For years I have been fascinated by the peculiar relationship between the perception of a situation and its reality.

My earliest recollection of such consternation was as a little leaguer trying to fathom the mysterious alchemy by which our manager divined that the .390 hitter batted fifth and the .412 hitter third, both obviously failing to get a hit six out of ten times at bat. Nonetheless, the superior batting average afforded its owner great status in our minds and in our club house, a situation ingeminate on every team in the league.

In juxtaposition, today I measure nuclear camera reliability by uptime, perceiving the 99 percent of my system clearly superior to the imperceptibly less 98 percent afforded by its unworthy competitor, a hard drive in my server by its claim to a ridiculously long 100,000 hour service life and, in that most practical example of the foolish chasm between perceived reliability and true dependability, I am angry when my automobile fails to start once every five or six years.

Medically, we do the same thing.  We measure STEMI angioplasty success by time to open artery, a few, probably insignificant minutes separating “excellent” from “fair” programs, the adrenaline charged environment and fierce intersystem competition conducive to team building and performance improvement while all but ignoring the fact that the majority of persons having myocardial infarction do not seek attention in a timely fashion.

And then there is atrial fibrillation (AFib). It is estimated that 5 to 6 million Americans have AFib, the median age of those suffering from it about 66 years for men and 74 years for women. It accounts for some 15-20 percent of strokes, and in contradistinction to coronary heart disease, the death rate for persons with AFib as a primary or secondary diagnosis has continued to increase over the last two decades. At present, its management cost is likely tens of billions of dollars and that does not include the cost of care, both acute and long term, for those suffering disabling stroke from AFib.

Every doctor I know, myself included, perceives they are doing a great job managing AFib. But in reality the actual rate of anticoagulation to prevent stroke is, in fact, only slightly short of abysmal.

Data from our own PINNACLE Registry in 2011 demonstrated that in those with moderate to high risk of stroke we properly anticoagulated only 55 percent, prompting the lead author, Paul S. Chan, MD, to comment that the data showed “an almost random pattern of treatment.”

Both our self-aggrandizing perception of our success and our factual failure to adequately treat our patients must change. Although it will not be easy, we are getting help from an unlikely source: the direct to consumer advertising of the novel oral anticoagulants. Never has the public been more receptive to discussion of anticoagulant choice and strategy.

I believe this opportunity is nothing short of our next “door to balloon (D2B) time,” perhaps with far greater implication. Unlike D2B, this effort involves all cardiologists and care team members, not just interventionists. Further, if we show leadership here it will quickly expand to our internal and family medicine colleagues, a force multiplier far greater than any experienced in the catheterization suite.

As the ACC continues to develop its Anticoagulation Initiative let’s take the opportunity to really lead on this issue. We have tools like the AnticoagEvaluator app, which for the first time permits at the point of care a factual, scientifically based discussion of stroke and bleeding risk based on the patients actual risk profile and the anticoagulant chosen, and are invaluable to physicians, nurses and patients, alike.

Since the triple aim of better care, better health and lower cost is our aspiration, perhaps this is a good place to start?

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