INTRODUCTION

To begin, it is important to introduce the two authors of this paper. Richard Grant is an orthopedic surgeon with national credentials serving on numerous governing boards. Michael Boylan is a philosopher who has written on medical ethics. The two of us began this paper over a year ago in various discussions we had together and decided that given what we feel is an increasingly hostile climate to minorities in the United States, it was time for those who felt differently to speak out.

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Our patient is unique in that he has ischemic cardiomyopathy with a focal origin for his VF. Polymorphic VT/VF and electrical storm occurring in this setting are often attributed to acute ischemia or electrolyte abnormalities, and this was not noted in our patient. Although focal origin of VT and successful catheter ablation of VT have been reported for more than 15 years, focal ablation of VF has been reported for the first time in 2002 in patients with idiopathic VF. Our case preceded these reports and is the first one describing transcatheter ablation for VF in ischemic cardiomyopathy.

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A 65-year-old male patient with a history of coronary artery disease (bypass grafting 10 years ago), diabetes mellitus, hyperlipidemia, and peripheral vascular disease experienced persistent substernal gripping chest pain and was evaluated in the local emergency room. He was found to be pale and diaphoretic, with runs of nonsustained VT. He was started on intravenous nitroglycerin, heparin, and eptifibatide, and transferred to our facility for suspected acute coronary syndrome. His cardiac enzymes showed a creatine kinase (CK) of 171 u/1 (39-195 u/1), CK MB fraction of 3.2 u/1 (0.0-5.0 u/1), and troponin T of 0.01 ng/ml (0.0-0.1 ng/ml). His serum creatinine was 2.1 mg/dl (0.5-1.4 mg/dl), drug sodium 135 meq/1 (135-145 meq/1), potassium 4.1 meq/1 (3.5-5.0 meq/1), magnesium 2.3 mg/dl (1.7-2.5 mg/dl), generic calcium 9.0 mg/dl (8.5-10.2 mg/dl), and albumin 3.3 g/dl (3.5-5.0 g/dl). Echocardiogram showed mildly dilated left atrium, dilated left ventricle with posterior hypokinesis, and an ejection fraction of 40%.

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INTRODUCTION

Three-hundred-fifty-thousand patients die each year of sudden cardiac death alone in the United States. Ventricular fibrillation (VF) and sustained ventricular tachycardia (VT) are the major causes of sudden cardiac death. Patients who survive an episode of sustained VT or VF have a recurrence rate of 30% in the next year, which increases to 50% in two years. …..Click here to read more

Physicians play a key role in providing both curative and preventive healthcare. Counseling may be an effective tool in reducing behavioral risk factors for CVD. Yet, physicians do not counsel their patients aggressively about lifestyle changes to prevent CVD. As hypothesized, the reported frequency of preventive counseling in this study was low, especially for diet, exercise, and weight loss. Rates of counseling for smoking cessation and medication adherence were much higher than for other CVD risk factors, a finding which has been reported by others. Counseling behaviors mirrored physicians’ beliefs about the importance of different risk factors: more physicians reported counseling for smoking cessation and medication adherence was “very important” than exercise, diet, and weight reduction. This suggests that messages about the importance of diet, exercise, and weight control for prevention of CVD are not reaching most physicians.

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Physicians’ CVD Counseling Practices

Prevention counseling rates were significantly lower for exercise and diet than for smoking and medication compliance (Table 2). Only 16% and 20% of physicians reported that they “always” counseled about exercise and diet, respectively, whereas 88% and 52% reported counseling smoking cessation and medication adherence, respectively (p<0.0001). Attending physicians were significantly more likely than residents (79% vs. 45%) to “always” counsel new patients about medication compliance (p=0.025). No other statistically significant differences between attending physicians and residents were found. Additionally, no significant differences were found in CVD counseling practices for new patients based on physician gender (data not shown).

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Study Setting

A survey was administered to Emory University Internal Medicine residents and attending physicians who worked in the medicine clinics at Grady Memorial Hospital, a 1,000-bed, inner-city, indigent care teaching hospital located in Atlanta, GA. The primary care outpatient medical clinics of Grady Memorial Hospital serve a primarily older (mean age 61), female (66%), African-American (93%), low-literate (third-to-fifth-grade reading level), and lower-socioeconomic status (SES) population. A high percentage of patients suffer from hypertension (78%), obesity (45%), high cholesterol (38%), and diabetes (26%). Patients also engage in many high risk behaviors for CVD, including smoking (23%), and sedentary lifestyles (39%).

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