Atrial Fibrillation. Will you Ever Have it?

Atrial Fibrillation is one of the most common arrhythmias of the heart. It is often referred as “irregular heart beat” or “quivering of the heart”¹. It is important because it is related to strokes, heart failure and cognitive decline. Its treatment, in addition to trying to control the arrhythmia, usually involves anticoagulation in order to decrease the risk of stroke.

Even if people are healthy and have few or no cardiovascular risk factors, there is a age-related risk of developing atrial fibrillation. This risk has been measured and it increases progressively with age. In one study, people between 55-59 years old have a 0.7% risk, 60-64 years old 1.7%, 65-69 years old 4.0%, 70-74 years old 6.0%, 75-79 years old, 9.0%, 80-84 years old 13.5% and older than 85 years old 17.8%². The risk seems to be slightly higher in men than in women.

The risk of developing atrial fibrillation increases with the presence of conditions such as hypertension, diabetes mellitus, hyperthyroidism, heart failure, obesity, obstructive sleep apnea, excessive sports practice, chronic inflammatory states, and alcohol abuse³. In addition there are genetic markers that might explain why certain people develop atrial fibrillation at a younger age and why white people are more affected than people from African of Hispanic descent. There are mutations in certain genes that increase the risk and there are genetic variants called single nucleotide polymorphisms (SNP) that are associated with early onset atrial fibrillation.

Like with every condition, there are modifiable risk factors and non-modifiable risk factors (like the genetic ones). If anyone has any of the non-modifiable risk factors, it is better to be on the safer side and make sure that more risk is not added to the already present ones. Also, be in close communication with your personal physician for proper prevention and treatment if needed.

References

1. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.V3RKAFeL1M8. Obtained June 20, 2016

2. Jan Heeringa, Deirdre A.M. van der Kuip, Albert Hofman, Jan A. Kors, Gerard van Herpen, Bruno H.Ch. Stricker, Theo Stijnen, Gregory Y.H. Lip3, and Jacqueline C.M. Witteman. European Heart Journal. 2006;27: 949-953

Marco A. Ramos MD

MTHFR mutation. One in 6 people have it. What to do if you have it?

MTHFR mutations are one of the commonly found mutations in genetic testing. If someone is homozygous (carrying one mutation from your father and one from your mother) for the C677T mutation, it may be associated with increased cardiovascular events (heart attacks, strokes), malignancies and birth defects (spina bifida). This does not mean that if someone has the homozygous mutation that person will have a problem. It means that there may be an increased risk.

MTHFR stands for methylenetetrahydrofolate reductase, an enzyme in the metabolic of folic acid. It is also the name of the gene that codes for that enzyme. People with the homozygous mutation have a defective enzyme and  may have some difficulty with the metabolism of folic acid. At the same time, there may be increased levels of homocysteine in the blood, an amino acid associated with thrombotic problems. 

What to do if someone is homozygous for the C677T mutation? Many people find this after testing in commercially available genetic testing. If this mutation is found, a physician or genetic counselor should be contacted. The most likely next step would be an evaluation of homocysteine levels in blood. If normal, the person should be reassured that its risk for cardiovascular events and other problems is probably similar as the rest of the population. If the levels of homocysteine are high, it does not hurt to try to reduce it by having folate supplements and increased vegetables with the diet.

Marco A. Ramos MD

3 Reasons to Obtain a Second Medical Opinion

Healthcare is complicated. Specially if we are talking about complex situations like chemotherapy, dialysis, surgery or advanced procedures. The decisions made between the doctors and the patient will always involve the body of the patient. 

First, a second medical opinion is a way to reassure the patient regarding the course of action its healthcare is taking. There might be many doubts concerning a proposed surgery, for example. A second medical opinion would provide the patient the peace of mind necessary to minimize anxiety associated to the procedure.

Second, a new opinion rendered by a specialized physician would complement and supplement the information that the patient already has. A problem with the current healthcare system is the lack of time physicians have to provide the necessary data that patients need to make informed decisions

Third, a second medical opinion may broaden the options a patient can have. Specialized physicians looking specifically into the patient’s case can provide new insights withe respect to the case and when doing this, alternative therapies can emerge as possibilities when they were not considered initially.

A second medical opinion is a tool that all patients should consider, specially when the the proposed treatment strategies are complex and involve a certain level of risk for the life or wellbeing of the patient.

Marco A. Ramos MD

3 Situations to be Careful if Taking Diuretics

Taking diuretics has become one of the cornerstones of the treatment of hypertension and heart failure. Although it has benefits, it has risks too. Here are 3 situations that any person taking diuretics has to be watchful for.

People usually follow the doctor’s recommendations and take the diuretics faithfully once, twice or thrice a day. However, if the person taking the diuretics develops, diarrhea, vomiting or loses its appetite, he or she runs the risk of developing low blood pressure for volume loss in the vascular system. This can cause dizziness, syncope (passing out) or kidney failure.

Diuretics always carry the side effect of losing potassium and/or magnesium though the increased urine production. The best way to avoid this is to have a balanced diet or to take supplements. Low potassium or magnesium can cause dangerous cardiac arrhythmias or muscle weakness.

A low sodium concentration in the blood is also a potential consequence of the use of diuretics. This can happen if the person taking this type of medication drinks too much water while replacing the losses through the urine. Low sodium concentration in the blood can cause headaches, loss of balance, and if severe, lethargy, seizures and death. All diuretics can be associated with low sodium concentrations, however, the thiazide type of  diuretics are more commonly  related to this problem.

All medications cause side effects. Always talk with your doctor regarding these when starting a new one.

Marco A. Ramos MD

Three Reasons for Electing Private Pay Over Insurance for Outpatient Health Care

Being insured in order to to see your primary doctor or specialty physician has become the norm. Many traditional physician practices will only accept you as a patient if you are enrolled in an insurance plan, either government funded or non-government funded. This has created a change in the relationship between a physician and the patients. In this post, I will show three reasons why patients should seek private pay arrangements with the physicians of their choice. 

1. To keep the decision-making between the doctor and the patient. The moment a doctor is allowed by an insurance company to see  patients who pay premiums to it, that doctor is accepting that there is a third entity that will monitor, question and in many changes change the decisions made by the doctor and the patient in the office encounter. 

2. To assure privacy. Once a patient participates in an insurance plan, the patient is surrendering its private health information to a third party. There will be other individuals, employed or contracted by the insurance company, that will review the medical record for different purposes including quality of care, financial analysis and approval or denial of specific treatments.

3. To not be subject to restrictions and limits in insurance plans. Insurance companies can change their plans. Benefits that were part of the plan might not be present in the amended plan. Most of benefits are partially paid and the remainder has to be paid “out-of pocket” by the patient.

The concept of insurance is to spread the risk amongst a pool of people. The greater the pool, the better spread the risk is and the premiums may be lower. This is necessary when we take into account that hospitalizations, surgeries and prolonged treatments like, for example, dialysis or chemotherapy can be extremely costly. However, for outpatient care, when we deal with preventive medicine or with specialist consultations, it would be probably better to seek models that keep the relationship between a doctor and patient strictly between them.

Marco A. Ramos MD

Can a Doctor be Offended if We Request a Second Medical Opinion?

Unfortunately the answer to that question is yes. Physicians are usually highly driven individuals who dedicate most of their time to their patients. They have studied at least 13 years between medical school (doctorate), residency (post doctorate) and fellowship (post post doctorate). Some of them have 2 or more fellowships or are employed by a famous university. Others are the owners of their own successful practices. For a lot of doctors, the prospect of a second medical opinion is a challenge to their knowledge, a challenge to the “loyalty” that a patient should have. 

What we have to do is always keep things in perspective. The human body that the physician is treating belongs to us, the patients. The patient is the one who would suffer if a mistake is made an the one who would miss the opportunity of a better treatment if the treating physician fails to offer it. The other thing that needs to be kept in perspective is the degree of autonomy that we should have. A physician does not order a treatment. A physician recommends a treatment. The decision to follow the physician’s recommendation belongs to the patient and to follow a recommendation is a measure of trust.

What to do in the event that doubt arises? What happens if we need reassurance about a new treatment or a new diagnosis? What if the treatment or diagnosis is complicated? This is the territory of the second medical opinion. The treating physician would be the one releasing the records to the second medical opinion physician. The best approach, as always is to be transparent and upfront, but always respectful. The second medical opinion is a tool which should strengthen the relationship between the treating physician and the patient. 

The way that healthcare is evolving means that there might be less and less time for physicians to spend with us. This means that there will be less time to explain complicated issues and more second medical opinion consultations. Treating physicians can be offended, but they should not be offended, specially if the process is respectful. Two brains always think better than one.

Marco A. Ramos MD

How to Obtain a Second Medical Opinion?

Obtaining a second medical opinion is very important, specially when the medical problem that a person is dealing with is complicated, chronic or needs aggressive and expensive medical care. The primary care provider and the specialist who sees you or your relative may be very good, but ultimately, the body belongs to you and not only you must be seeking  care, but also making sure it is good care.

Here are some steps that may be followed:

1. If you are thinking about obtaining a second medical opinion, you must make up your mind first. If the last medical visit was left with more questions than answers, or you need reassurance, it is always a good habit to give the physician who saw you a call in order to clarify things. Keep in mind that time is not a luxury of doctors these days, so they might just need more time to talk to you. If after talking to the doctor again, questions remain unanswered, then, there is a good case to look for a second opinion.

2. Once the decision is made, you should contact your insurance company in order to see if second medical opinions are covered by your plan and in case they are, to see what physicians can provide it. 

3. When the options are provided, the physicians’ credentials must be verified. You can look into the specific Specialty Board’s website to check the physician’s background and experience.

4. If the choices do not satisfy you, there can be other physicians available. Look into medical schools, hospitals and friends and family recommendations. Do a thorough internet search and verify credentials. Be prepared to pay out of pocket money in these cases.

5. Once the second opinion is obtained, request a written report. This is important because it will give you a document to refer to and will help you when going back to your original physicians. It can contain valuable information and it can help you and your doctor in the developing of the plan of care.

Although requesting a second medical opinion is a right, some physicians may be offended by the fact that you are doing it. Reassure your physician by saying that this is meant for you to be further educated about your condition and its treatment options.

Marco A. Ramos MD

Take a look at www.smopinions.com

Why a Second Medical Opinion?

The doctor-patient encounter has traditionally been a strict relationship between a physician and the patient requesting the services. However, there were always concerns regarding the cost of the services and how accessible the services were. Starting some decades ago, insurance companies (private and government owned) started to participate in the relationship in an effort to make it more efficient. This had the consequence of spreading the risk and making healthcare more available to people. 

As time passed, healthcare became more dependent on the wellbeing of the insurance programs or companies. In order to be able to provide for all enrollees, the reimbursements to the providers started to decrease and, as a consequence of that, the time that the providers give to the patients also started to decrease (because they had to see more patients in less time so as to pay for overheads and remain profitable.) 

The natural result of this is that people remain with more unanswered questions and more doubts regarding their conditions or diseases. In this current world of gigantic leaps in the development of pharmaceuticals, surgical techniques, gene therapy, amongst others, the explanations that professionals (primary care providers and specialists) need to give their patients are complex. Many patients try to enhance their knowledge by using the internet. This is risky. The internet is filled with unreviewed information posted by un-credentialed people who might confuse or even misguide the patient who needs more answers.

A second medical opinion is a tool that will enable patients to be better informed, to be more reassured regarding their conditions and to bring up the possibility of more educated and effective communication with their doctors. For complex problems, two minds are better than one.

Marco A. Ramos MD