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: