Unexpected development: a small study reports good efficacy of a cage-like device implanted in the hearts of patients with atrial fibrillation. Right now we give people a medicine coumadin to prevent strokes from atrial fibrillation (a common heart arrhythmia). A company has introduced a device that evidently accomplishes the same goal. Complications were up around 7% which is more toxic than coumadin which has about a 1% per year serious bleed risk (about the same as aspirin). The Reuter's article calls coumadin "notoriously difficult to manage " as if it were some sort of villain. Truth is thousands if not millions of patients are on coumadin and they do pretty well with it. It's pretty easy to manage coumadin too since we have a cheap fast and accurate blood test the INR to measure the coumadin dose and make adjustments over time. I hardly see coumadin-induced bleeding though when you do get a case it can be pretty bad. This would be the first example in recent memory of a procedure taking the place of a drug--usually it's the other way around. I go back to that seminal moment in medical school when a surgeon sounded the now-familiar lament that he doesn't get to do as much gastric surgery as before because of Zantac. This is the story that made me into an internist--pills are more powerful than the knife. Makes sense. I think what we have in cardiology is a procedure infrastructure that is looking to get bigger. We have all these beautiful cath labs all over the country ostensibly to treat acute MI but they then sit there many hours unused. You know what they say about nature and vacuums and all that. Manufacturers and researchers are rushing to fill the empty down time in the cath lab with procedures for new indications--ablations for atrial fib and now a mesh to catch clots. I think this device will eventually get safer and then there will be the big soul-searching of whether we want to pay $10 000 to prevent someone's stroke in atrial fib or just put them on coumadin. So far that moment hasn't arrived but it's on the horizon.