WEBVTT 00:00.338 --> 00:15.468 [SPEAKER_00]: That's honestly like how everything in medicine works, which is when we start out and we have seen things a couple of times were like, oh, this is simple and it's straightforward and that there's something about you do this a hundred times and then 200 times and then 500 times and the 00:18.190 --> 00:23.972 [SPEAKER_00]: questions that seem like they're so basic and straightforward and like, oh, dot, like that's obvious. 00:24.332 --> 00:27.713 [SPEAKER_00]: Well, you often realize that actually it's just convention. 00:27.973 --> 00:33.815 [SPEAKER_00]: It's not actually based on the level of evidence that any of us would want our family to be taken care of and show. 00:34.575 --> 00:40.357 [SPEAKER_00]: But like, it's passed down and it's like codified through the hundred and language of medicine and I'm looking forward to talking about the case. 00:41.550 --> 00:49.634 [SPEAKER_03]: Welcome to the bread and butter series, a new series where we compare and contrast cases to help you better appreciate the nuances that we all tend to oversimplify. 00:50.075 --> 01:03.062 [SPEAKER_03]: Today, Dr. Angela Wing, a resident from NYU will present scenarios that come up often in post-op A-Fibb, to one of our favorite cardiologists, Dr. Greg Katz, and we also have another special guest, Open Evidence. 01:05.073 --> 01:05.613 [SPEAKER_02]: Hi, Greg. 01:05.973 --> 01:10.294 [SPEAKER_02]: So, tonight I wanted to talk with you about a case I had on the words at the end of entry year. 01:10.314 --> 01:17.256 [SPEAKER_02]: It was a case my thought was relatively straightforward, and then later realized there was a lot of nuances that I didn't really think about. 01:18.036 --> 01:23.457 [SPEAKER_02]: So I put it into open evidence who gave me super confident answers on how to manage this patient. 01:23.857 --> 01:29.218 [SPEAKER_02]: But I'm now really curious to hear your thoughts on the case and also on how you think open evidence answered my questions. 01:30.800 --> 01:40.987 [SPEAKER_03]: And throughout the episode, you will hear the Meded King, Dr. Groupree Dalai Wall from UCSF on his reflections on human versus AI when it comes to management reasoning. 01:41.788 --> 01:52.196 [SPEAKER_03]: I just love this episode and really I have sent it to so many people because I just appreciate having that headspace to see, okay, what does human versus AI kind of bring to the convoy? 01:52.216 --> 01:59.461 [SPEAKER_03]: It's not a fair comparison by any means, but at least we can appreciate it a little bit more in this specific context of post-op A-Fib. 02:06.575 --> 02:07.956 [SPEAKER_02]: Amazing, okay, let's get started. 02:08.337 --> 02:10.218 [SPEAKER_02]: So this is a 63-year-old man. 02:10.698 --> 02:17.384 [SPEAKER_02]: Pasmatic was straight of hypertension, hyperlipidemia, type 2 diabetes, his last A1c is 8.4 on an insulin. 02:17.864 --> 02:20.326 [SPEAKER_02]: He was initially admitted for a total knee replacement. 02:21.027 --> 02:26.311 [SPEAKER_02]: He underwent this knee replacement with no complications, and then imposed up he develops aphid with RVR. 02:27.372 --> 02:35.437 [SPEAKER_02]: His heart rates are 140s, otherwise he wouldn't amically stable, and because of this, he's transferred to medicine for further observation and management of his aphid. 02:36.198 --> 02:42.002 [SPEAKER_02]: We started him on top of a large heart rate, his heart rate decreases to the 100s, but he remains an aphid. 02:42.842 --> 02:47.025 [SPEAKER_02]: So, what further information do you want to know to figure out how to manage this patient? 02:48.046 --> 02:49.907 [SPEAKER_00]: Did you have any kind of preoperative evaluation? 02:50.027 --> 02:50.688 [SPEAKER_00]: You have a baseline 02:55.189 --> 02:58.854 [SPEAKER_02]: He has a baseline EKG from a couple years ago, which is normal sinus. 02:59.115 --> 03:02.840 [SPEAKER_02]: No abnormalities on it, and otherwise his lads are all with normal limits. 03:04.052 --> 03:04.952 [SPEAKER_00]: Yeah. 03:04.972 --> 03:08.273 [SPEAKER_00]: So post-op A-Fib is insanely common. 03:09.233 --> 03:18.295 [SPEAKER_00]: And how you approach it or how I approach it is like completely based on who is this person, what was their surgery and how are they doing? 03:18.355 --> 03:29.857 [SPEAKER_00]: And so when I hear a patient goes for a near replacement and then they develop post-op A-Fib, the first five things on my mind are make sure this patient does not have a PE. 03:30.277 --> 03:30.757 [SPEAKER_00]: And so 03:34.518 --> 03:38.842 [SPEAKER_00]: I'm going to stare at that EKG and I'm going to look in two places specifically. 03:39.202 --> 03:52.592 [SPEAKER_00]: First I'm going to look at Lead 1 and I'm going to examine it for the hint of an S wave because an S wave in Lead 1 is telling me about late-rightward forces that make me suspicious for PE. 03:54.093 --> 03:56.114 [SPEAKER_00]: You know, he told me he's in his 60s. 03:56.134 --> 04:16.725 [SPEAKER_00]: He has an A1C of over eight and so it is very plausible that Even an S wave and lead one or even an S1Q3T3 is actually just somebody was untreated sleep apnea But it's gonna go through my mind as something that I'm paying attention to and I'm gonna look to see is there any RSR prime in v1v2 because that's telling me the same story 04:17.245 --> 04:26.636 [SPEAKER_00]: I'm going to say my job in a post-op orthopedic surgery patient is I need to rule out a PE and I need to be pretty sure that there is no PE before I decide I'm not going to scan this guy. 04:26.956 --> 04:29.960 [SPEAKER_00]: And then I want to know how much blood he lost during surgery. 04:30.020 --> 04:33.264 [SPEAKER_00]: I want to know the nature of what his labs look like now. 04:33.344 --> 04:36.047 [SPEAKER_00]: I want to make sure that he doesn't have an unacceptable TSH. 04:36.628 --> 04:48.346 [SPEAKER_00]: And surgical site infection, make sure he's not septic because I think of aphib with RVR and a hospitalized patient as the same way I think of sinus tachycardia and so I'm gonna go through all of the things that make somebody tachycardic 04:49.615 --> 04:55.476 [SPEAKER_02]: Okay, so we largely followed your thought process to rule out reversible underlying ideologies of this new A-Fibb. 04:56.057 --> 04:57.397 [SPEAKER_02]: We sent a basic workup. 04:57.657 --> 04:59.977 [SPEAKER_02]: His CVC showed a white blood cell count of seven. 05:00.378 --> 05:03.718 [SPEAKER_02]: His hemoglobin was 13.4, which is stable from pre-op. 05:04.258 --> 05:05.799 [SPEAKER_02]: His platelets are 256. 05:06.619 --> 05:08.419 [SPEAKER_02]: His BMP had normal electrolytes. 05:08.479 --> 05:10.180 [SPEAKER_02]: His liver function test ring normal. 05:10.360 --> 05:11.980 [SPEAKER_02]: His TSA chose 2.1. 05:13.080 --> 05:16.501 [SPEAKER_02]: On infectious workup, his urine was bland with no reflex to culture. 05:16.901 --> 05:18.962 [SPEAKER_02]: And his blood cultures were so far no gross. 05:19.802 --> 05:25.084 [SPEAKER_02]: His chest Xray had a largely normal cardiac silhouette, no plural of fusion, and no pulmonary congestion. 05:25.924 --> 05:26.624 [SPEAKER_00]: Does he have symptoms? 05:26.664 --> 05:27.244 [SPEAKER_00]: How does he feel? 05:28.325 --> 05:31.946 [SPEAKER_02]: On exam, he appears really comfortable, no chest pain, no publications. 05:32.386 --> 05:33.986 [SPEAKER_02]: He doesn't feel light-headed, sitting in bed. 05:34.246 --> 05:37.667 [SPEAKER_02]: He has no lower extremity, a Dima, and he has no pain in his legs. 05:38.187 --> 05:41.168 [SPEAKER_02]: He isn't requiring oxygen, and he's setting a final room air. 05:41.188 --> 05:46.770 [SPEAKER_00]: Okay, and if he was not hooked up to a telemetry monitor, he had no clue that he was in A-Fib. 05:47.727 --> 05:48.348 [SPEAKER_02]: That's correct. 05:49.049 --> 05:51.594 [SPEAKER_02]: So in summary, he is an asymptomatic aphid. 05:51.854 --> 05:56.843 [SPEAKER_02]: He went in a weekly stable with some slow rates with metoprolol, but no cardioversion back to sinus. 05:57.464 --> 05:59.087 [SPEAKER_02]: Now what's your approach to managing him? 06:00.352 --> 06:19.688 [SPEAKER_00]: he stayed in a fib despite an evaluation and some beta blocker and so for me, I'm treating this as though my default is going to be anti-coagulate him at least for the time being especially because I'm going to cardiovert him and the reason I'm going to cardiovert him is I don't actually know whether he has exertional symptoms. 06:20.288 --> 06:23.890 [SPEAKER_00]: He is sitting in bed postoperatively after a knee replacement. 06:24.070 --> 06:48.605 [SPEAKER_00]: That rehab stinks and anything that is going to limit his ability to participate fully in that rehab is a true problem for this guy moving forward because the way that somebody recovers from surgery is very much dictated by like how much mobility do they do and how hard do they work on their rehabilitation and so if there's even a small chance that he's going to be limited rehab-wise because of his aphib. 06:49.285 --> 06:53.071 [SPEAKER_00]: I want to put him in sinus rhythm and I want to see whether or not he feels better. 06:53.692 --> 06:59.500 [SPEAKER_00]: And there's a fair number of people who are in a fib and don't think that they have symptoms. 07:00.181 --> 07:05.389 [SPEAKER_00]: And then you put them into sinus rhythm and they're like, oh, actually I did have symptoms and I just didn't realize it. 07:05.869 --> 07:09.431 [SPEAKER_00]: And a TE with cardioversion is a pretty low risk procedure. 07:09.451 --> 07:11.213 [SPEAKER_00]: He literally just had this surgery. 07:11.253 --> 07:21.519 [SPEAKER_00]: And so, if he hasn't bled in the hospital on the medications, he's on his bleeding risk over the short-term horizon in that 30-day period after I put him in sinus, which is when thrombone block risk is higher. 07:21.539 --> 07:23.040 [SPEAKER_00]: It's just like reasonably low. 07:23.321 --> 07:26.823 [SPEAKER_00]: And so that's like my immediate approach to a case like this. 07:27.884 --> 07:28.884 [SPEAKER_02]: OK, this is great. 07:29.004 --> 07:30.806 [SPEAKER_02]: Let me give you the AI a chance to catch up. 07:30.846 --> 07:33.407 [SPEAKER_02]: And let me tell you what it said to do up to this point. 07:34.308 --> 07:34.468 [SPEAKER_00]: Sure. 07:35.635 --> 07:42.521 [SPEAKER_02]: Interestingly, Open Evidence told me that he could be discharged once we get adequate rate control, and there's no evidence of any post-opt complication. 07:43.082 --> 07:46.085 [SPEAKER_02]: But we ended up doing what you suggested while he was still in the hospital. 07:47.182 --> 07:52.825 [SPEAKER_00]: And so open evidence is not wrong that the patient can be discharged from the hospital if feeling well. 07:53.325 --> 08:03.630 [SPEAKER_00]: The question of like can be versus should be and like how would I want to be taken care of versus what is like the minimum medical legally acceptable nature of medical. 08:03.650 --> 08:13.895 [SPEAKER_00]: Like those are very different things and so if that were me and I had post-op A-Fib in my A1C was 8.3 and I was 63 years old and I just had a knee replacement 08:14.495 --> 08:17.218 [SPEAKER_00]: Honestly, I would want a little bit more done for myself. 08:17.518 --> 08:19.320 [SPEAKER_00]: And I would want the same thing for my family. 08:19.521 --> 08:28.811 [SPEAKER_00]: Like, it's totally okay, but the difference between okay and the level of care that you want to provide to somebody that you really are trying to take wonderful care of is different. 08:29.852 --> 08:30.112 [SPEAKER_03]: Okay. 08:30.593 --> 08:34.297 [SPEAKER_03]: With that, let's turn to Dr. Group pre-dollywood on his reflection so far. 08:35.547 --> 08:41.212 [SPEAKER_01]: One of the things that you saw that Greg does, which AI systems can't do, is he exhibited moral judgment. 08:41.292 --> 08:56.887 [SPEAKER_01]: So if you listen to how he said tan versus should, or what's the minimal versus the optimal, really like wrong versus right, there's just a lot of moral judgment cycle into it, and you know, human to sign off on it, but you actually really need someone who cares that much to make the judgments. 08:57.247 --> 08:57.988 [SPEAKER_01]: I think that's a mistake. 08:58.108 --> 09:13.867 [SPEAKER_01]: Almost all of this make and we start medical education is like I just want to send to all the scientific knowledge and if I can master it, then my decision making will be highly not perfect, but it'll keep getting better and better understanding the scientific literature is just a modest part of what we do as doctors. 09:14.468 --> 09:21.170 [SPEAKER_01]: People don't hire us or seek our care because you master this whole canon of knowledge and apply it to every person the same way. 09:21.510 --> 09:24.911 [SPEAKER_01]: They seek us because you're really exceptional at customizing it per patient. 09:24.951 --> 09:26.532 [SPEAKER_01]: It's the exact opposite of science. 09:26.952 --> 09:32.113 [SPEAKER_01]: And I think what Greg did was a really great job of explaining why he would do things the way he did for this patient. 09:32.153 --> 09:34.194 [SPEAKER_01]: He said rehab is very difficult. 09:34.614 --> 09:36.895 [SPEAKER_01]: In order to go through rehab, you have to be at your very best. 09:37.155 --> 09:40.477 [SPEAKER_01]: It's very possible if I can get him in a normal sinus rhythm, he will be at his very best. 09:40.537 --> 09:43.218 [SPEAKER_01]: But he has a mental model of what needs to happen post-op. 09:43.238 --> 09:49.641 [SPEAKER_01]: I mean, that is an incredibly sophisticated number of steps that we may find routine until you try to program that into a computer. 09:57.365 --> 10:02.107 [SPEAKER_02]: What is your threshold of keeping this patient in the hospital to get an echo before discharge? 10:03.470 --> 10:15.818 [SPEAKER_00]: hundred percent i want the echo before i like you know if this patient is going to have quick follow up that's totally fine but he shouldn't wait four weeks for an echo and honestly like i probably would not have him leave the hospital 10:16.828 --> 10:23.292 [SPEAKER_00]: without restoring sinus rhythm, and so I'm going to look at his heart on a TE before I cardio over him. 10:23.793 --> 10:36.141 [SPEAKER_00]: He's a patient who has like somewhat poorly controlled diabetes, and so my suspicion that he has some kind of underlying coronary disease is pretty high, you know, a 60-year-old diabetic patient who just went for a knee replacement. 10:36.525 --> 10:45.307 [SPEAKER_00]: probably has some plaque in his arteries, and so I don't know that his ejection fraction is not 35% that this decision of do they need to stay in the hospital? 10:45.407 --> 10:46.827 [SPEAKER_00]: Do they not need to stay in the hospital? 10:47.227 --> 10:50.307 [SPEAKER_00]: I would actually sort of like put it back on you and I'd be like, how confident are you? 10:50.327 --> 10:52.768 [SPEAKER_00]: You have any idea what is going on with this guy's heart. 10:52.848 --> 10:56.089 [SPEAKER_00]: And the answer is like you shouldn't be that confident because you don't have very much information. 10:56.629 --> 11:00.769 [SPEAKER_00]: And when you don't have very much information, it's somebody has an unexpected complication. 11:00.789 --> 11:03.950 [SPEAKER_00]: And I would describe post-op A-thib as an unexpected complication. 11:04.550 --> 11:08.511 [SPEAKER_00]: Your job is not to satisfy the ODE ratio. 11:08.791 --> 11:12.652 [SPEAKER_00]: Your job is to take care of the patient and it's to figure out what's going on. 11:12.712 --> 11:20.394 [SPEAKER_00]: And if you discharge this guy with no echo in a family, gets an echo 48 hours later and his EF is 35%. 11:21.314 --> 11:25.175 [SPEAKER_00]: You're gonna feel like you missed the boat taking care of him in the hospital. 11:25.275 --> 11:32.997 [SPEAKER_00]: And so my sense is that when somebody has an unexpected complication happen, the right thing to do is to figure out as much 11:35.398 --> 11:36.218 [SPEAKER_02]: Okay, I like that. 11:36.498 --> 11:42.321 [SPEAKER_02]: And we've kind of hit on this already, but now let's talk a little bit more about anti-quagulation and stroke prevention and aphid. 11:43.882 --> 11:50.285 [SPEAKER_00]: He's at elevated thromble and ball-grisk and he's at elevated thromble and ball-grisk because his Chad's vascular is quite high. 11:50.986 --> 11:56.309 [SPEAKER_00]: He's in his 60s, I think he's 63, but like his 63 truly that different than 65 probably not. 11:56.769 --> 11:58.430 [SPEAKER_00]: He has diabetes with an A1C of 8. 11:59.050 --> 12:21.829 [SPEAKER_00]: He's hyper-tensive, and so I have enough points in Chad's vascore for me to say that I'm probably going to anticoagulate him, and he didn't have a self-limited episode of A5, and so the persistence of the A5 for even just the duration of the hospital's day says to me that I am treating him now as a proxistable A5 case, and you know the other part of this that's really important is he had no clue that he was in A5. 12:22.230 --> 12:26.954 [SPEAKER_00]: I have no idea whether he's had A5 on and off for the last five years of his life, and so 12:27.454 --> 12:33.077 [SPEAKER_00]: He's 100% somebody I'm anti-quigulating, regardless of whether or not we cardiovered him based on the data that we have. 12:34.277 --> 12:41.641 [SPEAKER_02]: You know, we talk about stroke risks in AFib a lot, and we use the Chad's mask score to risk stratify, but how exactly does AFib call stroke? 12:42.121 --> 12:45.543 [SPEAKER_02]: Is it really a simple as stasis in the left atrial appendage? 12:47.109 --> 12:53.413 [SPEAKER_00]: Stroke-riscan aphib is something that doctors are overly simplistic and concrete about too often. 12:53.914 --> 12:57.316 [SPEAKER_00]: And so what I mean by that is like why do people have strokes when they have aphib? 12:57.836 --> 13:07.523 [SPEAKER_00]: Well, one possibility is you have a throbus form in your left atrial appendage from the disorganized atrial contraction, and then a piece of that breaks off and it travels to the brain. 13:08.103 --> 13:11.286 [SPEAKER_00]: But that's only one mechanism of aphib, and so like what's in the Chad's vascular? 13:12.334 --> 13:20.780 [SPEAKER_00]: Nothing to do with the left-atrial appendage, nothing to do with the left-atrial appendage emptying velocity, the size of the left-atrial, like nothing about the mechanics of the heart. 13:21.301 --> 13:28.006 [SPEAKER_00]: The chads vascular is basically asking how likely is this person to have after a sclerotic cardiovascular disease. 13:28.086 --> 13:30.548 [SPEAKER_00]: And the chads vascular, it's not magical. 13:31.008 --> 13:47.329 [SPEAKER_00]: It was derived like every other risk calculator in medicine, which is a retrospective cohort of patients they figured out through some complex statistical analysis what seemed to independently cause an increased risk of stroke, and then they prospectively validated and then 13:47.830 --> 13:52.294 [SPEAKER_00]: It just sort of gets put into the medical cannon as the way that you're supposed to do it. 13:52.314 --> 13:56.477 [SPEAKER_00]: And if you have a chads vascore of zero or one, well, you can't have a stroke with a fib. 13:56.497 --> 14:03.182 [SPEAKER_00]: And if you have a chads vascore of three or more, two or more, then like God helped the doctor who doesn't prescribe that person anti-coagulation. 14:03.323 --> 14:06.325 [SPEAKER_00]: And like you look at like the eloquises all that matters. 14:06.565 --> 14:12.070 [SPEAKER_00]: But I think it's super, super important that when you think about a patient who has a fib, 14:12.650 --> 14:35.238 [SPEAKER_00]: You don't fixate on the chads vascore and the left-hedral appendage as the be all in and all of stroke because even if you take patients who have a fib and strokes and continuous monitoring, not all of the people with a fib who have strokes are in a fib at the time of their stroke and not all people who have a fib and have strokes have a blood clot leave their left-hedral appendage and go up to the brain. 14:35.318 --> 14:39.780 [SPEAKER_00]: And so if you don't think about all of the other competing risks of stroke, 14:40.240 --> 14:52.568 [SPEAKER_00]: That's an incomplete mental model of how to think about stroke in a fib and I would just recommend that everybody who thinks about stroke doesn't get fixated on just the left atrial appendage. 14:53.609 --> 14:54.489 [SPEAKER_02]: Okay, makes sense. 14:54.990 --> 15:01.254 [SPEAKER_02]: Next question, what if he's self-comverted to sign is like what if the a fib only lasted five minutes while he was post-op? 15:01.514 --> 15:03.015 [SPEAKER_02]: Would that change your decision making? 15:04.557 --> 15:27.530 [SPEAKER_00]: If the A-Fib only lasted five minutes, it's a wildly different ballgame and then my default is not going to be to anticoagulate him, it's going to be to monitor him more and so the duration of A-Fib to me is really influential and whether or not somebody like converts because we did something to them versus just converts on their own is also an influential thing for me as far as I know there's no really good data. 15:28.030 --> 15:33.393 [SPEAKER_00]: to assess whether self-conversion versus medical conversion actually makes that much of a difference. 15:33.453 --> 15:40.496 [SPEAKER_00]: But my perception is that if somebody is converting on their own without intervention, means that their phenotype is somewhat lower risk. 15:40.636 --> 15:53.883 [SPEAKER_00]: But if somebody has a really short self-limited run of a fib, then I think that you need to look at them like they're probably not the same level of risk as somebody who's in a fib for 36 hours and needs to be cardioverted 15:56.704 --> 15:58.805 [SPEAKER_00]: There's a bunch of different clinical trials, right? 15:58.825 --> 16:01.086 [SPEAKER_00]: There's Artisha, which looked at subclinical AFib. 16:01.647 --> 16:06.589 [SPEAKER_00]: There's no AFNet, which looked at subclinical atrial high rates that were really, really short. 16:07.090 --> 16:09.091 [SPEAKER_00]: And they all kind of like tell a different story. 16:09.171 --> 16:11.732 [SPEAKER_00]: No AFNet was less impressive than Artisha was. 16:11.792 --> 16:14.514 [SPEAKER_00]: Artisha basically looked at pretty long episodes. 16:14.694 --> 16:16.935 [SPEAKER_00]: But those are not post-op patients. 16:17.155 --> 16:19.516 [SPEAKER_00]: Both of those studies are not post-op AFib. 16:19.737 --> 16:21.978 [SPEAKER_00]: Both of those studies are people who have pacemakers. 16:22.378 --> 16:28.544 [SPEAKER_00]: who just incidentally find that the pacemaker has detection of atrial fibrillation or atrial hyerate sense. 16:28.604 --> 16:30.526 [SPEAKER_00]: In medicine, you need kind of need to be careful. 16:30.807 --> 16:35.592 [SPEAKER_00]: So the question of what is reasonable extrapolation and what is unfair? 16:35.692 --> 16:36.613 [SPEAKER_00]: It's a gray line. 16:36.753 --> 16:38.655 [SPEAKER_00]: I'm super curious what open evidence has to say. 16:39.904 --> 16:40.124 [SPEAKER_02]: Right. 16:40.164 --> 16:51.598 [SPEAKER_02]: So for the question of if it only lasted five minutes, it said a five minute episode of a fifth is not worn anti-quagulation based on current guidelines, even with the Chad's Vascore of three. 16:52.279 --> 16:55.103 [SPEAKER_02]: And then it goes on to quote the studies that you just talked about. 16:55.223 --> 16:59.168 [SPEAKER_02]: So it quoted our t-ja and then it quoted Noah Affnet to back up its decisions. 17:00.627 --> 17:06.989 [SPEAKER_00]: Noah Affnet was not a Fibu's atrial hyrates, and so is atrial tachycardia the same. 17:07.490 --> 17:15.193 [SPEAKER_00]: One of those things like as you dig into, there's no way you come away with like a higher level of confidence that anybody knows anything. 17:15.713 --> 17:20.655 [SPEAKER_00]: It's nice to think that we really understand it, but I think that really it's way more complex. 17:21.635 --> 17:31.785 [SPEAKER_00]: We need to have a fair amount of intellectual humility when we think about how we counsel patients and just the level of uncertainty is truly profound in cases like this. 17:33.350 --> 17:46.026 [SPEAKER_01]: Greg had one interesting thing, it was sort of philosophical, he was talking about the trials and then he was talking about the shortcomings and how you can't really extrapolate them to our case, so we make, we do so in faith even though we have a reference class problem. 17:51.994 --> 17:54.335 [SPEAKER_01]: but it gets back to the point like there is no answer. 17:54.375 --> 17:59.198 [SPEAKER_01]: I think somebody you're like well there's just some answer in the literature and it knows it but it's all in perfect information. 17:59.398 --> 18:09.823 [SPEAKER_01]: Patient days in perfect, our brains in perfect, the literature is in perfect and what a professional judge is makes a judgment right but there's always uncertainty and that's a key point that's why we're training everyone. 18:09.843 --> 18:13.825 [SPEAKER_01]: If there was no uncertainty then you don't need a doctor like that's our job. 18:21.390 --> 18:28.714 [SPEAKER_02]: Is there a specific time marker that you kind of change your mind about, like, is five minutes where you draw the line or is it still a super gray area? 18:29.954 --> 18:32.716 [SPEAKER_00]: It's a super gray area and it's also like, who is this patient? 18:33.316 --> 18:40.920 [SPEAKER_00]: And so for this patient, if he has five minutes of a fib, he is so much better to be just put on a GLP one egg. 18:40.940 --> 18:44.261 [SPEAKER_00]: And it's then he is to be put on an anticoagulant when it comes to stroke reduction. 18:45.062 --> 18:46.862 [SPEAKER_00]: And like does he have sleep apnea? 18:47.043 --> 18:49.604 [SPEAKER_00]: How are the rest of his atherosclerotic risk factors controlled? 18:50.104 --> 18:53.409 [SPEAKER_00]: then he's had CTs in the past, how much calcium does he have in his arteries? 18:53.729 --> 19:06.448 [SPEAKER_00]: And so I really try to be holistic when I think about stroke prevention in patients who have uncertain amounts of aphib, and I think that you need to look at the entirety of what his stroke risk profile is. 19:07.682 --> 19:10.363 [SPEAKER_01]: Greg was talking about Chad's vask and he raised a great point. 19:10.383 --> 19:17.124 [SPEAKER_01]: He's like, all the things in Chad's vask are not exactly directly mechanistically tied to how a firm causes a stroke. 19:17.144 --> 19:18.624 [SPEAKER_01]: There's sort of correlations. 19:18.664 --> 19:23.225 [SPEAKER_01]: It's really as a deep understanding of mechanisms in a way that are wouldn't expect the LLM to know. 19:23.825 --> 19:33.927 [SPEAKER_01]: And then the ability of humans to think outside the box, outside of this whole conversation, he's like, you know, actually if I wanted to reduce stroke, I might say maybe the GLP-1 is a more promising avenue 19:38.108 --> 19:48.075 [SPEAKER_01]: LLMs are great at remixing, things that if humans have come up within the past before in the literature, but humans are still right now, at least we have the advantage in creative solutions. 19:48.316 --> 19:49.777 [SPEAKER_01]: That was a really great example of it. 19:50.057 --> 20:04.307 [SPEAKER_01]: I myself thought about that, that maybe when I learn from that, that maybe when I'm focusing on stroke reduction in my affid patient, there's other processes I might want to think of and if we don't go down the anticoagulant route that doesn't mean that there aren't some really promising and who knows they'd be even better approaches. 20:11.808 --> 20:20.318 [SPEAKER_02]: All right, I'm curious now about your thoughts and how do you use IO patches or loop recorders for more long-term monitoring of AFib in these patients? 20:22.128 --> 20:30.571 [SPEAKER_00]: We make a decision based on a snapshot in time, but to really take care of a patient like this, you need longitudinal followup. 20:30.591 --> 20:34.333 [SPEAKER_00]: Like you need to have somebody wear a heart monitor. 20:34.353 --> 20:49.439 [SPEAKER_00]: If I don't know whether open evidence recommend it to the loop recorder, but a loop recorder, it's something you would consider, but loop recorders have been studied really interestingly because they've been studied for detection of AFib in patients with cryptogenic stroke. 20:50.275 --> 21:07.050 [SPEAKER_00]: Very importantly, like Crystal AF, which is the study looking at detection of AFib in scriptogenic stroke with loop recorder versus standard monitoring, which is like 28 or 30 days, which found over the course of a year, I think around 12 and a half percent of patients with loop recorder were found to have AFib. 21:07.510 --> 21:13.515 [SPEAKER_00]: It's really, really important that we remember, Crystal AF was not a stroke prevention trial. 21:14.096 --> 21:16.438 [SPEAKER_00]: Crystal AF was an AFib detection trial. 21:16.978 --> 21:33.185 [SPEAKER_00]: And so we don't actually know whether using a loop recorder to detect a fib and then choosing to prescribe anti-coagulation because of the presence of a fib is a stroke reduction strategy because that's not how it was studied. 21:33.845 --> 21:38.967 [SPEAKER_00]: Crystal AF tells us when we look for a fib for a long time, we find more a fib when we look for a short time. 21:39.568 --> 21:44.169 [SPEAKER_00]: But it doesn't give me any confidence that I have truly identified the 21:46.621 --> 21:47.462 [SPEAKER_02]: Okay, make sense. 21:47.903 --> 21:50.567 [SPEAKER_02]: So we did end up discharging him with a zio patch. 21:50.988 --> 21:57.557 [SPEAKER_02]: So say now that you see him in clinic and the zio patch is completely negative, and he is still super asymptomatic. 21:58.038 --> 21:59.200 [SPEAKER_02]: Now where do we go from there? 22:00.695 --> 22:09.503 [SPEAKER_00]: He got the zeo when he was in sinus and then he leaves the hospital and he wears the zeo for two weeks in sinus and he's on aliquus and he follows up in clinic. 22:10.003 --> 22:15.788 [SPEAKER_00]: I would probably keep him on the aliquus for at least a full month because he was in a fib for a pretty long period of time. 22:16.029 --> 22:26.177 [SPEAKER_00]: And then I'm at least repeating a monitor after like another couple of months because my level of confidence that we really understand things over two weeks is pretty low. 22:26.938 --> 22:47.391 [SPEAKER_00]: But I also look at this case as a case where at least in the short term the risk of staying on anticoagulation is pretty asymmetric in a way that favors anticoagulation and so what I mean by that is the likelihood of a 63 year old non chronically ill non frail man what is risk of having a serious bleeding complications like pretty well. 22:48.151 --> 22:51.193 [SPEAKER_00]: And you can plug in whatever risk calculator you want it. 22:51.273 --> 22:57.096 [SPEAKER_00]: But to me, that misses some of the nuance of like how I actually think about this decision. 22:57.156 --> 23:00.978 [SPEAKER_00]: And so we put on that's a quite a lot for a short period of time. 23:02.199 --> 23:03.600 [SPEAKER_00]: And what's the downside of that? 23:03.920 --> 23:06.341 [SPEAKER_00]: Well, he might have a self-limited bleed. 23:07.162 --> 23:12.805 [SPEAKER_00]: The chance of him having a serious life threatening, life changing, bleeding complication is pretty low. 23:13.867 --> 23:19.351 [SPEAKER_00]: And if he has a stroke, it has the potential to just totally ruin his life. 23:20.011 --> 23:26.035 [SPEAKER_00]: In, like, to me, the burden of proof is on why we should stop the anti-quayulation super early. 23:26.515 --> 23:28.556 [SPEAKER_00]: In real life, you run into practical implications. 23:28.576 --> 23:34.220 [SPEAKER_00]: Like, he wants to go skiing, or he hates being on a blood dinner, or his copay is a million dollars a month. 23:34.660 --> 23:38.823 [SPEAKER_00]: I think that, ultimately, like, the real world implications are going to dictate. 23:39.323 --> 23:47.753 [SPEAKER_00]: What we actually do about that point of risk is asymmetric is a really vital component of how I think about what that decision making is going to be. 23:55.566 --> 24:00.029 [SPEAKER_02]: Open evidence said that his chance of bleeding is much less than his chance of having a stroke. 24:00.489 --> 24:04.131 [SPEAKER_02]: And so it would advocate keeping this patient eloquence indefinitely. 24:04.712 --> 24:09.775 [SPEAKER_02]: And then I asked what if he follows up in one year and he's not had another episode of A-FIN. 24:10.095 --> 24:12.196 [SPEAKER_02]: What are its thoughts on continuing? 24:12.297 --> 24:20.862 [SPEAKER_02]: A-C at that time, and it said you should still just continue it because the benefits of continuing A-C far outweigh the risks for this patient. 24:22.198 --> 24:27.108 [SPEAKER_00]: Yeah, maybe you should but like maybe you shouldn't like that's a real that's just like a gray area. 24:27.689 --> 24:28.992 [SPEAKER_00]: Nobody knows what the answer is 24:30.218 --> 24:38.105 [SPEAKER_01]: When I was earlier in my career, I would be frustrated that three neurologists would handle it this way, or that two GI doctors would approach this GI bleed differently. 24:38.445 --> 24:44.811 [SPEAKER_01]: But as you go on further and further, you just realize there is no one right way, because there's too many variables on this too much complexity. 24:45.251 --> 24:50.596 [SPEAKER_01]: It's really sort of, is it a defensible plan that's put in place, rather than sort of being fixated? 24:50.616 --> 24:51.917 [SPEAKER_01]: I'm there as an optimal one. 24:52.518 --> 24:56.221 [SPEAKER_01]: And if I get the right consultant, or if I get the right AI, I will get there. 24:57.102 --> 25:02.084 [SPEAKER_01]: We got Greg consulting on this case with the fans who picked up the phone and got a different cardiologist. 25:02.104 --> 25:09.486 [SPEAKER_01]: There's no doubt she would have heard some different advice and guidance, and it would have been defensible and logical in its own way, but non-identical. 25:09.866 --> 25:12.027 [SPEAKER_01]: You know, in AI, I think many of you listeners know this. 25:12.047 --> 25:16.668 [SPEAKER_01]: If you type them the same case a second time or third time, they'll be different variations on the advice. 25:16.768 --> 25:17.948 [SPEAKER_01]: It's not fixed advice. 25:18.008 --> 25:19.989 [SPEAKER_01]: It's stochastic in what it puts out. 25:27.377 --> 25:27.597 [SPEAKER_02]: Yeah. 25:28.438 --> 25:34.741 [SPEAKER_02]: I thought it was really interesting because it never asked me if the patient was symptomatic from the thefid. 25:35.641 --> 25:36.361 [SPEAKER_00]: That's pretty wild. 25:37.062 --> 25:47.887 [SPEAKER_02]: You asked me, but the initial stem I gave didn't comment, and then halfway through the prompt, it assumed this patient with symptomatic 25:52.925 --> 25:53.886 [SPEAKER_00]: What's our job as a doctor? 25:53.986 --> 25:54.927 [SPEAKER_00]: Like I think we have two. 25:55.448 --> 25:58.711 [SPEAKER_00]: One is to help patients live better and one is to help them live longer. 25:59.272 --> 26:08.601 [SPEAKER_00]: And so if you don't figure out if somebody has symptoms, you completely lose the ability to figure out the first one of how do you make somebody live better. 26:09.382 --> 26:14.808 [SPEAKER_00]: And so I hope the chat bot learns its lesson and is gonna ask a do a little bit more thorough history taking next time. 26:16.030 --> 26:23.414 [SPEAKER_01]: I think what it really showed is that humans and other humans, and perhaps more intellectually, they have a mental model of how humans operate, right? 26:23.835 --> 26:29.318 [SPEAKER_01]: But Greg, just like all doctors over time, learn that patient may minimize, patients may not recognize symptoms. 26:29.338 --> 26:36.402 [SPEAKER_01]: But he had a great point, he's like, you know, they often, his patients feel better after our treatment, and then they recognize what they thought was an asymptomatic state was. 26:36.742 --> 26:38.003 [SPEAKER_01]: But I just want to point out that 26:38.363 --> 26:42.628 [SPEAKER_01]: Humans have mental models of a lot of things that computers don't have. 26:42.648 --> 26:45.892 [SPEAKER_01]: So they have mental models of how humans behave and they minimize symptoms. 26:46.192 --> 26:48.835 [SPEAKER_01]: They have mental models of how the health system works. 26:49.075 --> 26:53.380 [SPEAKER_01]: I mean, so many of the things in the conversation about how can this be done in health care, right? 26:53.721 --> 26:55.142 [SPEAKER_01]: Can the TE happen? 26:55.182 --> 26:57.625 [SPEAKER_01]: Can the echo happen before discharge? 26:57.905 --> 26:58.406 [SPEAKER_01]: What are the... 26:58.666 --> 27:01.827 [SPEAKER_01]: You know, what things might be a barrier to taking in that coagulation. 27:01.867 --> 27:04.187 [SPEAKER_01]: That is an extremely rich mental model. 27:04.548 --> 27:07.648 [SPEAKER_01]: And again, it goes way beyond what can be captured in PubMed. 27:07.668 --> 27:10.469 [SPEAKER_01]: There's nothing in PubMed that would help someone make those judgments. 27:10.529 --> 27:17.311 [SPEAKER_01]: And if you accept the premise that our job is to make professional judgments, you have to know humans, and you have to know the health system. 27:17.331 --> 27:21.612 [SPEAKER_01]: And if you don't know either one of those two things, you will be ineffective in judgment. 27:22.132 --> 27:23.493 [SPEAKER_01]: I really enjoyed the conversation. 27:23.573 --> 27:27.977 [SPEAKER_01]: I learned a lot of perspectives on post-op, a fib, and maybe a fib in general. 27:28.337 --> 27:42.588 [SPEAKER_01]: I came away thinking that, you know, open evidence was a useful tool, but more than anything, I think it was a really great example of the power of the human brain, and the role of what we do in medical education, which is that we train for professional judgment. 27:42.768 --> 27:45.030 [SPEAKER_01]: That is what we do, and that was on full display there. 27:46.565 --> 27:50.950 [SPEAKER_03]: Today we talked a lot about what we should do for our patients first is what must be done. 27:51.490 --> 28:00.219 [SPEAKER_03]: So I do want to acknowledge in real life there's so many other factors that go into what may be the best thing that we can do for our patients first is what we actually do. 28:00.720 --> 28:07.527 [SPEAKER_03]: And I will say like I think that thing that hurts me the most is whenever I hear like oh that's something we do inpatient with to do that outpatient like that always trips me up. 28:08.087 --> 28:11.108 [SPEAKER_03]: And I just want to acknowledge that that aspect of the application, right? 28:11.148 --> 28:21.410 [SPEAKER_03]: Whether it comes from a thoughtful cardiologist friend or from AI, there are just very practical barriers to implementing it for our patients and that is so real. 28:21.910 --> 28:24.090 [SPEAKER_03]: But thank you so much for joining us today. 28:24.530 --> 28:26.171 [SPEAKER_03]: We hope you appreciated this episode. 28:26.251 --> 28:29.811 [SPEAKER_03]: I know for me it was so eye-opening and I can't wait to do more of these. 28:30.272 --> 28:34.332 [SPEAKER_03]: If you'd like to join the team of people who help think about bread and butter cases, 28:37.833 --> 28:41.896 [SPEAKER_03]: Plus, mine is, where does AI compare and help in the fold of things? 28:42.317 --> 28:47.340 [SPEAKER_03]: Please reach out via coreampotcast.com, send us an email, coreampotcast at gmail.com. 28:47.841 --> 28:49.963 [SPEAKER_03]: We'd love to hear from you and via prior to team. 28:50.063 --> 28:54.506 [SPEAKER_03]: And if you like this episode, as always, our one ask is, to please send it to one other colleague. 28:54.546 --> 28:59.790 [SPEAKER_03]: It really helps people find us and hopefully get some thought provoking ideas to from this episode. 29:00.210 --> 29:02.212 [SPEAKER_03]: Thank you to everyone who made this episode possible. 29:02.272 --> 29:04.934 [SPEAKER_03]: Both on and off air, as always, it pains 29:06.416 --> 29:09.161 [SPEAKER_03]: and do not represent the opinions of any affiliated institutions. 29:09.221 --> 29:09.602 [SPEAKER_03]: Thank you.