LAF Survey Results - Part 3

[Guest guest]

If you haven't read Hans Larsen's latest Report.......I highly recommend it,

especially to our newcomers.

I was, however, a wee bit disappointed that Dofetilide wasn't

discussed.....or did I miss it?

Ellen

69 NC

(NSR on Dofetilide)

*****************

----- Original Message -----

> THE AFIB REPORT>

> EDITOR: HANS R. LARSEN MSc ChE>

> NUMBER 18 JUNE

> 2002 2nd YEAR

> --------------------------------------------------------------------------

--------------------------------------------

>

> EDITORIAL

> =============

>

> In this issue we report on the effectiveness of antiarrhythmic drugs as

> determined from our recent surveys. Not surprisingly, the only drugs that

> showed any appreciable benefit were flecainide (Tambocor) and disopyramide

> (Norpace) when used by vagal afibbers. Metoprolol (Toprol, Lopressor) was

> somewhat effective for adrenergic and mixed afibbers either on its own or

> in combination with flecainide or disopyramide. Digoxin (Lanoxin) and

> sotalol (Betapace) turned out to be totally useless for preventing

episodes

> in paroxysmal afibbers and among other side effects clearly promoted

> palpitations and atrial fibrillation. A very poor choice

> indeed! Amiodarone has benefited some afibbers, but its horrendous side

> effects rule it out as a viable drug for a non-life threatening condition

> such as LAF.

>

> The research report this month investigates the connection between stress

> and lone atrial fibrillation with particular emphasis on a possible

> connection between LAF and cortisol levels. We also explore the

> association between cortisol levels and diet and lifestyle.

>

> Enjoy!

>

> Yours in health and sinus rhythm,

> Hans Larsen

>

>

> ---------------------------------------------------------------

> TABLE OF CONTENTS

> ----------------------------------------------------------------

> A. Findings from LAFS II - Part 3

> - Effect of antiarrhythmic drugs

> - How they work

> - Use versus episode frequency and duration

> - Drugs in vagal LAF

> - Drugs in adrenergic LAF

> - Drugs in mixed LAF

> - Drugs in chronic LAF

> - Subjective evaluation of drug performance

> - Follow-up on ablation procedures

> B. The Stress Connection

> - The body's reaction to stress

> - The glucose connection

> - The ins and outs of cortisol

> - Managing cortisol levels

> - Can cortisol levels be too low?

> - Conclusion

> -References

> ------------------------------------------------------------------

>

>

> FINDINGS FROM LAFS II - PART 3

> ==============================

>

> A. Effect of Antiarrhythmic Drugs

> ----------------------------------------------------

> I have taken a two-pronged approach in evaluating the effectiveness of

> antiarrhythmics and beta and calcium channel blockers. First, I have

> compared the overall episode frequency and duration in afibbers taking

> these drugs with the frequency and duration among afibbers not taking

> drugs. This comparison is further stratified by type of afib (vagal,

> adrenergic, and mixed) and by major subgroup of drugs.

>

> Second, I have compiled and evaluated 211 responses regarding the

> effectiveness of individual drugs by the 115 respondents who had tried

> them. Most afibbers have tried several drugs thus there are many more

> individual responses than there are actual respondents.

>

> I believe this subjective evaluation of drug effectiveness is extremely

> revealing and worthwhile. The individual afibber is, by far, the best

> judge of what works and what doesn't. If a drug reduces the frequency or

> duration of episodes without significant side effects then the afibber

will

> declare it a success and be keen to continue on it. If, on the other

hand,

> the drug does not produce noticeable benefits or has horrendous side

> effects then the afibber trying it will get off it and declare it a

failure.

>

> Before we get into the actual evaluation it may be worthwhile to just

> briefly recap the properties and mode of action of the drugs evaluated.

>

> How They Work

> ---------------------------

> The very first thing to realize is that no drug has ever been developed

> specifically for the treatment of LAF. All the antiarrhythmics available

> were expressly developed for the treatment of arrhythmias arising from

> cardiovascular disease and heart attacks. The second thing to bear in

mind

> is that ALL arrhythmias connected with heart disease are adrenergic in

> nature. As a consequence there is very little research on the use of

> antiarrhythmics in the management of vagally mediated LAF.

>

> Antiarrhythmic drugs are divided into 4 classes depending on their mode of

> action. To understand how they work let us take a brief look at the modus

> operandi of an individual muscle cell (myocyte) in the heart. The

> membranes of myocytes act as small pumps that pump sodium, potassium and,

> to a lesser extent, calcium and magnesium ions in and out of the

> cells. When the cell is at rest the concentration of potassium is high

> inside the cell and the concentration of sodium is high outside the

> cell. At certain times the ion channels which allow entry of sodium into

> the cell open and sodium ions rush into the cell causing it to generate an

> electric charge (depolarization) and contract. The contractions proceed

> from cell to cell making the whole muscle fiber contract and ultimately

> making the whole atria contract.

>

> Potassium leaks out of the cell during the depolarization period, but as

> soon as the depolarization is over it begins to flow back into the cell

> during what is called the rest or refractory period. Atrial fibrillation

> is characterized by a total lack of refractory periods. Calcium and

> magnesium ions follow the sodium and potassium ions respectively, but at a

> slower rate. Thus sodium and calcium are " excitatory " ions while

potassium

> and magnesium can be viewed as " calming " ions. This underscores the

> importance of having adequate intracellular levels of both potassium and

> magnesium and also explains why a magnesium infusion often halts AF. It

is

> likely that a potassium infusion would have a similar effect, but it would

> be far too dangerous because of the much faster action of potassium ions.

>

> The rate of the fibrillating heart can be slowed by partially blocking the

> ion channels that allow the influx of sodium or calcium or the outflow of

> potassium. Antiarrhythmic drugs owe their effectiveness to their

> capability to block ion channels. Class I drugs such as quinidine,

> disopyramide, flecainide and propafenone primarily block the sodium

> channels, but also have some potassium blocking effect. Class III drugs

> such as sotalol, amiodarone and dofetilide primarily block the potassium

> channels and class IV drugs such as verapamil and diltiazem block the

> inward movement of calcium. Class II drugs, the so-called beta-blockers,

> have no direct effect on the heart cells, but slow the heart rate by

> blunting the stimulatory effects of norepinephrine and the sympathetic

> nervous system.

>

> Beta-blockers such as atenolol and propranolol, and antiarrhythmics like

> flecainide, propafenone, sotalol, amiodarone, verapamil, and diltiazem are

> the drugs most often prescribed for LAF. Digoxin (Lanoxin) used to be

> widely used, but has now been totally discredited. Several clinical

trials

> have shown that it can lengthen attacks and even cause the LAF to become

> chronic. Verapamil and diltiazem are useful in lowering the heart rate

> during an attack, but do not prevent attacks or speed up the conversion to

> sinus rhythm. Flecainide is useful in converting afib to sinus rhythm and

> somewhat useful in preventing attacks. It does, however, have some rather

> nasty side effects including sudden death. It, like other antiarrhythmic

> drugs, can also cause arrhythmias.

>

> It is easy to see why drugs like flecainide have serious side

> effects. Their action is not limited to the atria. They also slow down

> the action of the ventricles sometimes with disastrous

> results. Propafenone is somewhat similar to flecainide; however, it also

> has slight beta-blocking properties making it a poor choice for afibbers

> with vagal LAF. Sotalol is not effective in converting to normal sinus

> rhythm, but supposedly has some preventive action. It also has

> beta-blocking properties. Amiodarone is used in patients with serious

> ventricular arrhythmias and is generally not recommended for LAF due to

its

> potentially devastating adverse effects.

>

> Use Versus Episode Frequency and Duration

> ----------------------------------------------------------------------

> A total of 179 respondents submitted data concerning drug use and episode

> severity. Of the 148 paroxysmal afibbers 77 had the vagal variety, 20 the

> adrenergic, and the remaining 51 the mixed form of LAF. Thirty-one were

in

> chronic afib; these respondents are omitted from the following evaluation

> as drugs would clearly not affect the frequency and duration of episodes

> although they may affect their heart rate and general feeling of

well-being.

>

> Eighty-seven (59%) of the paroxysmal afibbers were currently using a

> pharmaceutical drug to ward off or shorten episodes while 61 (41%) were

not

> taking any such drugs. The average number of episodes over a six-month

> period was 11 for drug takers and 8 for non-drug takers; this difference

> was not statistically significant.

>

> The average duration of an episode was 9 hours for both drug takers and

> non-drug takers and there was no significant difference in the total time

> spent in fibrillation over the six-month survey period (79 hours versus 75

> hours).

>

> There were no differences between drug takers and non-drug takers as far

as

> average age, gender distribution or total years of LAF. The finding that,

> overall, afibbers who take antiarrhythmics are no better off than afibbers

> who do not is indeed surprising; however, it should be kept firmly in mind

> that none of the drugs prescribed for LAF have been specifically developed

> to deal with this condition and, as a matter of fact, some of them are not

> even approved for the treatment of paroxysmal atrial fibrillation as

> such. So essentially whenever a LAF patient is prescribed an

> antiarrhythmic it is a trial and error procedure there is no guarantee of

> success. This is compounded by the fact that many afibbers are clearly

> receiving the wrong drugs for their particular condition. This is

> particularly pronounced among vagal afibbers.

>

> Drugs in Vagal LAF

> -------------------------------

> Forty-eight of the 77 vagal afibbers (62%) were taking antiarrhythmics or

> other drugs to prevent or ameliorate episodes. The average number of

> episodes over a six-month period was 12 for drug takers and 10 for

non-drug

> takers. The average duration of an episode for drug takers was 9 hours as

> compared to 11 hours for those not on drugs. None of these differences

> were statistically significant.

>

> A closer look at the collected data shows that the seeming overall lack of

> effect of drugs is actually caused by the fact that some drug takers are

on

> drugs that are clearly contraindicated for their condition while others

are

> on drugs that are beneficial. There is ample evidence that vagal afibbers

> should not take digoxin (Lanoxin), beta-blockers or antiarrhythmics with

> beta-blocking properties as these drugs are known to markedly worsen their

> condition. Yet, of the 48 vagal afibbers on drugs 24 (50%) were on

> beta-blockers or drugs with beta-blocking properties. These people had an

> average of 9 episodes lasting 12 hours over the six-month survey

> period. In comparison, vagal afibbers on the drugs best suited for them

> flecainide (Tambocor) or disopyramide (Norpace, Rythmodan) had 17 episodes

> lasting an average of only 4 hours over the survey period. Vagal afibbers

> on contraindicated drugs spent an average of 106 hours in afib over the

> period as compared to 41 hours for those on flecainide or disopyramide and

> 116 hours for those taking no drugs at all. The number of afibbers having

> no episodes at all was 7 (41%) in the flecainide/disopyramide group, 3

> (12%) in the beta-blocking group, 1 (17%) in the group on a variety of

> other drugs, and 7 (24%) in the group taking no drugs.

>

> The conclusion from this data is that vagal afibbers who cannot tolerate

> flecainide or disopyramide are better off taking no drugs at all.

>

> Drugs in Adrenergic LAF

> ---------------------------------------

> Eleven of the 20 adrenergic afibbers, for which complete data is

> available, took drugs while 9 (45%) did not. Afibbers on drugs had an

> average of 2 episodes over the six months while those not on drugs had

> 6. The duration of episodes was 13 and 17 hours respectively. Although

> these differences were not statistically significant due to the small

> sample size, there is a trend for some drugs to be beneficial for

> adrenergic afibbers. The most successful would appear to be metoprolol

> (Lopressor, Toprol).

>

> Drugs in Mixed LAF

> ------------------------------

> Twenty-eight (55%) of the 51 mixed afibbers took drugs while the remaining

> 23 (45%) did not. Those on drugs had an average of 15 episodes lasting 9

> hours during the six months as compared to 7 episodes lasting 5 hours for

> the non-drug group. Overall, the drug group spent an average 107 hours in

> afib over the period compared to 29 hours for the non-drug group. This

> difference is statistically significant (p=0.04) and indicates that mixed

> afibbers may be better off not taking any drugs. This finding is perhaps

> not too surprising as most of the drug group were taking drugs

> (beta-blocking), which would aggravate the vagal component of their

condition.

>

> Drugs in Chronic LAF

> ---------------------------------

> Eleven (35%) of chronic afibbers took no drugs while the remaining 20 were

> on a variety of beta-blockers and other drugs. Most popular were

> amiodarone (5 respondents), diltiazem (5 respondents), verapamil (3

> respondents), sotalol (2 respondents), and flecainide (2 respondents). It

> is not immediately clear why some chronic afibbers are on antiarrhythmics

> (amiodarone, sotalol, flecainide) as there is no evidence that this will

> help them convert to sinus rhythm unless they are being prepared for

> cardioversion none of these respondents were. It would make more sense

> just to take diltiazem or verapamil to keep the heart rate under control

> and avoid highly dangerous drugs like amiodarone and flecainide.

>

>

> In conclusion, the data collected in the survey does not support the

> assumption that treatment with antiarrhythmics is generally beneficial to

> people with lone atrial fibrillation. There are clearly cases where

> afibbers have been helped by these drugs, e.g. flecainide or disopyramide

> for vagal afibbers, but in general terms they do not seem to be helpful

> and, in many cases, are clearly detrimental. It would appear to be up to

> each individual, in cooperation with his or her physician, to find the

> right drug or to forego antiarrhythmics altogether. Remember that LAF is

> not life-threatening, but antiarrhythmics can be. The best and safest

> approach for many afibbers may well be to just take verapamil or diltiazem

> during an episode to keep the heart rate under control.

>

>

> B. Subjective Evaluation of Drug Performance

> --------------------------------------------------------------------------

-----

> A total of 115 respondents reported on the various drugs they had tried

and

> provided their judgment as to which ones were beneficial and what side

> effects were observed. The results are as follows:

>

> Atenolol (Tenormin)

> -----------------------------

> A total of 22 afibbers (7 vagal, 7 adrenergic, 7 mixed and 1 chronic) had

> tried atenolol. None of the vagal afibbers had found it beneficial when

> taken continuously, but one respondent had found if useful to take

> periodically when under stress. Only 2 out of 7 adrenergic afibbers had

> found it useful with one entering a " maybe " . Again, only 2 of the mixed

> afibbers had found it useful while the remaining 5 had not. One chronic

> afibber thought that it may be beneficial. Thirteen of the atenolol users

> (59%) reported one or more side effects with fatigue being reported by 7

> respondents, slow heart rate and low blood pressure by 4, and dizziness by

> 3. The most common dosage was 25 mg once a day with a range of 12.5 to

100

> mg/day. Overall benefit rate with daily use of atenolol was 0% for vagal

> and 29% each for adrenergic and mixed afibbers.

>

> Metoprolol (Toprol, Lopressor)

> -------------------------------------------

> A total of 21 afibbers (11 vagal, 5 adrenergic and 5 mixed) had tried

> metoprolol. None of the vagal afibbers had found it beneficial. Two of

> the adrenergic afibbers had found it beneficial, 2 had not, and 1 had

> entered a " maybe " . Four mixed afibbers had found metoprolol useful while

1

> had not. Fifteen (71%) of users reported side effects with fatigue being

> reported by 7 respondents and slow heart rate and low blood pressure

> reported by 4. The most common dosages were 25 or 50 mg once or twice a

> day, but 2 respondents took 200 mg/day. Overall benefit rate with daily

> use of metoprolol was 0% for vagal, 40% for adrenergic, and 80% for mixed

> afibbers.

>

> Other beta-blockers (bisoprolol, propranolol)

> --------------------------------------------------------------

> Four afibbers (3 vagal and 1 adrenergic) had tried bisoprolol or

> propranolol. None had found these beta-blockers beneficial, but one vagal

> afibber had entered a " maybe " . Two of the respondents reported fatigue as

> a side effect. Overall benefit rate with daily use of bisoprolol or

> propranolol was 0% for both vagal and adrenergic afibbers. Please not

this

> conclusion is based on data from only 3 afibbers.

>

> Amiodarone (Cordarone, Pacerone)

> ---------------------------------------------------

> Seventeen afibbers (8 vagal, 1 adrenergic, 4 mixed and 4 chronic) had

tried

> amiodarone. Four vagal afibbers had found it beneficial while 4 had

> not. One adrenergic had found it beneficial, but none of the 4 mixed

> afibbers had done so. Two (50%) of the chronic afibbers had found

> amiodarone to be of no benefit while 1 had found it beneficial and one was

> not sure. Ten users (59%) reported side effects with thyrotoxicosis being

> experienced by 5 users. The most common dosage was 200 mg once a

> day. Overall benefit rate with daily use of amiodarone was 50% for vagal,

> 100% for adrenergic, 0% for mixed, and 25% for chronic afibbers.

>

> Disopyramide (Norpace, Rythmodan)

> ----------------------------------------------------

> Eight afibbers (5 vagal and 3 mixed) had tried disopyramide. Four (80%)

of

> vagal and 2 (67%) of mixed afibbers had found the drug beneficial. The

> most common side effects were urinary problems and dry mouth, which was

> experienced by 38% of all afibbers taking disopyramide. Overall benefit

> rate with daily use was 80% for vagal and 67% for mixed afibbers.

>

> Flecainide (Tambocor)

> --------------------------------

> Twenty-six (19 vagal, 1 adrenergic and 6 mixed) had tried

> flecainide. Twelve (63%) of vagal afibbers had found it beneficial while

6

> (32%) had not. The lone adrenergic respondent had not found it

beneficial,

> but 4 out of 6 (67%) of mixed afibbers had. Twelve (46%) of all users

> reported side effects with fatigue being the most common. The most common

> dosage was 100 mg twice a day ranging from 50 mg to 300 mg/day. Overall

> benefit rate was 63% for vagal, 0% for adrenergic, and 67% for mixed

afibbers.

>

> Propafenone (Rythmol)

> ----------------------------------

> Nineteen (8 vagal, 2 adrenergic, 7 mixed and 2 chronic) afibbers had tried

> propafenone. Three (38%) of vagal afibbers, one (50%) of adrenergic, and

2

> (29%) of mixed had found it beneficial. The 2 chronic ones were not sure

> about the benefits. Nine (47%) of all users reported side effects with

> fatigue being the most common. The most common dosage was 150 or 225 mg 3

> times a day ranging from 100 mg to 300 mg 3 times a day. Overall benefit

> rate was 38% for vagal, 50% for adrenergic, and 29% for mixed afibbers.

>

> Sotalol (Betapace, Sotacor)

> ----------------------------------------

> Thirty-eight (22 vagal, 3 adrenergic, 11 mixed and 2 chronic) afibbers had

> tried sotalol. Not one (0%) had found it beneficial although one vagal

> afibber thought it might have reduced severity, but not frequency of

> episodes. Twenty-nine (76%) of all users reported side effects with 11

> actually reporting heart palpitations or fibrillation as the main side

> effect. Another 7 reported increased fatigue. The most common dosage was

> 80 mg twice a day. With a success rate of 0% and side effects occurring

in

> 76% of users sotalol is easily classified as the most useless drug for

lone

> afib. Unfortunately, it is the most frequently prescribed one.

>

> Digoxin (Lanoxin)

> --------------------------

> Twenty-two (12 vagal, 1 adrenergic and 9 mixed) afibbers had tried

> digoxin. Only 1 mixed afibber had found it useful in keeping heart rate

> under control. The remaining 21 (95%) had found no benefits from taking

> the drug. Seventeen (77%) of all users reported side effects with the

most

> common being palpitations and atrial fibrillation (32%) and fatigue

> (23%). The most common dosage was 0.25 mg daily. With only one

respondent

> out of 22 finding some benefit from digoxin and 77% experiencing serious

> side effects digoxin clearly ranks right alongside sotalol as the most

> useless drug for LAF.

>

> Diltiazem (Cardizem, Tiazac)

> -----------------------------------------

> Eleven (5 vagal, 1 adrenergic, 2 mixed and 3 chronic) afibbers reported

> that they had tried diltiazem. None of the paroxysmal afibbers had found

> it useful in preventing episodes. The 3 chronic afibbers were not sure if

> it had been beneficial. Five users (45%) reported unspecified side

> effects. The most common dosage was 240 mg once a day. While it is not

> surprising that diltiazem was not found to prevent episodes it is somewhat

> surprising that nobody found it beneficial in other ways (keeping heart

> rate down).

>

> Verapamil (Veramil)

> ------------------------------

> Twelve (6 vagal, 1 adrenergic, 3 mixed and 1 chronic) afibbers had tried

> verapamil. Only 1 vagal, 1 mixed and 1 chronic afibber had found it

> beneficial in reducing symptoms (not frequency) of episodes. Eight (67%)

> users reported side effects with fatigue being the most common. Most

> common dosage was 240 mg once a day, but dosages of 80 mg 4 times a day

and

> 120 mg once a day were also reported.

>

> Drug combinations

> ---------------------------

> Five afibbers had tried a combination of flecainide and a beta-blocker or

> calcium channel blocker. One mixed afibber had found this combination

> beneficial [using 100 mg/day flecainide and 10 mg/day propranolol

> (Inderal)] and one vagal afibber had found a combination of 200 mg/day of

> flecainide and 10 mg/day of nadolol to be of benefit. The remaining 3 had

> found no benefit of the combinations although one mixed afibber on 50 mg

> flecainide and 50 mg atenolol twice daily thought it might be somewhat

> beneficial. Side effects were few.

>

> Three afibbers had tried a combination of propafenone and

> beta-blockers. One adrenergic afibber had found a combination of 150 mg

> propafenone and 50 mg metoprolol twice a day to be beneficial. The other

2

> found no benefits.

>

> One mixed afibber had found a combination of 25 mg metoprolol and .125 mg

> digoxin daily to be of benefit.

>

> Drugs for conversion only

> -------------------------------------

> One vagal afibber has found that taking 225 mg of propafenone at the

> beginning of an episode helps speed up conversion usually converts within

> a few hours. One mixed afibber has found that taking flecainide at the

> onset of an episode speeds up conversion. Both of these findings are in

> accordance with the results of clinical trials aimed at testing the

> efficacy of flecainide and propafenone for conversion.

>

> Conclusion

> -----------------

> It is clear that the most effective drugs for vagal afib are flecainide

and

> disopyramide. Although not terribly effective the best drugs for

> adrenergic afibbers would appear to be metoprolol and propafenone either

> singly or in combination. Mixed afibbers may do well on metoprolol with

> flecainide and disopyramide either singly or in combination with

metoprolol

> also showing some effectiveness. No drug except perhaps verapamil was

> deemed to be of benefit for chronic afibbers. Sotalol and digoxin are

> totally useless and have serious side effects. Amiodarone has been

> beneficial to some afibbers, but its terrible side effects rule it out as

a

> viable drug for a non-life threatening conditions such as LAF.

>

> Although the above conclusions are based on subjective evaluations by 115

> afibbers they are in remarkably good agreement with clinical experience

and

> with the conclusions reached by relating actual episode severity to drug

> use. I believe these conclusions can be used as guidelines if you want to

> try a drug to reduce the number or duration of LAF episodes. Bear in mind

> though that both flecainide and disopyramide are very powerful and should

> only be used by afibbers with structurally sound hearts; they also tend to

> lose their effectiveness over time.

>

> Finally, do keep in mind that 40% of all afibbers participating in our

> survey use no drugs to prevent episodes and, on aggregate, have no more

> episodes than do afibbers on drugs. Whether or not drugs help is clearly

a

> highly individual matter and much experimentation will likely be required

> to find the optimum one for you if indeed there is one.

>

> C. Follow-up on Ablation Procedures

> ---------------------------------------------------------

> In the May issue we reported on the results of 15 ablation

> procedures. Four had been completely successful, 4 were clearly not

> successful, and 6 were done so recently (November 2001 January 2002) that

> it was too early to tell whether they had been successful or not. One of

> the respondents was still on beta-blockers after the operation.

>

> We have now followed up on the recently performed procedures and can

report

> that we have heard from 4 of the afibbers who underwent ablation therapy

> late last year or early this year. Three of the procedures were

completely

> successful and one was not. This brings the final score to:

>

> Vagal - 4 successful; 3 not

> Adrenergic - No procedures done

> Mixed - 2 successful; 3 not

> Chronic - 1 successful; 1 not

>

> The successful procedures were done at the Cleveland Clinic (3),

> Presbyterian Hospital (1), Duke Medical Center (1), and Virginia Mason in

> Seattle (1).

>

>

> That's it for our now. In the next issue we will discuss the benefits of

> supplements and relaxation therapies.

>

>

>

############################################################################

###############################

>

> THE AFIB REPORT is published monthly by:

> Hans R. Larsen MSc ChE, 1320 Point Street, , BC, Canada, V8S 1A5

> E-mail: editor@... World Wide Web: http://www.afibbers.org

> Copyright 2002 by Hans R. Larsen

>

> THE AFIB REPORT does not provide medical advice. Do not attempt

> self-diagnosis or self-medication based on our reports. Please consult

> your healthcare provider if you are interested in following up on the

> information presented.

>

>