Passing the Test

EHM: Did you ever question the idea of testing the Autonomic Nervous System (ANS), and whether or not you would use the ANSAR test?
GM: Sure, of course. I asked myself, why do I need ANS testing? How will it help my patients? Do I have enough patients? I must admit I was pleased that the answers are “Yes”. If you see cardiovascular patients, you know there are serious ANS imbalances, especially a sympathetic excess that predisposes one to sudden cardiac death, and a progression of diseases. By detecting and addressing these imbalances, you will be amazed at how many patients are maximally managed per guidelines.

If you see diabetics, you know that up to 30% can have the life threatening disorder, Cardiovascular Autonomic Neuropathy (CAN) that can be asymptomatic for a very long time. If you see patients who are tired, faint, dizzy, have BP problems, palpitations, or if you prescribe medications such as beta-blockers, anti-depressants, anti-hypertensives, or bronchodilators then you need to monitor their ANS. Side effects may be due to manipulation of the ANS through those drugs. Also, secondary symptoms can arise from ANS imbalances as a result of chronic conditions. Restoring autonomic balance addresses secondary symptoms and improves outcomes.

Only ANSAR enables independent, simultaneous measures of both sympathetic and parasympathetic activity by simultaneous analyses of both HR variability (HRV) and respiratory activity. The respiratory activity analysis is the key. It is required to assess true autonomic balance. Granted, autonomic testing comes in many forms, but all the rest provide mixed measures. HRV alone, as provided by all of the rest, only indicates whether or not a patient’s ANS as a whole is functioning. Well, we knew that already. The patient walked in and is breathing. Of course their ANS is working. But the key is understanding the specific activity in each branch of the ANS in order to improve outcomes, preserve quality of life, and protect longevity.

EHM: Back in 2003, Congress passed the Medicare Act promoting physicians becoming more proactive. The intent is early detection and more aggression toward the primary disorder, and to minimize secondary disorders. How has the ANSAR improved your patient care?
GM: With ANSAR we can detect parasympathetic and sympathetic imbalances at a stage where they are treatable. When you correct imbalance, patients feel better whether it’s the general well being, dizziness, blood pressure control, heart rhythm, GI, or urogenital function. ANS balance slows autonomic decline, improves outcomes, and can prevent unexpected sudden cardiac death.

Testing is based on the presence of chronic disease (e.g., Hypertension, Diabetes, Heart Diseases, Sleep Apnea, COPD, Pain, Fatigue, and Depression). Chronic diseases are associated with autonomic imbalances. Persistent autonomic imbalance leads to autonomic neuropathy. Since chronic disease is a perpetual threat to autonomic balance, two or more tests per year are reimbursed.

EHM: What percent of your patients has performed this test? And how often have you made some change of treatment?
GM: 90% or more of my practice is eligible for ANS testing, and have been tested. At first, a large majority of my patients had some change to their therapy based on measured parasympathetic or sympathetic imbalance. Once balance is established, maintaining it typically requires only small adjustments.

EHM: If you have a diabetic patient that has some heart issues, what have you done and what have you seen to help that patient?
GM: By the time diabetics have heart issues they typically have Diabetic Autonomic Neuropathy (DAN) or CAN. CAN is a great concern because of the associated risk of sudden cardiac death. DAN and CAN are treatable based on the measured ANS imbalance. Proper autonomic balance mitigates risk in geriatric and cardiac patients. It involves relative parasympathetic excess, known to help protect the heart. This, of course can be established with sympathetic blockade (beta-blockers and anti-hypertensives). Care must be taken however, to not over-block. As we all know, too much parasympathetic activity can increase mortality. ANSAR provides a digital range specific for each individual patient.

In hypertensive patients with difficulty controlling BP, the ANSAR tells me why, and I modify therapy accordingly. For example, ANSAR ANS-guided therapy for a patient resulted in a 50mmHg drop in systolic BP. So it changes how I manage patients, including diabetics, arrhythmias, and people whose BP is too low. ANSAR helps me determine the best way to maintain BP to a sustainable level.

EHM: Do doctors today, realize that there are over 60 applicable ICD- 9 codes for testing a patients’ ANS?
GM: The misconception is that doctors do not have many patients with ANS imbalance. I mean how many people are fainting, have paralyzed stomachs, are not sleeping well, or have dysfunctional bladders. The mistaken belief is that I don’t have the patients that need this type of testing. It is unfortunate because those patients are the end result of many years of ANS dysfunction that manifest as just not feeling well, fatigue, frequent urination, change in bowel habit, abnormal sweating, dizziness, or palpitations. When these things are mentioned to physicians (since there has not been a way to asses these traits before ANSAR) it sort of goes in one ear and out the other. People who are tired, or who are having side effects from their medications need ANS testing to measure their underlying condition. If you do not see it, how can you measure it? Recall CAN in diabetics? This life threatening malfunction is also associated with numb or burning feet – peripheral neuropathy (PN). However, CAN is not PN. PN is paralysis and parasthesia. CAN is risk of heart attack. This is why ANSAR is a helpful compliment to PN testing.

EHM: Could you give us one success story from anyone of your patients?
GM: One of my favorite success stories is a dentist who has paroxysmal atrial fibrillation. There are certain autonomic imbalances that predispose someone to paroxysmal atrial fibrillation. His arrhythmia was interrupting his practice so frequently in the middle of procedures, which he would have to stop, lie down on the sofa in his office for awhile, then come back and return to his patient. Well, we gave him an ANSAR test and the machine detected an imbalance which was treated. As it turned out, by treating his autonomic imbalance, it lessened the frequency of his atrial fibrillation, made the duration shorter and made the rate slower. Yes, he still had some paroxysms of autonomic function, but they did not stop him from working anymore, so he could actually function and make income based on the therapy from the ANSAR machine.

EHM: ANSAR prints out a report with interpretation when the 15-minute test is over, so as far as the interpretation, how has that helped you, and is that interpretation page useful, and is it as accurate as you want?
GM: Yes, that is what makes this so easy. There are two main advantages to the ANSAR. First, it is simple and easy to administer by a technician. Patients simply sit for 10½ minutes and stand for five while doing some simple breathing exercises. Secondly, interpretation is automated. Again, ANSAR is the only ANS monitor that can provide independent, simultaneous measures of parasympathetic and sympathetic activity so we can see how they are functioning together. For example, are the parasympathetics high or are the sympathetic too low? This may sound like the same thing, but in the case of the former, anti-depressants may be indicated depending on patient history, and in the case of a latter vasopressor may be indicated, again depending on history. So you see, ANSAR testing illuminates the activity of both the parasympathetic and sympathetic branches in a way that can better specify proper therapy for the individual patient.

Gary L. Murray , MD, is a board-certified cardiologist who has practiced in Memphis for more than 21 years, and a graduate of Rhodes College and Tulane University Medical School. Dr. Murray was the first nuclear cardiologist in Memphis, and the first Cardiologist in Memphis to perform peripheral angioplasty and stenting.