Progress in cardiology has plateaued in recent years. A small single-center study involving pacemakers may have just sparked the next big advance in heart failure therapy
From my clinical observation as a young PCP, the largest (and often ignored) modifiable risk factor for people with HFpEF is sleep apnea leading to pulmonary hypertension and diastolic dysfunction.
I suspect we would probably get a lot farther if EVERYONE (patients with both HFrEF and HFpEF) had evaluations and optimization of their sleep.
Thanks for the article and insights. When I teach students about HF I ask them to think about the unifying issue in HFrEF and HFpEF, namely a reduced stroke volume and hence cardiac output. The mechanisms are different but the result is the same.
Cardiac output is a product of heart rate x stroke volume. It never made sense to me that reducing the heart rate would magically increase your cardiac output in HFpEF. Prolonging diastole in people with small poorly compliant ventricles will only prolong the duration of Diastasis. Most of the filling will be in early diastole, then you climb up your pressure volume loop and filling stops! Waiting a bit longer won’t achieve much.
There’s a reason that chronotropic incompetence leads to functional impairment. Augmenting cardiac output by increasing heart rate makes more sense to me.
I tell you waht, I am excited too. As a former recipient of beta blockers which did nothing but harm me and exacerbate my heart problems, pushing me into bradycardia even at .a quarter of the minimum therapeutic dose I can understand this concept all too well.
Beautiful article. Compelling, clear, and accessible! Thank you. It leaves me again with questions and profound respect:
How do “we” transform stiffening hearts in the network of highly-paid professionals who earn their salary by appearing in conventional roles as highly skilled experts, using a very narrow range of technology (equipment and products)?
Your observations raise important but well-embedded (i.e., subclinical) concerns, such as the persistence of profitable protocols, including professionals’ self-prioritized bias towards making the most of liability-free technology to perpetuate not-so-lowly paychecks.
I don’t question the well-meaning intentions of front-line clinicians. Yet, Biomedical protocols never really equip them to address a person’s right to informed consent involving the clinical commitment to making the most of the person’s innate health capacities rather than ‘capitalizing’ on the emerging specializations in technique using the most recent technology. Doctors face daily competition for patient supply, with no requirement for personalized tracking or measuring patient-specific outcomes from particular protocols.
It’s all about professional relativistic measures akin to investment management. No absolute benefits are required when a proprietary product or service needs only to operate in a theoretically mass market showing a little better marginal gain than an average of other options... if the person was left to their own uninformed devices. The underlying method involves diagnosing people in terms of terrible disease states, so their biological margins for improvement are theoretically very wide.
My dear Grandfather treated his own ‘Type 1 Diabetes” diagnosis to the age of 88 through control of a “normal” (whole simple foods) diet. How is that possible? He was practical and respected everyone, including person-able doctors. But he also knew that some modern MDs picked up “advanced” American-style Medicine to star as spectacular “one-trick ponies.” He said, you know, if you end up at the hospital, even for tests, understand that some of these guys are like skilled carpenters who are really good with their hammer. You can be sure when he sees you, he’ll be equipped to look at you and find anyTHING loose. So, he can treat you as if you need his new nail and have it well hammered in with the most advanced hammer. Getting a second opinion involves pleading for a referral to the next “good guy” with a hammer. The next guy is NOT trained in stonework or using a screwdriver.
His comments fit well with disease-driven discovery in the global bioeconomy. It’s been regulated since the 1950s to grow good ol’ US of A capitalism. And Canadians are just a small colony in the American regulatory chain (i.e. a cohort the size of California awaiting capture by carpenters with the best hammers).
Specialized medicine is something even more extreme in the Covid era.
My elderly neighbor’s son is a top cardiologist at one of the most person-centered hospitals in the massive downtown University Hospital Network in Toronto. Any heart problems, and he can get you in fast. That's amazing because regular health services have been set aside for "ventilation" emergencies. He's there because he took the devil’s bargain of believing in the unstratified need for everyone to participate in the Covid vaccine experiment, to keep his job. He's had unexplained health problems since getting jabbed. Yet, he’s the top guy and teaching young doctors how to place stents. When he speaks, you gotta bet you just got Informed you need to give him your consent to do his thing... as if there are no downsides or better options for some, if not most, people.
It’s something about conventional care and highly standardized and increasingly specialized protocols. Doctors can do things without thinking, so patients need not hesitate and appear “medically illiterate.” No need for patients and their families to lack confidence that they’re getting peer-reviewed and agreed forms of the best-in-class (standard) of care. The best doctors CAN go home at night to rest easy on a good day’s pay, practicing by protocol.
Your Substack offers good information that people and their doctors SHOULD use! Medicine is a deontic practice about how we SHOULD help people who suffer from dis-ease. Yet, do many experts or GPs abandon their paychecks to say, hey, wait a minute? Rather than put me on the hospital advanced medicine pedestal, why don’t we stop to think here WITH AND ABOUT THIS PERSON? It’s not just their attitude that matters. It’s their bio-physiological condition that deserves protection from needless harm. What specialists care enough to keep up to date with competing perspectives on treatment options after big investments in technology delivers a fast and convenient treatment?
What if there’s more than a 50/50 probability WE can offer genuine care to a living being in terms of something more wholesome -- that makes the most of their own biological capacities without the iatrogenic harms -- than the convenient, insurance-covered technology that triggers my medical team’s ability to take home a chunk of the paycheck of the person named in the case file?
So here we are… In the post “Covid” era, in the post-Bush era, when HHS was put under military interests with unaudited budgets. Alarming numbers on heart conditions and the virtues of protective experimental vaccine technology are being overwhelmed by excess deaths in states with advanced medical regimes.
Top MDs have generally amplified the Faustian bargain as damage to patients has been displayed as the only Science. It's a new-fangled Faucian bargain in advanced countries now that we know the preferences of Dr. Science, the highest-paid government medical authority on all things health-related. Biomedical forms of immunity work well, especially for authorities with no liability or responsibility for providing actual data. Specialized MDs are now the only informed voices on the few options they care to offer because they see payback on their particular protocol. It’s a life-and-death game of Oligopoly.
Thank you for writing about specific cardiac patients’ needs, standard protocols, and well-silenced alternatives to four specialized drugs and pacemaker technology. With those five elements, patients and doctors can feel they have options.
What stiffens hearts? In actual human conditions? In doctors who SHOULD care?
Protocols. But no blame goes to patients or doctors for ‘lost’ case files, as people die anyways.
How pathetic am I to dare feel concerned that employed clinicians and cardiologists are falling for all that US regulators and academic standard-bearers give them as conventional practices and protocols?
Rather than risk their jobs, medical pros might prefer feeling well-deserved when receiving pay for Pandemic and protocol compliance. It’s worrisome. Because our well-vaccinated University Hospital Network and surrounding medical systems are LOSING young and otherwise healthy MDs, including cardiologists, to sudden death at a rate much higher than any previous period. If the data was allowed to be published in Canada, it might even wake up medical pros to the harms of protocols.
Its a challenge to wonder. When does a doctor wake up, look in the mirror, and see himself as a robot with a solid paycheck based on simple protocols that short-circuit his mind and stiffen HIS heart? When does he truly wake up and feel love for good people who are doctors and patients with life as a living person?
Maybe Covid protocols pushed too many past the basics of first do no harm. But conventional and unwritten professional protocols will never let anyone think that happens. MDs lose their license if they ponder possibilities.
Thank you again for your writing about real-world conditions. It raises questions about protocols and medical academics that are quietly profound in a post-Covid context.
May living and loving people stay humane and well. For the love of good doctors...
As a patient who's experienced lone afib, higher pacing leading to reduced afib tracks with my experience with beta blockers. In addition to triggering asthma, they drag my heart rate so low (into the 30s at rest), that I feel miserable, can't move, can't think, and experience increased palpitations. Stopping the beta blocker and taking action to increase heart rate eliminated these issues.
How does the physician approach an 81YO with a RHR of 38-41 BPM over years of intense activity and determine that that HR is clinically pathogenic or normal for that individual given the athletic history ?
Had a friend on beta blockers for ten years, then she changed family doctors and it was quickly determined she shouldn’t have been put on them to begin with. Must be lots of that going on. The studies highlighted are incredibly exciting. Thanks for sharing.
Since the use of beta blockers in CHF with preserved ejection fraction is unproven, I wonder why these patients were given beta blockers in the first place. Treating hypertension with them often
decreases exercise tolerance. This is a common outcome in many people.
So why was this study done.? The result was a foregone conclusion.
David West, a British lay-person aged 79 with a comment on beta-blockers in the context of PAF.
Back in 2017 I was diagnosed with PAF by my local GP. I subsequently had an ablation in Papworth Hospital, here in England.
Five days later my pulse went up to around 160 bpm and stayed there for 48 hours. I was admitted to a local hospital and it took them a further five days to get it down below 100.
I was then put on beta-blockers even though my BP was already low for my age.
In the following year or so I experienced syncope twice in public, fortunately without injuring myself.
I then wrote to my consultant at Papworth giving him the reasons why I had unilaterally decided to stop taking beta-blockers. He wrote back agreeing with my decision.
Since then I have only taken a precautionary 2.5 mg daily dose of Eliquis/Apixaban and have not experienced syncope again. My AF episodes are now infrequent and mild and my pulse seldom goes above 100 bpm.
Previous to my diagnosis in 2017 I had enjoyed robust good health all my life, eaten a good healthy diet, maintained a weight of about 60 kg (around 140 pounds) and for over 25 years I spent around 60 minutes, three times a week exercising in my local gym. My average BP is still 112/75 (including readings taken in occasional episodes of AF). I still go the gym three times a week.
May I take this opportunity to express my heartfelt gratitude to Dr. John Mandrola for his many web articles on AF with practical lifestyle advice that took away the fear my AF diagnosis had created in me.
I’m a layman doing what I can to advocate for my partner with HF (with hardly any symptoms), I admit by now I am most cynical and sceptical of big pharma, are the four classes of drugs and defibrillators truly “a godsend”. The ARR I saw for for example Dapagliflozin looked to be around 1.5%?!? And the maintenance and restrictions around the defibrillators feels high for a “you might be at higher risk” situation 😔 sorry, I’m struggling to know what is the right way forward and where to find more genuine research/trial data.
Hi John: I just found your sight-congrats! Non-cardiologist question for fun: could one then theoretically use pacer atrial rate adjustments with TEE to potentially determine an individual's heart rate that optimized diastolic filling? Thanks-Bryan Bridges (Hobart)
I'm new here and glad I discovered you while searching on, "Stop Afib.org. I've read several of your articles including this one and it all makes sense to me. I'm at wits end on my next step at leaving my current cardiologist who, in my opinion, doesn't really care and hasn't done much in the way to help me in the last 6 years (no heart disease here). Many, many episodes of AFIB and tachacardia later, I have finally been put on fleciainide because of a 'first" event with AFIB w/RVR or is it ventricular tachacardia? Either way, the flecainide, of which I have been on for 1.5 weeks is not cutting it with Afib almost every day or every other and after 12 hours in AFIB yesterday, I'm almost hoping to find a very experienced electrophysiologist to consult with, (only because there appears to be no other option and not my first choice}. The dilemma, is it appears to be a "hidden" secret in the medical industry to have any written reviews on a specialty medical provider by patients through a search on line. Even Google (who certainly would have some sort of reviews by patients) or any other search produces nothing. A rating is not good enough. It's the same thing as a lot of Amazon sellers upping their own ratings which they do. Anyway, thanks for your articles and info, it's refreshing to hear the truth.
From my clinical observation as a young PCP, the largest (and often ignored) modifiable risk factor for people with HFpEF is sleep apnea leading to pulmonary hypertension and diastolic dysfunction.
I suspect we would probably get a lot farther if EVERYONE (patients with both HFrEF and HFpEF) had evaluations and optimization of their sleep.
Thanks for the article and insights. When I teach students about HF I ask them to think about the unifying issue in HFrEF and HFpEF, namely a reduced stroke volume and hence cardiac output. The mechanisms are different but the result is the same.
Cardiac output is a product of heart rate x stroke volume. It never made sense to me that reducing the heart rate would magically increase your cardiac output in HFpEF. Prolonging diastole in people with small poorly compliant ventricles will only prolong the duration of Diastasis. Most of the filling will be in early diastole, then you climb up your pressure volume loop and filling stops! Waiting a bit longer won’t achieve much.
There’s a reason that chronotropic incompetence leads to functional impairment. Augmenting cardiac output by increasing heart rate makes more sense to me.
I tell you waht, I am excited too. As a former recipient of beta blockers which did nothing but harm me and exacerbate my heart problems, pushing me into bradycardia even at .a quarter of the minimum therapeutic dose I can understand this concept all too well.
Beautiful article. Compelling, clear, and accessible! Thank you. It leaves me again with questions and profound respect:
How do “we” transform stiffening hearts in the network of highly-paid professionals who earn their salary by appearing in conventional roles as highly skilled experts, using a very narrow range of technology (equipment and products)?
Your observations raise important but well-embedded (i.e., subclinical) concerns, such as the persistence of profitable protocols, including professionals’ self-prioritized bias towards making the most of liability-free technology to perpetuate not-so-lowly paychecks.
I don’t question the well-meaning intentions of front-line clinicians. Yet, Biomedical protocols never really equip them to address a person’s right to informed consent involving the clinical commitment to making the most of the person’s innate health capacities rather than ‘capitalizing’ on the emerging specializations in technique using the most recent technology. Doctors face daily competition for patient supply, with no requirement for personalized tracking or measuring patient-specific outcomes from particular protocols.
It’s all about professional relativistic measures akin to investment management. No absolute benefits are required when a proprietary product or service needs only to operate in a theoretically mass market showing a little better marginal gain than an average of other options... if the person was left to their own uninformed devices. The underlying method involves diagnosing people in terms of terrible disease states, so their biological margins for improvement are theoretically very wide.
My dear Grandfather treated his own ‘Type 1 Diabetes” diagnosis to the age of 88 through control of a “normal” (whole simple foods) diet. How is that possible? He was practical and respected everyone, including person-able doctors. But he also knew that some modern MDs picked up “advanced” American-style Medicine to star as spectacular “one-trick ponies.” He said, you know, if you end up at the hospital, even for tests, understand that some of these guys are like skilled carpenters who are really good with their hammer. You can be sure when he sees you, he’ll be equipped to look at you and find anyTHING loose. So, he can treat you as if you need his new nail and have it well hammered in with the most advanced hammer. Getting a second opinion involves pleading for a referral to the next “good guy” with a hammer. The next guy is NOT trained in stonework or using a screwdriver.
His comments fit well with disease-driven discovery in the global bioeconomy. It’s been regulated since the 1950s to grow good ol’ US of A capitalism. And Canadians are just a small colony in the American regulatory chain (i.e. a cohort the size of California awaiting capture by carpenters with the best hammers).
Specialized medicine is something even more extreme in the Covid era.
My elderly neighbor’s son is a top cardiologist at one of the most person-centered hospitals in the massive downtown University Hospital Network in Toronto. Any heart problems, and he can get you in fast. That's amazing because regular health services have been set aside for "ventilation" emergencies. He's there because he took the devil’s bargain of believing in the unstratified need for everyone to participate in the Covid vaccine experiment, to keep his job. He's had unexplained health problems since getting jabbed. Yet, he’s the top guy and teaching young doctors how to place stents. When he speaks, you gotta bet you just got Informed you need to give him your consent to do his thing... as if there are no downsides or better options for some, if not most, people.
It’s something about conventional care and highly standardized and increasingly specialized protocols. Doctors can do things without thinking, so patients need not hesitate and appear “medically illiterate.” No need for patients and their families to lack confidence that they’re getting peer-reviewed and agreed forms of the best-in-class (standard) of care. The best doctors CAN go home at night to rest easy on a good day’s pay, practicing by protocol.
Your Substack offers good information that people and their doctors SHOULD use! Medicine is a deontic practice about how we SHOULD help people who suffer from dis-ease. Yet, do many experts or GPs abandon their paychecks to say, hey, wait a minute? Rather than put me on the hospital advanced medicine pedestal, why don’t we stop to think here WITH AND ABOUT THIS PERSON? It’s not just their attitude that matters. It’s their bio-physiological condition that deserves protection from needless harm. What specialists care enough to keep up to date with competing perspectives on treatment options after big investments in technology delivers a fast and convenient treatment?
What if there’s more than a 50/50 probability WE can offer genuine care to a living being in terms of something more wholesome -- that makes the most of their own biological capacities without the iatrogenic harms -- than the convenient, insurance-covered technology that triggers my medical team’s ability to take home a chunk of the paycheck of the person named in the case file?
So here we are… In the post “Covid” era, in the post-Bush era, when HHS was put under military interests with unaudited budgets. Alarming numbers on heart conditions and the virtues of protective experimental vaccine technology are being overwhelmed by excess deaths in states with advanced medical regimes.
Top MDs have generally amplified the Faustian bargain as damage to patients has been displayed as the only Science. It's a new-fangled Faucian bargain in advanced countries now that we know the preferences of Dr. Science, the highest-paid government medical authority on all things health-related. Biomedical forms of immunity work well, especially for authorities with no liability or responsibility for providing actual data. Specialized MDs are now the only informed voices on the few options they care to offer because they see payback on their particular protocol. It’s a life-and-death game of Oligopoly.
Thank you for writing about specific cardiac patients’ needs, standard protocols, and well-silenced alternatives to four specialized drugs and pacemaker technology. With those five elements, patients and doctors can feel they have options.
What stiffens hearts? In actual human conditions? In doctors who SHOULD care?
Protocols. But no blame goes to patients or doctors for ‘lost’ case files, as people die anyways.
How pathetic am I to dare feel concerned that employed clinicians and cardiologists are falling for all that US regulators and academic standard-bearers give them as conventional practices and protocols?
Rather than risk their jobs, medical pros might prefer feeling well-deserved when receiving pay for Pandemic and protocol compliance. It’s worrisome. Because our well-vaccinated University Hospital Network and surrounding medical systems are LOSING young and otherwise healthy MDs, including cardiologists, to sudden death at a rate much higher than any previous period. If the data was allowed to be published in Canada, it might even wake up medical pros to the harms of protocols.
Its a challenge to wonder. When does a doctor wake up, look in the mirror, and see himself as a robot with a solid paycheck based on simple protocols that short-circuit his mind and stiffen HIS heart? When does he truly wake up and feel love for good people who are doctors and patients with life as a living person?
Maybe Covid protocols pushed too many past the basics of first do no harm. But conventional and unwritten professional protocols will never let anyone think that happens. MDs lose their license if they ponder possibilities.
Thank you again for your writing about real-world conditions. It raises questions about protocols and medical academics that are quietly profound in a post-Covid context.
May living and loving people stay humane and well. For the love of good doctors...
As a patient who's experienced lone afib, higher pacing leading to reduced afib tracks with my experience with beta blockers. In addition to triggering asthma, they drag my heart rate so low (into the 30s at rest), that I feel miserable, can't move, can't think, and experience increased palpitations. Stopping the beta blocker and taking action to increase heart rate eliminated these issues.
How does the physician approach an 81YO with a RHR of 38-41 BPM over years of intense activity and determine that that HR is clinically pathogenic or normal for that individual given the athletic history ?
Had a friend on beta blockers for ten years, then she changed family doctors and it was quickly determined she shouldn’t have been put on them to begin with. Must be lots of that going on. The studies highlighted are incredibly exciting. Thanks for sharing.
Since the use of beta blockers in CHF with preserved ejection fraction is unproven, I wonder why these patients were given beta blockers in the first place. Treating hypertension with them often
decreases exercise tolerance. This is a common outcome in many people.
So why was this study done.? The result was a foregone conclusion.
I hope this pans out so that this population which is usually on a fist full of meds can have one less pill to worry about.
David West, a British lay-person aged 79 with a comment on beta-blockers in the context of PAF.
Back in 2017 I was diagnosed with PAF by my local GP. I subsequently had an ablation in Papworth Hospital, here in England.
Five days later my pulse went up to around 160 bpm and stayed there for 48 hours. I was admitted to a local hospital and it took them a further five days to get it down below 100.
I was then put on beta-blockers even though my BP was already low for my age.
In the following year or so I experienced syncope twice in public, fortunately without injuring myself.
I then wrote to my consultant at Papworth giving him the reasons why I had unilaterally decided to stop taking beta-blockers. He wrote back agreeing with my decision.
Since then I have only taken a precautionary 2.5 mg daily dose of Eliquis/Apixaban and have not experienced syncope again. My AF episodes are now infrequent and mild and my pulse seldom goes above 100 bpm.
Previous to my diagnosis in 2017 I had enjoyed robust good health all my life, eaten a good healthy diet, maintained a weight of about 60 kg (around 140 pounds) and for over 25 years I spent around 60 minutes, three times a week exercising in my local gym. My average BP is still 112/75 (including readings taken in occasional episodes of AF). I still go the gym three times a week.
May I take this opportunity to express my heartfelt gratitude to Dr. John Mandrola for his many web articles on AF with practical lifestyle advice that took away the fear my AF diagnosis had created in me.
God bless you, Dr. Mandrola.
I’m a layman doing what I can to advocate for my partner with HF (with hardly any symptoms), I admit by now I am most cynical and sceptical of big pharma, are the four classes of drugs and defibrillators truly “a godsend”. The ARR I saw for for example Dapagliflozin looked to be around 1.5%?!? And the maintenance and restrictions around the defibrillators feels high for a “you might be at higher risk” situation 😔 sorry, I’m struggling to know what is the right way forward and where to find more genuine research/trial data.
Hi John: I just found your sight-congrats! Non-cardiologist question for fun: could one then theoretically use pacer atrial rate adjustments with TEE to potentially determine an individual's heart rate that optimized diastolic filling? Thanks-Bryan Bridges (Hobart)
Great stuff. Thank you.
Moving to pay.
I'm new here and glad I discovered you while searching on, "Stop Afib.org. I've read several of your articles including this one and it all makes sense to me. I'm at wits end on my next step at leaving my current cardiologist who, in my opinion, doesn't really care and hasn't done much in the way to help me in the last 6 years (no heart disease here). Many, many episodes of AFIB and tachacardia later, I have finally been put on fleciainide because of a 'first" event with AFIB w/RVR or is it ventricular tachacardia? Either way, the flecainide, of which I have been on for 1.5 weeks is not cutting it with Afib almost every day or every other and after 12 hours in AFIB yesterday, I'm almost hoping to find a very experienced electrophysiologist to consult with, (only because there appears to be no other option and not my first choice}. The dilemma, is it appears to be a "hidden" secret in the medical industry to have any written reviews on a specialty medical provider by patients through a search on line. Even Google (who certainly would have some sort of reviews by patients) or any other search produces nothing. A rating is not good enough. It's the same thing as a lot of Amazon sellers upping their own ratings which they do. Anyway, thanks for your articles and info, it's refreshing to hear the truth.
High dose omega-3 to keep your AA/EPA ratio between 1 and 3 can benefit patients with HFpEF and their associated metabolic problems:
https://pubmed.ncbi.nlm.nih.gov/34453204/
It's likely because omega-3 fatty acids can reduce the systemic inflammation that drives many pathological processes.