awaited and was hoped to answer that question

This was a large (n=2204),multicenter trial  with five year followup comparing standard AF ablation procedure with either rhythm or rate control medication.When the data were analyzed by the venerable,preferred, orthodox method of analysis ( intention-to-treat or ITT) there was no difference in the combined end points of death,disabling stroke,or cardiac arrest nor was there for each component of the combined end point.

ITT is also referred to as "once randomized always analyzed". If 1,000 were assigned to medication and another 1000 assigned to ablation, all of the Medication group would be analyzed according to the group to which they  were assigned even if they switched over to the ablation group. This method is ,according to standard epidemiologic-statistical dogma, is the only analytic approach which will preserved the "integrity of the randomization process." Randomization is done in the first place to control for the effect of known and unknown variables so that the two groups are balanced in regard to prognostic variables. ITT has been called the de facto standard and it is "conservative", i.e it minimizes Type I error,  it is less likely to show a difference when there is no difference. In criticism of ITT one could say it is too conservative and more susceptible to Type II .

Per protocol analysis (PPA) compares treatment groups that include only those who completed the treatment as originally allocated.Whereas ITT makes the two treatments look similar PPA is more able to how differences.

When PPA was applied to the CABANA data there was demonstrated a decrease in mortality in the ablation group.So there are dueling conclusions based on the method of analysis.(1)

My argument is that regardless of there being no difference in mortality (or maybe there is a difference favoring ablation depending of what analysis you prefer) ablation works better to decrease atrial fibrillation and people feel better without AF and the procedure is safe. It is safe according to either way  you analyze CABANA and we already knew it was safe. The extensive data from Cleveland Clinic  (2) makes that clear. So you do not have to believe that ablation save lives or decreases strokes to favor ablation over rhythm control medication, but of course ablation is not for everyone.

After the data were presented the predictable flurry of spin emerged touting the results  of the PPA and of the "as treated "data.But the EP folks did not really need an alternative analysis to continue with business as usual as ablation is safe,it works better and when successful in decreasing or eliminating the atrial fibrillation "burden" there is better quality of life.

This is certainty not a recommendation to treat everyone with af with ablation but rather an argument in favor of ablation over medication for rhythm control.For  many patients for various clinical reasons, rate control may be the better choice and  a trial of rhythm control meds before ablation is a reasonable and common approach.

1) "...a man hears what he wants to hear and disregards the rest".The Boxer, Simon  and Garfunkel.1982

2)Rehman,KA Life-threatening complications of atrial fibrillation ablation. 16 year experience in a large tertiary care cohort. JACC,March2019, vol 5 no. 3, p 284
(fifteen year period,10,278 patients, no deaths, 100 life threatening complications (mainly pericardial effusions and stroke),no aorto-esophageal fistulas,

Addendum: 10/30/19 This article from the Nov.2019, Journal of American College of Cardiology by Cheng et al presents data suggesting that the Cleveland Clinic experience may not be universal.
http://www.onlinejacc.org/content/74/18/2254?download=true

Does a high coronary calcium score in long time endurance athletes mean greater mortality

Another article (2)  has  been published regarding the proposed relationship between high level endurance exercise and coronary calcification.

 We get this comment from the chief science officer and CEO of the Cooper Institute , Dr. Laura DeFina :

" The key question addressed in the present study was whether the presence of a high CAC associated with high levels of exercise training as typically practiced by masters marathon runners is associated with greater mortality.For this question,the answer is clearly no"

During times when I am influenced by Lily Tomlin's observation (1) I tend to think - perhaps unfairly-of studies such as these as coarse-grain,multi-comparison, big "n" small "RRs" fishing trips.

It is big n  study with 21,758 men followed for about ten years. The significance of n size is that with large numbers,small differences may be statistically significant but not clinically important. The point of saying multi-comparison is that sometimes researchers will do many regressions that may or may not be mentioned in the article searching for a p value of statistical significance. ( I ,of course, am not accusing authors of this article with that practice.)This article cannot be considered fishing as earlier work has suggested that high or very high levels of endurance exercise are associated with more coronary calcification but no increase and possibly a decrease in cardiac disease mortality.This article seems consistent with that notion.

We also get this quote from Dr. Carl Lavie : " Despite the fact that this type of high volume physical activity and exercise may promote calcific coronary atherosclerosis, it appears to still be associated with safety and possible lower mortality risks" Dr. Lavie has written several articles with Dr. James O'Keefe arguing that some relatively low level of exercise described as "excessive" would increase one's risk of death but has subsequently softened views what is excessive.

The analogy with the more potent statins and more coronary artery calcifications and lower C-V mortality seems obvious



1) Lilly Tomlin: No matter how cynical you become its never enough.


2)DeFina, LF et al ,"Association of all cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification. JAMA Cardiol 2019 4 (2)174

Is it possible for experts to determine objective high value health care

Is value objective or subjective?

A common, though oversimplified and exaggerated view,  is that Adam Smith was the father of economics. His views were published in 1776 in his Wealth of Nations.He along with several other early giants of classical economists,David Ricardo,John S. Mill, promoted the Labor theory of value. Karl Marx continued that line of thinking in 1867 in his magnum opus Capital  in which he said " If a pair of shoes usually takes twice as long to produce as a pair of pants,for example then..the competitive price of shoes will be twice the price of pants."

Lawrence H, White , in his book The Clash of Economic Ideas talks about what he describes as the fundamental flaw in the labor theory of value is "its supposition that the price of a good reflects an intrinsic feature of the good,...rather than something in the minds of its buyers". The belief was that input costs determines the selling price rather than the reverse.

It was not until 1871 that the labor theory  of value was displaced by what is known as the subjective or marginal utility theory of value. Karl Menger one of the three co-founders of this idea,who worked independently, said in his Principles of Economics , "Goods always have value to certain economizing individuals and this value is also determined only by those individuals."

Simply put the value of a good or service is the subjective evaluation of the buyer.

In fact,it is this subjective value that underlies exchange-Fred values the apple more than dollar he give the grocer who in turn value the dollar more than the apple.Both  typically thank each other as exchange is mutually beneficial.


So since the late 19th century economists of almost all stripes have agreed that value is subjective.
If this is the overwhelming consensus views of economists what is the rationale or justification for organizations such as the American College of Physicians and others to  claim to be able to determine which medical procedures and treatments are "high value". Are they claiming that value is objective,that they can determine scientifically the real value,and further determine which values are high enough to merit the designation "High value"

First how is value determined by health outcome experts and how is a value determination judged to be "high". Is the process objective and scientific all the way down or is it the case that at some point someone's subjective value is inserted .

Through clinical research it is possible to determine if the outcome of treatment X versus treatment Y is better in terms of survival.So one could talk about life years saved by treatment X versus treatment Y-this is clinical effectiveness research.X is better-more effective than Y in terms of simple survival. But to determine value cost has to be injected into the analysis.How much did X cost versus how much did Y cost.,then one could look at life years saved per dollars and compare X  and Y in that way.

Obviously  years lived  per se is not the only relevant outcome to consider.How one lives (pain,mobility,level of cognition etc) are all important and those and other elements are lumped under the heading "quality of life" (QOL). Measuring quality to transform life years into quality adjusted life years is a difficult and ambiguous slippery  area and we will defer a discussion about whether than can ever be done for later but for discussion we'll assume that something called quality adjusted life years(QALY) can measured. (I seriously doubt that it can be measured  because in part I do not believe you can aggregate quality of life.I doubt that it is meaningful to add Frank and Fred's  quality of life and transform that some aggregate of quality years.)

After the QALY are determined for procedure X and Y then in theory one can sum the cost of the two procedures and then derive a ratio of QALY s per dollar spent. Ignoring for the moment the difficulties and ultimately the arbitrary nature  of teasing out cost from charges in the context of what is certainty not a free market unencumbered by price control  but rather one whose costs exist behind a veil of various variable negotiated prices between providers groups and third party payers with an even more opaque series of subsidies and discounts.


When you brush past the bewildering display of statistical artifacts and step to view the overall landscape what you see is another utilitarian procedure. Some new wine is there but the bottles are stamped underneath with the imprint  "utilitarian analysis" A  resurrection of Benthams "greatest good for the greatest number." in the form of a cost benefit analysis done in the tradition of and with the tools of Neo-classical economics.

Has the movement to debase medical ethics become a done deal now

In 2013,  when I posted the essay found below in a slightly revised version found ,there was still considerable resistance to the "New Medical Professionalism" which had been introduced in 2002 by the American College of Physicians and the European Federations of Internal Medicine. and published in the Annals of Internal Medicine in an article entitled  "Medical Professionalism in the New Millennium: A Physician's Charter." Numerous medical blogs protested and there was some public debates.Now I find little comment or concern about what I believe was a effort to destroy traditional medical ethics.

Here is my earlier essay entitled "The Great Linguistic Coup of 21Th Century Medical Ethics"

"George H. Smith in his book "The System of Liberty" in the chapter entitled "Liberalism,Old and New" discusses how the concept of liberalism and its advocates were victims of a linguistic coup in the latter part  of the nineteenth century.

 The classic liberals considered freedom as the absence of coercion.They championed   limited government whose function was to secure the rights of individuals.Enter a group of thinkers who proposed a " new liberalism" , one that would,in their view, correct this inadequate,limited definition of freedom.To the newcomers liberty without equality was freedom in name only  and true freedom involved equal opportunity and power to enjoy one's life. They wanted to replace the idea of "negative freedom" of the classical liberals with what would become  the focus  of  the welfare state.True freedom in their view was more than mere removal of compulsion or coercion.  The new liberals were paternalistic and believed  the state should do much more than secure the people from internal and external predators but rather protect them from the effects of their own uncoerced actions.The classic liberals defended their position in part by asserting that the new liberalism was old wine in new bottles, with the wine being advocacy for a paternalistic government.The new liberals continued to dispense rhetoric that seemingly supported liberty but they had redefined the word liberty.

The new liberals won the day and the old or classic liberals lost much influence  but re-appeared in the 20th century with a new label, libertarian. The new liberals were simply known as liberals and later referred to by some as progressives.

I argue analogously that the traditional ,classical medical ethics and its advocates ( physicians themselves) were victims of a similar linguistic coup. Throughout most of the 20th century and earlier the core of medical ethics was primacy of patient welfare and respect of the autonomy of the patient,the later gradually replacing an older paternalism of medicine.Physicians were considered to have a fiduciary duty to the patient.

At the end of the 20th century and the early years of the 21th century a new medical ethics emerged,one in which -while  its proponents claimed nothing had really changed-there was a radical sea-change in regard to the duties of the physician.This was accomplished by nothing more rhetorically solid based  or intellectually justified  than a simple gratuitous assertion.The notion of social justice was simply declared to be part of medical professionalism and medical ethics.The degree to which this bogus concept has been accepted and endlessly repeated in medical publications is a tragic shame.The victims of this linguistic coup are the physicians themselves but to a greater degree the patients are the real losers as they have lost their advocates at a time when they may need them the most.