Update on Atrial Fibrillation (Goyal, 1/26/2026)

A recording of this presentation is available HERE.

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Many thanks to Dr. Rajat Goyal for a fantastic Update on Management of Atrial Fibrillation, which has really changed over the last few years. Many of us trained in a time where we were taught that "rate control is as good as rhythm". We got pretty accustomed to starting a rate med (beta blocker or calcium channel blocker) and a DOAC and leaving it at that. . . that mantra of the 2000s is not quite right anymore. Turns out that rhythm control is the way to go!

Practice changing pearls:

• Afib begets Afib
• Everyone with atrial fibrillation (including paroxysmal) should be referred to EP 
• Ablation shows better outcomes (decreased progression, improved morbidity and mortality) than medication management alone
• The earlier the ablation, the better (i.e. within first year of onset) because AF is a progressive disease
• Patients with heart failure and AF definitely benefit from ablation
• Patients s/p ablation who show no AF at one year can safely discontinue anti-coagulation
• Lifestyle modification is important: weight loss, alcohol/tobacco use, hypertension and DM management, OSA, and stress

Rhythm vs Rate Control: 

Older studies showed no difference in M&M, BUT subsequent analysis found that patients in sinus rhythm and on anticoagulation had lower risk of death (AFFIRM trial). 

EAST-AFNET trial showed that early rhythm control associated with lower M&M (death, stroke, HF admits, coronary events). Of note, many were treated with anti-arrhythmic, not all were converted via ablation

Once in persistent AF, rhythm control efforts no longer effective. Essentially, AF begets AF due to the structural changes that lead to permanent changes in the conduction system

Ablation:

• Goal is to kill triggers that initiate afib and kill unhealthy tissue. They approach the pulmonary veins and electrically isolate them, but also look at LA, LA appendage, RA, etc.
• Ablation is MORE effective than ablation in controlling AF and maintaining sinus rhythm, and the earlier the better.
• Fewer progress to eventual persistent AF after ablation

What about in setting of HFrEF?

• Yes, they benefit from ablation!
• AF causes decreased CO, RVR, loss of atrial systole and increased MR and TR so in patients with HF, maintaining sinus rhythm is VERY important.
• The CAMERA-MRI study 2017 showed that after ablation the EF improved 18% after ablation compared to 4% with medical rate control.
• A follow up study also showed reduction in mortality, hospitalization after ablation thus became a Class 1 indication (including paroxysmal AF)

 

Ablation Modalities: Pulsed Field Ablation (PFA) created at UCSF in early 80s and alters cell membranes. The mapping is done via catheter which maps the LA and PVs and able to find high areas of voltage to ablate. Pulsed Field ablation a bit more effective than Thermal ablation

Technique isolates PV about 80%.

Complications of ablation: atrial-esophageal fistula. PFA allows more selective injury and less injury to esophagus (so far 0 events). Tamponade < 1%, stroke <.05%, AE fistula <1%, vascular events <3%, coronary spasm 0.14%

Who needs to be on Anticoagulation?

Left Atrial Appendage is where many clots form, so closing that area with Watchman after ablation helps reduce stroke significantly

Ablation + closure vs Ablation + anticoagulation: no difference in strokes long term

See image below:

• for patients with a low CHADS2VASC score (<2 for men and <3 for women), if you can prove no AF at 1 year post ablation, they can safely STOP anticoagulation
• for patients with a higher DHADS2VASC score, most should either be continued on anticoagulation OR be referred for a LAA occlusion.

Smartwatches?

What about everyone with their smart watches? Turns out that smartwatches have terribly sensitivity but pretty good specificity. SO, if a patient has NO AF on their watch, they probably don't have AF. On the other hand, just because the watch shows AF doesn't mean they actually have AF. Intermittently monitor every few months, but consider encouraging your patients to get a smartwatch

Lifestyle modification 

Lifestyle modification is still a mainstay of treatment/prevention of Afib. Patients with AF really need to be counselled on weight reduction, blood pressure management, glycemic control (if DM), alcohol and tobacco use, stress management. They should also be assessed and treated for OSA. Working on these risks is essential for long term maintenance of sinus rhythm 

The Care of Children with Medical Complexity (Naber, 1/21/26)

A recording of this presentation is available HERE.

Deep gratitude this week to Dr. Urs Naber, CPMC PICU Medical Director, who jumped in last minute to give a moving Grand Rounds this week on the Care of Children with Medical Complexity (CMC). Please do watch his presentation at the above link if you are interested in the topic. 

In the literature 0.7-11% of ALL children have medical complexity (definition somewhat vague)>> about 1-2% of all children

Defining CMC: chronic condition + substantial family needs + functional limitation + heath care utilization

• previously CF patients were the highest percentage of CMC, but new treatments has changed this.
• Any medical condition can count as a chronic condition, depending on its length >> technology dependence is a driver that makes this population so vulnerable

Children with CMC have specific in home needs: medical equipment, medication administration, assistance with ADLs. CP/MD often have respiratory support technology and functional limitations that lead to high needs and high healthcare utilization

Dr. Naber shared with us a video (included in the link of the full presentation above) about a child with medical complexity named Connor and his two dads and four adopted siblings. Connor was born with Trisomy 9 and is G-tube dependent, wheelchair bound, non-verbal. The video really showed us how complex it is to take care of these children, a reminder of what it means to families to be together. Reminder to

CMC have a substantial impact on healthcare, which is expanding, 2006 <1% population, making up 10% of pediatric hospitalizations, 25% of all hospital days, 41% of all healthcare costs (attributed to hospitalizations). . . 2022, now 1-2% of population, 63% of hospitalizations attributed, 79% of all hospital days, 84% of healthcare costs. Many times these kids have to stay in ICU for their respiratory care. 

Why is this happening? 

• increased survival for children with chronic conditions (e.g. spina bifida, esophageal atresia, biliary atresia, congenital heart disease, prematurity>> previously led to non-survival, but over the last 50 years, rate of survival has increased and continues to increase)
• Total ICU costs are driven dramatically by CMCs (see image below), only 10% of pediatric critical care do not have chronic disease
• ED visits: CMCs comprise 20-30% of all visits (even though 1-2% of population), most commonly respiratory infections, medical device malfunction
• presents unique challenges for ED physician (medical complexity, long medlists), as well as caregiver and patients (subspecialists not available, ED is dangerous)

Dr. Naber shared data from Houston looking at the impact of a comprehensive care program  (JAMA, Mosquera, et al 2014), over 3 year timespan>> care coordinator, nurse, cluster care, how much would that effect care?

• 52% reduction in ED visit
• 55% reduction in days of serious illness
• 42% reduction in cost (including the comprehensive care costs)
• time investment decreased over time>> had to invest 6 hours/month per child up front, down to 2 hours/month per child over time  and still maintain the drastic impact (see image)

Helping families cope with medical complexity-- surrounding structures really matter 

Dr. Naber reminded us of the IHSS program in California, which allows parents to get some income for their caregiving of children with medical complexity. Doesn't cover medical care, but does help cover ADLS (feeding, bathing, clothing)>> family  must register and become a provider through the program. Payment is low but is something for parents who are unable to work due to their children with medical complexity. Caregivers with CMC experience an overwhelming burden (almost double) of financial hardship (JAMA 2025)

Families of CMC struggle with cost of living, housing instability, transportation challenges. 

Access to specialists and subspecialists is particularly challenging: long wait times (more pronounced if poor or brown in CA). These access challenges add to the parental burden>> leading to missed work/school days, delays diagnosis, delays treatment, etc.

Subspecialty access is only readily available in concentrated metropolitan areas of California (SF Bay area and LA area). See map. Most children don't have adequate access. 1/3 of CMC families report they have drastic challenges accessing pediatric specialty care. Can be average 84 minutes of travel one way to access specialists>> every trip is one day. Again, time off work, paying cost, finding childcare for other children. Though families still prefer in person care (over telemedicine)-- feel more of a connection, get physical exam, etc

Transitions of care can be complex: this includes discharge from hospital (changes in meds/regimens), but also the huge transition when patients age out and become adults. Family physicians can care for these patients as children and continue caring for them as they become adults. In SF Bay Area 1,000 CMC age into adulthood (50% of CMCs)>> these patients continue to have high healthcare utilization rates. 

What are additional supports:

• Evidence from the same Houston comprehensive care program>> adding telemedicine support showed even better outcomes and even more decreased cost
• CMC Emergency form, better for patients, caregivers and doctors (especially ED)
• some states have CNA model, where caregivers can get additional training and payment for medical care
• patient/care navigators 
• CPMC in process of building a Bridge program, hoping that will move care for CMC in our area to the next level, where they can get subspecialty access and better long-term care

Migraine: physiology, new medications, and integrated approaches to management (Dacre, 1/14/2026)

A recording of this presentation is available HERE.

Many thanks to Dr. Mike Dacre for a presentation this week on Migraines. 

My notes:

Migraine syndrome is super common (~10% of all people), 1 billion people globally, 2nd cause of disability worldwide, 50% underdiagnosed and undertreated. 2:1 female to male ratio

• Migraine headaches 4-72 hours
• Note Pediatric usually max 2-4 hours (often not unilateral)
• Classic pattern of prodrome>> aura>> headache>> postdrome

What causes migraine? Has long been thought of as a blood vessel problem (spasm vs dilation)>> pain often pulsatile, worse with movement/position changes, vasoconstrictors (caffeine, ergo alkaloids) then migraines get better, vasodilators (Viagra) make migraines worse. 

BUT this understanding is now known to not be true. In actuality, the blood vessel changes are SECONDARY. Now belief is that migraine is primarily a disease of neuronal activity: large ion shifts (potassium, glutamate, ATP across cell membranes)>> two receptors particularly notable now, include CGRP receptor and PACAP

• CGRP is potent vasodilator, but is a side effect of activation of this cascade>> mast cell degranulation, inflammation and sensitization
• get irritation and inflammation around the blood vessels, causing painful vasodilation

Migraines tend to start in the brainstem (where trigeminal nerve originates), direction impacts the type of migraine a person experiences. Where it moves, impacts the symptoms/manifestations

I love this simple diagram of how genetic set point+ cumulative burden push people toward migraine thresholds and lead to migraine syndromes:

Migraine headaches can move from being episodic to being chronic/intractable. Once you get migraines frequently enough, you can get medication overuse headaches, which then push you to central sensitization, which makes you more likely to get migraines. Similar to chronic pain syndrome progression>> it is not uncommon for people with headache syndromes to not seek care, overtake meds, and then have their disease progress to central sensitization and "chronification".

Abortive Treatments

Medications 

• NSAIDs are very effective (shouldn't be taken more than QOD due to risk of medication overuse headache)
• acetaminophen and caffeine can potentiate/help (care with overuse)
• Excedrin is "worse" for medication overuse (no more than 5 times/month)
• Corticosteroids + PPI
• short course of prednisone has good evidence (NNT 9)
• Triptans (actually inhibit CGRP release)
• should be used in episodic migraine, more effective when done before pain starts (aura phase), not useful after 1 hour after onset of pain
• NNT 4-5
• Sumatriptan and Rizatriptan are most commonly used (familiarity)> no head to head trials
• Care with vasoconstriction effect (e.g. contraindicated in CAD, uncontrolled Htn)

• Opioids don't work well, high risk for misuse/dependence
• Caffeine is very effective in some people for aborting migraine, but people with > 2 cups coffee/day have more frequent and worse migraines
• Ditans: not available in US (schedule 5) but do see them in Middle East and Latin America

Nerve Blocks

Greater occipital nerve block>> safe and effective even in people who don't have predominant occipital pain, helps to abort migraine. 

• can be done with or without ultrasound
• Can do block + anti-emetic + steroid
• lidocaine+ bupivacaine
• very safe (low vascular, infection risk)

Preventive Treatments

Medications

• Beta blockers all work (propranolol, metoprolol)
• TCA: Amitriptyline
• SNRIs
• ARBs
• Anti-seizure meds (e.g. valproate, topiramate)>> best responders are people who failed other classes
• Anti-CGRPs: American Headache Society released guidelines in 2024 that these meds are first line for anyone with migraine >15 days/month ($600-700/month)
• safe and effective
• can be prescribed by PCPs
• can get covered by PHP (prior auth)
• one comparison study vs. topiramate, better tolerated
  
  
• Gepants
• remigapant, ubrogopant (can be used for ppx and abortive)
• Supplements
• Magnesium 400mg/day (moderate evidence)
• Riboflavin 400mg/day (good evidence)
• Coq10 (not great evidence) 100 TID
• Botox NNT 9 (50% reduction in HA days)
• Acupuncture NNT 11 (weekly acupuncture, 50% reduction in HA days)
• OMT/PT/massage are all also very effective, studies to support their use in reducing HA days

Summary:

Non-Beneficial Treatment (Garson Leder 1/7/2026)

 A recording of this presentation can be found HERE (will be added as soon as it is available).

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Thanks to our Sutter bioethicist, Dr. Garson Leder, for a thoughtful presentation on Non-Beneficial Treatment. This is a heavy (and heady) topic, and I recommend you listen to the presentation if you want to get into the weeds on bioethical conundrums. 

If you just want the brief notes, keep reading!

Any good ethics lecture begins with terms and definitions:

• Medical Futility: a treatment is highly unlikely to benefit a patient or achieve a meaningful goal 
• quantitative futility: the chance of expected benefit is judged to be so low as to not justify treatment (sometimes but not always defined loosely as <1% chance of success, though numbers as high as a surgery that only has 30% chance of success may also fall into this category)
• qualitative futility: the quality of the expected benefit is judged to not justify treatment (quality as defined by who?)
  
• physiological futility: the treatment cannot achieve its intended purpose
• Moral authority: the right to make a decision for another person. 
• What gives physicians the power to be the decision-maker/moral authority?
• medical knowledge and experience (medical professionals are often right about likely outcome/course)
• don't patients still have right to make other/different decisions for themselves (i.e. do we have moral standing to unilaterally refuse treatment?)

(Resource allocation-- the question of should one be using limited resources to accomplish a specific goal-- is a different question)

A few pearls
-Continuing treatment is, no matter what, a decision

-Consider using the term "potentially inappropriate" rather than medically futile or even non-beneficial

-CA law supports the right of physicians to decline to continue care if it is deemed medically ineffective and/or is considered with "standard of care"

-Most conflicts about non-beneficial treatment can be resolved with clear communication AND time.