Knowledge is power. Doctors should empower their patients by teaching them how to use new technology. I had an optometrist that hid the fact I had cataracts because he suspected I would replace him for a competent ophthalmologist and the surgical solution for my poor eyesight. He was replaced quickly when his new associate let the cat out of the bag. Some doctors fear the loss of control. They deserve to be fired.
This trial adds vitally to our knowledge base. And still leaves much unanswered. And the study design led to some interesting questions.
First, we already knew from AVERROES that for “clinical” AF, FXa inhibitors are superior to ASA…and in fact ASA is no longer used for “stroke prevention”. We also know that ASA increases bleeding risk. So this trial essentially compared Apixaban with placebo for efficacy, while using “active comparator” for safety. In practice, when the treatment choice is Apix vs nothing, there will be no change to the efficacy size seen here, but the actual additional bleeding risk with Apix will be even higher. (Thankfully, at least there seems to be no signal of fatal bleeds or ICH, as you noted).
Second, the paper discussed stroke severity…which is an interesting deviation from simply counting all embolic events equally. It does seem that AF strokes may be more life changing than other strokes based on the Rankin score, which adds further nuance to pt discussions and pt choices.
Third, it should be noted that a chadsvasc score of 4 on average would connote an annual stroke rate of about 5% (for someone with “clinical AF”)…..but the placebo/ASA group event rate was only 1.26 % per year. So the “stroke risk” for subclinical device detected AF (anywhere from 6 min to 24 hours, based on trial design) is substantially lower than that of manifest “clinical AF” for someone with an identical risk score.
And fourth, the absolute risk reduction effect size is small, with an NNT about 200.
For me, I don’t think the results (with divergent stroke and bleeding effects) will lend itself to any “thou shalt” guideline decrees, which is the best part. Some pts will opt to avoid bad strokes, which is fair; others will choose to avoid actual bleeding risk larger than suggested by trial result, which is also fair. I await future papers where hopefully they will stratify events within the 6 minutes-24 hours window, to see if there is any inflection point above which one accrues better risk benefit tradeoffs. Hopefully the pt-level meta-analysis with NOAH will inform in this regard. But as you note, we are still nowhere as far as wearables is concerned.
No, I’m saying no one uses ASA for AF stroke prevention in 2023….and so the real world difference in bleeding risk btw apix vs placebo would be larger than that seen in the study discussed here.
Of course ASA continues to be used in secondary prevention…including for thrombotic stroke events….and rightfully so. That is a separate discussion from AF cardioembolic stroke prevention.
“Aspirin might be more efficacious for AF patients with hypertension or diabetes (213,214) and for reducing noncardioembolic versus cardioembolic ischemic strokes (49). Cardioembolic strokes are, on average, more disabling than noncardioembolic strokes (69).” https://www.ahajournals.org/doi/full/10.1161/circ.104.17.2118
Lol. “Aspirin might be” a lot of things. But I’ll wait for the RCT demonstrating that “aspirin IS” before using it or recommending it to pts for the purpose of AF stroke prevention. . YMMV.
I’d say you had me ALL THE WAY till you combined the words “administrator” and “talented.” Other than that I love the article and I sure am glad you are on substack! My dad used to say, “The nature of science is to go down a road, find or not find what you’re looking for, and go down the next road! Somewhere along the line we learn something!”
Anticoagulants are not the only way of treating A-fib. Yes, it helps with clots which can kill, but what about addressing the cause of A-fib itself? Clots are only a symptom of A-fib, if patients can do much on their own to control A-fib. Why wouldn’t you want them to know so they can take action!?!
Those are good questions. I think the detection of atrial fibrillation should lead to an examination and probably an echocardiogram to rule out certain structural causes of arrhythmia. I have always wondered about the true incidence of clots from the atrium causing thrombotic stroke. I don't know what evidence there is for this. Why isn't it more likely that most clots which end up in the cranial circulation originate from disruption of plaques in the carotid arteries much like it is thought that this is the mechanism for clots in the coronary arteries causing myocardial infarctions. I don't know of any way to document the origin of thrombotic strokes and would appreciate some references on the subject from anyone who does know.
A Fib is mostly iatrogenic. It results from high rT3 and/or low T3. After shock, surgery, etc., the T3 often drops and rT3 may go up. A Fib results. I discovered it in my health reasearch and it is super easy to fix. Anyone getting surgery should be prescribed a T3 supplement to take small amounts of during the days before and after surgery.
Has anyone done a similar study with a CGM? I suspect many folks may have normal glucose spikes and believe they are prediabetic especially if they have been on a low carb diet.
I'm surprised that you not only mentioned articles you considered "embarrassing" and "forgettable," but you actually linked to them - impressive! Not many would do that. (For what it's worth, I think the "forgettable" study examined a worthy topic; not all research is about breakthroughs. I also learned the correct way to spell "forgettable!"). My question is, if a very wise and "sensible" doctor like you can publish research you now view in such a negative light, does that mean we get wiser as we gain experience, or that the pressure to publish (especially at the time) was so strong it led to research you would likely criticize in "Sensible Medicine" if it were published today? If it's the latter, I surely hope the pressure today is a LOT less!
Well, those are tougher questions than I bargained for. I do think we all get better with time and do a better job of addressing more important topics. However, I do think the pressure to publish, especially early in your career (when you are worse), leads to a lot of drivel in the medical literature.
Sorry! Hopefully those young drivel producers read your Substack and learn. Maybe journal editors should require authors to include "years of experience" along with year of publication.
No, I'm not excusing them, I just didn't want to write a treatise which I tend to do. If you're implying I didn't explicitly mention editors so I wouldn't hurt my chances of getting work published, no again. I'm not a physician, I'm retired, and I only published one journal article in my life aeons ago because my dissertation advisor pushed me to. One of the reasons I chose not to go into academia is because of the "publish or perish" pressure.
As a cardiologist who has spent now close to 50 years reading articles - not only does your writing on Substack count for something ; if it was up to me and I was on ACC BOT at one point - I would grant MOC credit for reading (or writing ) .
As an intern I lamented to a resident that I was struggling to remember the correct dose of meds to give in a code - he said " Matt if you know the right med to use to save the persons life someone will get you the dose "- exactly . These articles are very useful as they allow us to recognize what is important in the noise that is the current literature .
Wonderful article. It was similar to an article that was linked to something I read elsewhere that led me to this web site a couple of months ago. We need more of this. Medical journals and popular media are full of articles touting drugs, diets, and other and remedies for prevention that have no scientific backing. Skepticism is often used as a pejorative term. But there is a reason that "First do no harm" is listed first. Every doctor should be a skeptic---you owe it to your patients.
This particular area of medicine has overdiagnosis/overtreatment written all over it. Adam and Vinay were prescient to have identified this possibility years ago. Current risk assessment is inadequate as Chads-vasc does not capture the nuance required to engage in good clinical decision making. When the provider assesses a frail, demented patient with AF, a guideline based mindset goes out the window. Big Pharma is also front and center here. Too much information promotes the cause of increased sales.
Asymptomatic afib means exactly what it sounds like! Some people, like you, feel it every time they go into an arrhythmia (n.b.: afib and aflutter are different beasts), but it is VERY common to be totally asymptomatic. (More common with afib than with aflutter, I would say.)
I need to buy a new heart rate monitor watch for when I work out, and I was all set to buy the cheap version without an ECG until I read your comment. So now you've got me thinking I should buy the ECG watch, but then I wonder if some cardiologist would want me to go on meds if I have a fib whether I need them or not! INDECISIONS! :( How common is continuous a fib, and wouldn't there more likely be noticeable symptoms if you have it? Like Kareem?
I think seeing Kareem in the a fib ad each time you turn on the TV has a very high odds ratio! :) I hope a smart cardiologist will take you up on your suggestion, hint, hint! If the topic has not been investigated, somebody should do the study. HINT, HINT! Thanks for your time in answering.
Thanks again for your insight!
Knowledge is power. Doctors should empower their patients by teaching them how to use new technology. I had an optometrist that hid the fact I had cataracts because he suspected I would replace him for a competent ophthalmologist and the surgical solution for my poor eyesight. He was replaced quickly when his new associate let the cat out of the bag. Some doctors fear the loss of control. They deserve to be fired.
This trial adds vitally to our knowledge base. And still leaves much unanswered. And the study design led to some interesting questions.
First, we already knew from AVERROES that for “clinical” AF, FXa inhibitors are superior to ASA…and in fact ASA is no longer used for “stroke prevention”. We also know that ASA increases bleeding risk. So this trial essentially compared Apixaban with placebo for efficacy, while using “active comparator” for safety. In practice, when the treatment choice is Apix vs nothing, there will be no change to the efficacy size seen here, but the actual additional bleeding risk with Apix will be even higher. (Thankfully, at least there seems to be no signal of fatal bleeds or ICH, as you noted).
Second, the paper discussed stroke severity…which is an interesting deviation from simply counting all embolic events equally. It does seem that AF strokes may be more life changing than other strokes based on the Rankin score, which adds further nuance to pt discussions and pt choices.
Third, it should be noted that a chadsvasc score of 4 on average would connote an annual stroke rate of about 5% (for someone with “clinical AF”)…..but the placebo/ASA group event rate was only 1.26 % per year. So the “stroke risk” for subclinical device detected AF (anywhere from 6 min to 24 hours, based on trial design) is substantially lower than that of manifest “clinical AF” for someone with an identical risk score.
And fourth, the absolute risk reduction effect size is small, with an NNT about 200.
For me, I don’t think the results (with divergent stroke and bleeding effects) will lend itself to any “thou shalt” guideline decrees, which is the best part. Some pts will opt to avoid bad strokes, which is fair; others will choose to avoid actual bleeding risk larger than suggested by trial result, which is also fair. I await future papers where hopefully they will stratify events within the 6 minutes-24 hours window, to see if there is any inflection point above which one accrues better risk benefit tradeoffs. Hopefully the pt-level meta-analysis with NOAH will inform in this regard. But as you note, we are still nowhere as far as wearables is concerned.
Are you saying that Eliquis doesn’t increase bleeding problems? You mean YOU don’t use ASA. You might want to tell Johns Hopkins that aspirin doesn’t work:https://www.hopkinsmedicine.org/health/wellness-and-prevention/is-taking-aspirin-good-for-your-heart
No, I’m saying no one uses ASA for AF stroke prevention in 2023….and so the real world difference in bleeding risk btw apix vs placebo would be larger than that seen in the study discussed here.
Of course ASA continues to be used in secondary prevention…including for thrombotic stroke events….and rightfully so. That is a separate discussion from AF cardioembolic stroke prevention.
“Aspirin might be more efficacious for AF patients with hypertension or diabetes (213,214) and for reducing noncardioembolic versus cardioembolic ischemic strokes (49). Cardioembolic strokes are, on average, more disabling than noncardioembolic strokes (69).” https://www.ahajournals.org/doi/full/10.1161/circ.104.17.2118
Lol. “Aspirin might be” a lot of things. But I’ll wait for the RCT demonstrating that “aspirin IS” before using it or recommending it to pts for the purpose of AF stroke prevention. . YMMV.
I’d say you had me ALL THE WAY till you combined the words “administrator” and “talented.” Other than that I love the article and I sure am glad you are on substack! My dad used to say, “The nature of science is to go down a road, find or not find what you’re looking for, and go down the next road! Somewhere along the line we learn something!”
Anticoagulants are not the only way of treating A-fib. Yes, it helps with clots which can kill, but what about addressing the cause of A-fib itself? Clots are only a symptom of A-fib, if patients can do much on their own to control A-fib. Why wouldn’t you want them to know so they can take action!?!
Those are good questions. I think the detection of atrial fibrillation should lead to an examination and probably an echocardiogram to rule out certain structural causes of arrhythmia. I have always wondered about the true incidence of clots from the atrium causing thrombotic stroke. I don't know what evidence there is for this. Why isn't it more likely that most clots which end up in the cranial circulation originate from disruption of plaques in the carotid arteries much like it is thought that this is the mechanism for clots in the coronary arteries causing myocardial infarctions. I don't know of any way to document the origin of thrombotic strokes and would appreciate some references on the subject from anyone who does know.
A Fib is mostly iatrogenic. It results from high rT3 and/or low T3. After shock, surgery, etc., the T3 often drops and rT3 may go up. A Fib results. I discovered it in my health reasearch and it is super easy to fix. Anyone getting surgery should be prescribed a T3 supplement to take small amounts of during the days before and after surgery.
Has anyone done a similar study with a CGM? I suspect many folks may have normal glucose spikes and believe they are prediabetic especially if they have been on a low carb diet.
https://www.sensible-med.com/p/in-pursuit-of-the-flat-line
I'm surprised that you not only mentioned articles you considered "embarrassing" and "forgettable," but you actually linked to them - impressive! Not many would do that. (For what it's worth, I think the "forgettable" study examined a worthy topic; not all research is about breakthroughs. I also learned the correct way to spell "forgettable!"). My question is, if a very wise and "sensible" doctor like you can publish research you now view in such a negative light, does that mean we get wiser as we gain experience, or that the pressure to publish (especially at the time) was so strong it led to research you would likely criticize in "Sensible Medicine" if it were published today? If it's the latter, I surely hope the pressure today is a LOT less!
Well, those are tougher questions than I bargained for. I do think we all get better with time and do a better job of addressing more important topics. However, I do think the pressure to publish, especially early in your career (when you are worse), leads to a lot of drivel in the medical literature.
Sorry! Hopefully those young drivel producers read your Substack and learn. Maybe journal editors should require authors to include "years of experience" along with year of publication.
Really. Are you excusing the editors of the journals for their part in promoting bad science? Is this just a case of brown nose?
No, I'm not excusing them, I just didn't want to write a treatise which I tend to do. If you're implying I didn't explicitly mention editors so I wouldn't hurt my chances of getting work published, no again. I'm not a physician, I'm retired, and I only published one journal article in my life aeons ago because my dissertation advisor pushed me to. One of the reasons I chose not to go into academia is because of the "publish or perish" pressure.
As a cardiologist who has spent now close to 50 years reading articles - not only does your writing on Substack count for something ; if it was up to me and I was on ACC BOT at one point - I would grant MOC credit for reading (or writing ) .
As an intern I lamented to a resident that I was struggling to remember the correct dose of meds to give in a code - he said " Matt if you know the right med to use to save the persons life someone will get you the dose "- exactly . These articles are very useful as they allow us to recognize what is important in the noise that is the current literature .
Wonderful article. It was similar to an article that was linked to something I read elsewhere that led me to this web site a couple of months ago. We need more of this. Medical journals and popular media are full of articles touting drugs, diets, and other and remedies for prevention that have no scientific backing. Skepticism is often used as a pejorative term. But there is a reason that "First do no harm" is listed first. Every doctor should be a skeptic---you owe it to your patients.
This particular area of medicine has overdiagnosis/overtreatment written all over it. Adam and Vinay were prescient to have identified this possibility years ago. Current risk assessment is inadequate as Chads-vasc does not capture the nuance required to engage in good clinical decision making. When the provider assesses a frail, demented patient with AF, a guideline based mindset goes out the window. Big Pharma is also front and center here. Too much information promotes the cause of increased sales.
Yes, why treat someone with dementia? Help them out the door ASAP. ☠️
I'm a layperson with occasional atrial flutter. What does "asymptomatic" afib mean? I can sure feel mine every time it happens.
Asymptomatic afib means exactly what it sounds like! Some people, like you, feel it every time they go into an arrhythmia (n.b.: afib and aflutter are different beasts), but it is VERY common to be totally asymptomatic. (More common with afib than with aflutter, I would say.)
"I'm still hoping for a time that publishing thoughtful articles on Substack counts for something."
🙂
I thought aspirin as a stroke prevention method in afib was proved ineffective??
Eliquis brings in 🤑 than aspirin.
And some of us can't tolerate Eliquis.
Ding ding ding!!!!
Hey, Doc, publishing thoughtful articles on Substack DOES count for something! Thank you!
🎯
I need to buy a new heart rate monitor watch for when I work out, and I was all set to buy the cheap version without an ECG until I read your comment. So now you've got me thinking I should buy the ECG watch, but then I wonder if some cardiologist would want me to go on meds if I have a fib whether I need them or not! INDECISIONS! :( How common is continuous a fib, and wouldn't there more likely be noticeable symptoms if you have it? Like Kareem?
I think seeing Kareem in the a fib ad each time you turn on the TV has a very high odds ratio! :) I hope a smart cardiologist will take you up on your suggestion, hint, hint! If the topic has not been investigated, somebody should do the study. HINT, HINT! Thanks for your time in answering.