The American Journal of Medicine, Vol 123, No 3,Pages e1-290 (March 2010)

130 Pages·1989·4.72 MB·English

by  Editor-in-Chief: Joseph S. Alpert

THE AMERICAN
JOURNAL of
www.amjmed.com
MEDICINE® CONTENTS
The Green Journal March 2010 Volume 123/Number 3
COMMENTARIES UPDATE IN OFFICE MANAGEMENT
193 We Can Reduce US Health Care Costs 213 Diabetic Retinopathy: An Update on Treatment
James E. Dalen Ryan J. Fante, Vikram D. Durairaj, and
Scott C.N. Oliver
195 Reexamining the Physician Scholar–Professional
Organization Relationship
Stephen A. Geraci CLINICAL EFFECTIVENESS
217 The Improving Continuous Cardiac Care (IC3)
Program and Outpatient Quality Improvement
EDITORIAL Paul S. Chan, William J. Oetgen, and
197 Thank You, Thank You, Thank You John A. Spertus
Joseph S. Alpert
DIAGNOSTIC DILEMMA
REVIEWS 220 Exotic Origin, Familiar Culprit
Tinsay A. Woreta, Leonard S. Feldman, and
198 Atrial Fibrillation in Heart Failure: Rosalyn W. Stewart
A Comprehensive Review
Prakash C. Deedwania and Joel A. Lardizabal
Chronic heart failure and atrial fibrillation are IMAGES IN DERMATOLOGY
major cardiovascular disorders that are fre- 223 A Post-cure Complication
quently associated with each other. A closer un- Joana Nunes, Rui Tato Marinho, and Jose´ Velosa
derstanding of the intricate relationship between
these two disorders could improve the approach
to their management. ECG IMAGE OF THE MONTH
205 Primary Care of the Transplant Patient 225 Computer Calls for Cardiology Consult STAT!
Peggy B. Hasley and Robert M. Arnold Charles Broy
Thousands of organ transplant survivors are liv-
ing in the United States. Given the high 5-year
IMAGES IN RADIOLOGY
survival rates after transplantation, it is important
for primary care physicians to understand the 228 Diabetes Mellitus and Confusion
nuances of treating and screening this population. Leonard Chow and Gulshan Sharma
A7
CLINICAL RESEARCH STUDIES 267 Higher Incidence of Mild Cognitive Impairment
in Familial Hypercholesterolemia
231 Analgesic Use and the Risk of Hearing Loss
Daniel Zambo´ n, Melibea Quintana, Pedro Mata,
in Men
Rodrigo Alonso, Jaume Benavent,
Sharon G. Curhan, Roland Eavey,
Felix Cruz-Sa´nchez, Jordi Gich, Miguel Pocov´ı,
Josef Shargorodsky, and Gary C. Curhan
Fernando Civeira, Sebastian Capurro,
Regular use of aspirin, acetaminophen and non- David Bachman, Kumar Sambamurti,
steroidal anti-inflammatory drugs, the most com- Joyce Nicholas, and Miguel A. Pappolla
monly used drugs in the US, may increase risk of
Prior studies have shown that older patients with
hearing loss in men.
sporadic hypercholesterolemia do not show a higher
238 Notification of Abnormal Lab Test Results in an incidence of mild cognitive impairment. The findings
Electronic Medical Record: Do Any Safety presented in this study suggest that early exposure to
Concerns Remain? elevated cholesterol or LDL receptor dysfunction
Hardeep Singh, Eric J. Thomas, Dean F. Sittig, may be risk factors for mild cognitive impairment.
Lindsey Wilson, Donna Espadas, Myrna M. Khan,
275 Adoption of Once-monthly Oral
and Laura A. Petersen
Bisphosphonates and the Impact on Adherence
Missed abnormal laboratory results are a sig- Becky A. Briesacher, Susan E. Andrade,
nificant reason for outpatient diagnostic errors, Leslie R. Harrold, Hassan Fouayzi, Robert A. Yood
adverse events, and liability claims. Even with
Low adherence occurs with all oral dosing formu-
automated notifications systems, almost 7% of
lations of bisphosphonates (daily, weekly, and
notifications lack follow-up 30 days after trans-
monthly). Merely reducing the dosing frequency of
mission.
oral bisphosphonates will not improve adherence.
245 Orthostatic Syndromes Differ in Syncope The worst adherence is associated with daily dosing.
Frequency
Ajitesh Ojha, Kevin McNeeley, Elizabeth Heller,
AJM ONLINE
Amer Alshekhlee, Gisela Chelimsky, and
Thomas C. Chelimsky
The results of this clinical study demonstrate that
Please note that articles with an “e” page
syncope (both tilt-table and clinical) occurs far
designation are available only in the online
more commonly in patients who have postural
version of the Journal at www.amjmed.com.
tachycardia syndrome than in patients with ortho-
static hypotension.
250 Long-term Effect of Chronic Oral REVIEW
Anticoagulation with Warfarin after Acute
281.e1 Postprandial Hypotension
Myocardial Infarction
Gina L. Luciano, Maura J. Brennan, and
Salman A. Haq, John F. Heitner,
Michael B. Rothberg
Terrence J. Sacchi, and Sorin J. Brener
Postprandial hypotension is common and under-
As compared with placebo or aspirin, oral anti-
recognized among the elderly. It is a common
coagulation with or without aspirin does not re-
cause of falls, syncope, and stroke. Diagnosis
duce mortality or reinfarction but does reduce
should be made based upon ambulatory blood
stroke. Unfortunately, it is associated with signif-
pressure monitoring and symptoms.
icantly more bleeding.
259 Acute Myocardial Infarction Hospitalization in
CLINICAL RESEARCH STUDY
the United States, 1979 to 2005
Jing Fang, Michael H. Alderman, Nora L. Keenan, 281.e7 Physical Activity and the Risk of Community-
and Carma Ayala acquired Pneumonia in US Women
Mark I. Neuman, Walter C. Willett, and
Over the past quarter century, hospitalizations for
Gary C. Curhan
acute myocardial infarction rose until the mid-
1990s and have declined since then. At the same Higher overall physical activity does not substan-
time, in-hospital case-fatality rates declined tially reduce pneumonia risk in well-nourished
steadily; this decline has been associated with women. Women who walk the most are less likely to
more aggressive therapeutic intervention. develop pneumonia than women who walk the least.
A8
CLINICAL COMMUNICATIONS TO THE EDITOR e15 Program Director Satisfaction Revisited:
An Alternate View
e1 Polymyalgia Rheumatica with Bilateral
Gregory C. Kane
Subclavian Artery Stenosis
Daniela Ghetie, Alla Rudinskaya, and e17 The Reply
Alan Dietzek Kevin T. Hinchey, Furman S. McDonald, and
Brent W. Beasley
e3 Nocturia: An Uncommon Presentation of
Lower-Limb Lymphedema
e19 Influence of Hispanic Ethnicity and Diabetic
Paola Cagnati, Barbara M. Colombo,
End-stage Renal Disease
Rossella Gulli, Rodolfo Russo, Francesco Puppo,
Patricio A. Pazmiño
Francesco Boccardo, Corradino Campisi, and
Giuseppe Murdaca e21 The Reply
Andy I. Choi, German T. Hernandez,
e5 Eroded Pacemaker in an Elderly Patient
Rudolph A. Rodriguez, and Ann M. O’Hare
Eliza Heather McCaw, Bryan Ristow, and
Richard Hongo
e7 Relief of Chronic Neuropathic Pain through
BRIEF OBSERVATION
Endothelin Antagonism
Desmond M. Murphy, Dermot S. O’Callaghan, 282 Severe H1N1-Associated Acute Respiratory
and Sean P. Gaine Distress Syndrome: A Case Series
Andrew R. Lai, Kevin Keet, Celina M. Yong, and
e9 Transient Collateral Circulation during
Janet V. Diaz
Coronary Vasospasm
Shigemasa Tani, Shingo Furuya, Ken Nagao, and
Atsushi Hirayama
e11 Bromide Toxicity from Consumption of Dead APM PERSPECTIVES
Sea Salt
286 Measuring Resident Hours by Tracking
Brent R. Taylor, Romina Sosa, and
Interactions with the Computerized Record
William J. Stone
Daniel Shine, Ellen Pearlman, and
Brendan Watkins
LETTERS
e13 Emergence of Fluoroquinolone Resistance in
CLASSIFIED ADS
Outpatient Urinary Escherichia Coli Isolates
Franc¸ois Caron and Manuel Etienne B1 Positions available
A9
COMMENTARY
We Can Reduce US Health Care Costs
10
The primary reason that the US needs health care reform is tice, and 19% chose internal medicine. Only a minority of
that we pay more for health care than any other country in those choosing internal medicine will become general in-
the world; yet our health outcomes are below that of other ternists; the majority will become subspecialists or hospi-
1
western nations. Our health outcomes are suboptimal be- talists. Hauer et al reported that only 2% of US senior MD
cause millions of Americans have limited access to ongoing medical students planned to have a career in general internal
11
primary and preventive care because they can’t afford our medicine.
health insurance. One reason that medical students enter specialties is that
the average educational debt of the class of 2008 MD
12
graduates was $150,000. This influences many graduates
REDUCING ADMINISTRATIVE COSTS
to enter specialties that pay, on average, twice as much as
We spend more than a third of our health care dollars on
primary care so that they can pay off their educational
overhead and administration: billing, advertising, profits, 13
2,3 debt.
and bonuses for health care executives. Administrative
To influence more physicians to choose primary care we
costs in countries such as Canada that have a single payer
need to pay off their educational debt if they choose and
(non-profit national health insurance) are half as much as in
2 remain in primary care. In addition, they should receive an
the US. If we had a single payer instead of hundreds of
annual stipend for each Medicare patient for whom they
insurers with thousands of different plans, we would save
coordinate care and provide a medical home. These stipends
15% of our health care costs. Fifteen per cent of trillions
added to their fee for service income should provide an
adds up!
income comparable to the average specialist. This would be
A Price Waterhouse Coopers study reported that our
an excellent investment for Medicare. If each primary care
complex, fragmented health care delivery system wastes
physician can avoid 1 unnecessary hospitalization or even 1
$210 billion per year on unnecessary billing and adminis-
4 expensive but unnecessary test for each patient, Medicare
trative costs. The ultimate solution to our excessive health
5 will come out far ahead!
care costs is national health insurance: Medicare for all ; but
To be effective in prevention, primary care physicians
that won’t happen–at least not in the very near future. What
must have certain skills that our current medical school
can we do to decrease health care costs now?
curriculum does not provide adequately. We offer minimal
training in nutrition, prescribed exercise, stress reduction
FOCUS ON PREVENTIVE CARE techniques, and other effective therapies for certain condi-
We need to change our focus from disease management to tions, for example, acupuncture for specific chronic pain
prevention and health promotion. To change our focus to syndromes.
prevention we need more primary care physicians, family
physicians, and general internists. Multiple studies have
ELIMINATE UNNECESSARY TESTS AND
shown that generalists practice more cost-effective medi-
PROCEDURES
cine than specialists and that their patients have better health
outcomes.6-8 In addition to training a new cadre of adult generalists with
Due to poor planning, currently we have an overall expertise in prevention, we must ensure that all physicians
shortage of physicians in the US.9 The number of medical (specialists and generalists) practice cost-effective medi-
students recently has increased, but we have an even greater cine. At the present time, physicians vary tremendously in
problem. The number of US MD graduates choosing pri- their use of expensive diagnostic tests and treatments. The
mary care careers keeps decreasing. In the 2009 National average cost of treating a Medicare patient in some parts of
14
Residency Match, only 7% of graduates chose family prac- the country is twice as expensive as in other areas. The
most expensive cities have more hospitalizations, and phy-
sician visits and their physicians order more expensive di-
Funding: None.
Conflict of Interest: None. agnostic tests and procedures. There is no ev1id4ence that
Authorship: Dr Dalen is the sole author of this manuscript and had full the more expensive treatment benefits patients. Much of
access to the data. the excessive treatment and unnecessary testing occurs at
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2009.12.011
194 The American Journal of Medicine, Vol 123, No 3, March 2010
the end of life. We must encourage all citizens to have living Finally, at some point in the future, we should adopt a
wills to avoid unwanted procedures at the end of life. policy of national health insurance, Medicare for all.
Many unnecessary tests are performed to prevent mal-
James E. Dalen, MD, MPH
practice suits. Kessler and McClellan, in 1996, estimated the
University of Arizona College of Medicine
annual cost of defensive medicine to be as much as $50
15 Tucson
billion per year. It must be much higher at present. We
need malpractice reform including limits on awards for pain
References
and suffering. Our current system of paying millions of
1. Organization for Economic Co-operation and Development. Health at
dollars to patients and their attorneys when malpractice is
a glance: 2007 OECD Indicators.
documented does not prevent malpractice. We need to re-
2. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care
quire retraining of physicians who are shown to practice administration in the United States and Canada. N Engl J Med. 2003;
substandard medicine. We need to suspend or deny partic- 349:768-775.
ipation in Medicare for repeat offenders. 3. Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insur-
ance administration in California: estimates for insurers, physicians,
In addition, we need to increase research funding for
and hospitals. Health Aff. 2005;24:1629-1639.
projects that will help to determine which diagnostic tests
4. PricewaterhouseCoopers Health Research Institute. The price of ex-
and procedures actually benefit specific patients. This re-
cess. http://pwchealth.com/cgi-local/hregister.cgi?link⫽reg/waste.pdf.
search will increase the number of evidence-based practice Accessed December 12, 2009.
guidelines. Medicare should not pay for procedures that do 5. Dalen JE, Alpert JS. National health insurance: could it work in the
not benefit patients. This is not rationing–it is common US? Am J Med. 2008;121:553-554.
6. Baicker K, Chandra A. Medicare spending, the physician workforce,
sense.
and beneficiaries’ quality of care. Health Aff. 2004;W4:184-197.
7. Starfield B, Shi L, Grover A, et al. The effects of specialist supply on
CONTROLLING THE COSTS OF PRESCRIPTION population’s health: assessing the evidence. Health Aff. 2005;W5:97-
107.
DRUGS
8. Kravet SJ, Shore AD, Miller R, et al. Health care utilization and the
Our government must control the prices of prescription proportion of primary care physicians. Am J Med. 2008;121:142-148.
drugs as is done in nearly every other nation. Drug compa- 9. Dalen JE. The moratorium on US medical school enrollment from
nies can charge whatever they wish in the US. Citizens of 1980 to 2005: What were we thinking? Am J Med. 2008;121:e1-e2.
10. National Resident Matching Program, March, 2009. http://www.nrmp.
other nations pay 20% to 40% less for prescription drugs
16 org/data/advancedatatables2009,pdf. Accessed August 18, 2009.
compared with what Americans pay.
11. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with
Millions of Americans have chronic conditions that re-
medical students’ career choices regarding internal medicine. JAMA.
quire life-long medications. If their insurance doesn’t pay
2008;300:1154-1164.
17
for them, or if they fall into Medicare‘s donut hole and 12. Association of American Medical Colleges, 2008. http://www.aamc.
cannot afford prescribed medicines, many patients stop tak- org/newsroom/reporter/dec08/graduates.htm. Accessed August 18,
2009.
ing their medications. The result is increased emergency
13. Bodenheimer T, Berenson RA, Rudolf P. The primary care–specialty
room visits and hospitalizations and a further increase in our
18 gap: Why it matters. Ann Intern Med. 2007;146:301-306.
health care costs.
14. Fisher E, Goodman D, Skinner J, et al. Health care spending, quality,
Some authorities have suggested that if we decrease the
and outcomes. The Dartmouth Institute for Health Policy and Practice.
profits of drug companies they will stop developing new http://www.dartmouthatlas.org/atlases/Spending_Brief_022709.pdf.
drugs. Given that drug companies spend more than twice as Accessed December 9, 2009.
much for marketing and advertising as they do for re- 15. Kessler DP, McClellan M. Do doctors practice defensive medicine? Q
19 J Econ. 1996;111:353-390.
search this is a very unlikely outcome.
16. Danzon PM, Furukawa MF. International prices and availability of
In summary, we must reduce the cost of health care in the
pharmaceuticals in 2005. Health Aff. 2008;27:221-233.
US. We can do this by developing a health care system that
17. Dalen JE. It’s time to bail out US seniors trapped in the Medicare
emphasizes prevention rather than disease management. To donut hole! Am J Med. 2009;122:595-596.
do this we must encourage more physicians to be adult 18. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated
generalists and we must provide them with new skills.20 with prescription drug cost-sharing among poor and elderly persons.
JAMA. 2001;285:421-429.
Furthermore, we must insure that all physicians have cost-
19. Reinhardt UE. Perspectives on the pharmaceutical industry. Health
effective practice patterns that avoid unnecessary tests and
Aff. 2001;20:136-149.
procedures and that all citizens adopt living wills. As a
20. Benn R, Maizes V, Guerrera M, et al. Integrative medicine in resi-
nation, we need to have better control over the cost of dency: assessing curricular needs in eight programs. Fam Med. 2009;
prescription drugs. 41:708-714.
COMMENTARY
Reexamining the Physician Scholar–Professional
Organization Relationship
Physician faculty at most medical schools are expected to nominal honoraria for such work, many are unable to even
establish a “national reputation,” often in part through fully reimburse travel and per diem expenses. The largely
scholarly contributions to national nonprofit professional uncompensated labor (writing, expert opinion and review,
organizations. Yet, those who generate most of their income presentations) provided to such organizations by physician
through clinical work and teaching (ie, clinician scholars, scholars frequently comprise the very products (continuing
clinician educators) find it increasingly difficult to volunteer medical education products, certification courses, examina-
their time and effort to these organizations compared with tion) by which the organizations are financially sustained.
their historical colleagues. Those receiving salaries, fixed or Information checking, assuring freedom from commercial
based on billings/collections or work relative value units, bi
as, vetting of ideas and presentations done by individuals
have increasingly limited discretionary time off-site, and
and committees, and a host of other necessary activities
protected time on-site, for such endeavors. Travel issues
would be unsustainable if the work of physician volunteers
(connecting, delayed and canceled flights, fewer travel op-
were fully compensated at a competitive market rate. Con-
tions) add further to the cost of committee and meeting
tinued productivity of professional nonprofit organizations
work. Employer-provided travel funding is a fraction of its
is dependent on the continued contributions of outside phy-
former level, having totally disappeared at many institu-
sician scholars.
tions, whereas support from healthcare-associated industry
Through the present torrential academic and financial
has been banned or severely limited by some employers as
an apparent conflict of interest, leaving the physician schol- climate change, the need for such scholarly products has
ars to provide their own out-of-pocket travel support for never been greater. Medicine increasingly strives to define
many such activities. Colleagues have less uncommitted and measure competence, while keeping growing numbers
time to provide coverage of clinical duties during off-site of health care providers updated on the explosive growth in
meetings. Simultaneously, the physician contributor’s re- scientific/clinical knowledge and expanding regulatory and
sponsibilities per activity have mushroomed by the need to statutory requirements for health care delivery. It follows
address a host of regulatory and quality requirements (se- that those who live and work daily on the cutting edge of
curing copyright releases, adhering to standardized format- their professional fields will be sought to fulfill these needs
ting, preparing educational goals and hand-outs, composing for expertise. But how can the cost—in time, effort, and
assessment questions, validating statistics, and reviewing dollars—be made more affordable, so those willing and
and rewriting test questions). capable can continue to contribute in this environment? As
The net result finds a few hours of inexpensive 1980s is the case with most complex issues, responsibilities are
commitment has become many days of 2009 work and broadly borne and solutions will require cooperation from
considerable personal financial expense. Junior faculty, pay- all stakeholders.
ing educational loans and supporting young children, are Professional organizations must take the lead. Full use
particularly hesitant to make such commitments despite a of web-based technologies (virtual meetings) can provide
mandate to establish national reputations.
much of the interaction of face-to-face conferences without
Nonprofit professional organizations also suffer under
the expense and time of interstate travel. Shorter, more
growing financial pressures. Although some may provide
focused physical meetings used only for those issues truly
requiring such interactions should be considered. Flexible
Funding: No funding from any source was used in the preparation of scheduling to include weekend meetings would reduce the
this paper. need for physicians to cancel income-generating clinical
Conflict of Interest: As sole author, I attest I have no conflicts of activities at home, while meetings held in geographically
interest, real or apparent, regarding this paper, its subject or content.
centralized locations or at airport hotels and conference
Authorship: As sole author, I had full access to all data, performed all
writing, and received no assistance from any other individual, in the facilities could reduce overall meeting time and associated
preparation of this manuscript. costs. Continuing education credit should be provided for
0002-9343/$ -see front matter Published by Elsevier Inc.
doi:10.1016/j.amjmed.2009.08.011
196 The American Journal of Medicine, Vol 123, No 3, March 2010
participation in these projects as an additional compensa- ments—need to acknowledge the value of the physician
tion. Administrative support for the work (eg, performing scholar and the scholarly products they produce. Whenever
literature searches, obtaining copyright releases, formatting possible, consumers should support those nonprofit organi-
goals and objectives, preparing slides and formatted graph- zations which give them the best educational value for their
ics) should be provided by the organization as a routine dollar, avoiding the lure of popular tourist sites and gourmet
business expense. Whenever possible, compensation should meals that too often drive their selections.
be increased to fully cover travel expenses and some hon- Finally, the physician faculty themselves must be part of the
oraria to defray the income sacrificed by the participating
solution. Physicians typically enter the health care field out of
faculty. Organizations also could consider forming a con-
a perceived responsibility to contribute more to society than
sortium to maximize their bargaining position for low-cost
possible through most other professions. Work with national
hotels and travel.
organizations is a force multiplier, enlarging the impact of each
Medical schools and teaching hospitals also need to
effort to help more patients (through fellow providers) than
contribute. Referring physicians, as much customers of ter-
possible through direct clinical care alone. In short, contribut-
tiary academic medical centers as the patients they send,
ing to continuing medical education activities, board and other
often consider it advantageous to refer their complex
certification examinations, and committee and advocacy work
patients to nationally recognized experts, conveying the
for nonprofit organizations is simply an important part of being
reputation of such experts to their patients. Indeed, na-
an academic physician.
tional scholarly recognition is often used by health care
Where to start? Perhaps beginning with small steps: by
organizations to advertise the quality of experts at their
nonprofit professional organizations to reduce the cost to
hospitals and clinics. Academic institutions also can spe-
faculty contributors on whom they depend; by medical
cifically identify these scholarly activities as meeting
school and hospital employers to make it a bit easier for
some promotion, tenure, or compensation criteria, plac-
those willing and so gifted to make the greater contribu-
ing them more on par with service toward other tradi-
tions; by the consumers to reward quality in the products
tional academic missions, perhaps developing a schema
they purchase; and by both established and younger phy-
of “relative value” for national activities with teaching,
sician scholars to make the extra sacrifice to do more.
research, clinical care, and administration; such a change
would increase the return-on-investment for the physi-
Stephen A. Geraci, MD
cians’ national work. Department of Internal Medicine
The consumers of these products—test takers seeking University of Mississippi School of Medicine
certification, practitioners wanting to learn the latest treat- Jackson
EDITORIAL
Thank You, Thank You, Thank You
The machinery that makes The American Journal of Med- reviewers are invited each year to join the editorial board of
icine (AJM) function is powered by many different individ- the AJM.
uals performing a variety of tasks. Without its long list of I am sometimes asked by residents, fellows, and junior
employees and volunteers, the Journal could not function. I faculty, what benefit accrues to an individual from review-
am writing this editorial to thank the individuals who have ing manuscripts for the AJM. My answer is: there are a
made AJM what it is today, and what it will become in the number of potential benefits associated with reviewing.
future. The order in which these expressions of appreciation First, the reviewer sharpens her/his critical sense during the
appear in this essay should not be construed as any indica- review process. Secondly, the reviewer is kept abreast of the
tion of the importance of the individual or the group named. latest scientific developments in the field even before they
They are all equally important in the success of the Journal. become public knowledge. Thirdly, young faculty members
To use a sports analogy, a baseball team needs a second can list their reviewing activities on their curriculum vitae
baseman just as much as it needs a center fielder. as scholarly activity, and this may help with promotion and
The American Journal of Medicine has been extraordi- tenure decisions. For example, I was recently asked by one
narily fortunate to have outstanding administrative, publish- of our elite reviewers to write a letter supporting his pro-
ing, and computer personnel in Tucson, New York City, motion package from assistant to associate professor at a
Philadelphia, San Diego, Amsterdam, and Oxford, UK. prestigious East Coast medical school. I was pleased to
These individuals function smoothly as a team and guaran- write this letter and the promotion was approved. We sub-
tee our ability to produce a high quality issue each month. sequently invited this individual to join our editorial board
We are sponsored by one of the premier professional soci- as another sign of our appreciation for his dedicated efforts
eties in the United States, the Association of Professors of on behalf of the AJM. Finally, when one reviews manu-
Medicine, whose members are the chiefs of medicine in scripts for the AJM the reviewer joins the AJM family,
every medical school in the US and Canada. which includes some of the very best minds in contempo-
Our associate editors, subspecialty editors, and editorial rary clinical medicine. Knowing that one is a part of this
board are the intellectual backbone of the Journal. The elite group of outstanding medical intellectuals is by itself
importance of their advice, suggestions, and scholarly ef- highly rewarding.
forts in producing and reviewing material on behalf of the So, as we enter the first months of 2010, let me express
Journal cannot be overestimated. In a similar vein, com- my sincerest and deeply held gratitude to everyone who
mitted, conscientious reviewers are essential to the publica- makes the AJM possible. It is literally true that “we could
tion process. The AJM is fortunate in having a large cohort not do this without your help.” I personally want to say
of dedicated reviewers, some of whom we designate as elite thank you to each and every individual who helps us make
reviewers because they have performed 8 or more quality The American Journal of Medicine a success. As always, feel
reviews for us during the last few years. As a reward for free to comment on our blog at http://amjmed.blogspot.com.
such diligent and essential service, a number of these elite
Joseph S. Alpert, MD
Funding: None. University of Arizona College of Medicine
Conflict of Interest: None. Tucson
Authorship: The author is solely responsible for writing the Editor-in-Chief, The American Journal of Medicine
manuscript. E-mail address:
REVIEW
Atrial Fibrillation in Heart Failure: A Comprehensive
Review
a,b c
Prakash C. Deedwania, MD, Joel A. Lardizabal, MD
aDepartment of Medicine, University of California, San Francisco School of Medicine, San Francisco; bDepartment of Cardiology,
Veterans Affairs Medical Center, Fresno, Calif; cDivision of Cardiology, University of California, San Francisco School of Medicine,
Fresno Medical Education Program, Fresno.
ABSTRACT
Chronic heart failure and atrial fibrillation are 2 major disorders that are closely linked. Their coexistence
is associated with adverse prognosis. Both share several common predisposing conditions, but their
interaction involves complex ultrastructural, electrophysiologic, and neurohormonal processes that go
beyond mere sharing of mutual risk factors. Rate control approach remains the standard therapy for atrial
fibrillation in heart failure because current strategies at rhythm control have so far failed to positively
impact mortality and morbidity. This is largely because of the shortcomings of current pharmacologic
anti-arrhythmic agents. Surgical and catheter-based therapies are promising, but long-term data are lacking.
The role of non-anti-arrhythmic therapeutic agents also is being explored. Further progress toward
improved understanding the complex relationship between atrial fibrillation and heart failure should
improve management strategies.
Published by Elsevier Inc. • The American Journal of Medicine (2010) 123, 198-204
KEYWORDS: Arrhythmia; Atrial fibrillation; Cardiomyopathy; Heart failure
Chronic heart failure and atrial fibrillation are major cardio- million hospitalizations and 3.4 million outpatient visits
vascular disorders that are frequently associated with each annually, with total costs estimated at $35 billion. The
other. They have common risk factors, and each compli- lifetime risk of developing heart failure is 1 in 5 after age 40
1
cates the course of the other. Both are associated with years, with an annual mortality of 20%.
significant morbidity and mortality, creating a serious pub- Atrial fibrillation, the most common clinically significant
lic health burden. A closer understanding of the intricate arrhythmia, has a prevalence of over 2.2 million in the
relationship between these 2 disorders would certainly im- United States. It accounts for nearly a half million hospi-
prove the approach to their management. talizations yearly, at an estimated cost of $7312 per dis-
2
charge. The lifetime risk of developing atrial fibrillation is
3
1 in 4 after age 40 years, and based on Framingham data,
EPIDEMIOLOGY
atrial fibrillation accounts for 14% of early deaths within the
Chronic heart failure afflicts 5.3 million adult Americans 4
first 4 months of its diagnosis in patients with heart failure.
with an equal sex distribution. It is associated with over a
With a steady incidence of both atrial fibrillation and
chronic heart failure in the setting of an aging global pop-
Funding: None.
Conflict of Interest: Dr Lardizabal does not have any relationship with ulation where more and more people survive to an age
industry and financial associations that might pose a conflict of interest. Dr where these conditions occur with increased frequency, the
Deedwania was a consultant and speaker and has been on the Advisory prevalence of heart failure and atrial fibrillation will con-
Board of Sanofi-Aventis. tinue to increase to epidemic proportions.
Authorship: Both authors were significantly involved in all steps of
the writing process, including the conception, design, drafting and critical
revision of the manuscript, as well as final approval for its submission. PREDICTORS OF ATRIAL FIBRILLATION IN
Requests for reprints should be addressed to Prakash C. Deedwania,
CHRONIC HEART FAILURE
MD, Division of Cardiology, VA Medical Center, 2615 E Clinton Avenue,
Fresno, CA 93703. In the Framingham Study, heart failure was the strongest
E-mail address: