For anyone in the UK with heart condition and in despair because they can’t get to see anyone on the NHS and don’t and can’t afford private insurance or private healthcare. ‘Healthcare’ for AF and other heart conditions may I recommend that you watch the last York Cardiology video - The Third Way.
Quote:- The only bit about the health care industry which lives up to its name is "industry" - The NHS is arrogant, sluggish and views the patient as a data set. The Private sector on the other views the patient as a cash cow.
There is a desperate need for a 3rd way.
I do hope it is successful and catches on and scaled up and include AF!
Love to have been able to post a link - sadly not allowed.
What do you all think?
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CDreamer
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Excellent. Its about time things were shown as they actually are rather than we expect and deserve them to be. A third way is well overdue. Thanks for highlighting this.
Dr Sanjay Gupta making it possible for people to get a quick response and a CT scan when they are getting chest discomfort. Not sure how I feel about this as there is still a cost. I think my A&E department are quite efficient when anyone goes there with chest pain. Though saying that, I heard of someone who after waiting for quite a while in A&E died of a heart attack while visiting the toilet there.
I was once taken to hospital by ambulance when having chest pain and went straight into a room, was also given morphine to ease the pain. The pain went and I was told I had an infection, but they didn't know where, was sent home with antibiotics and am still alive and kicking. This happened in my lead up to having pneumonia and actually being admitted to a hospital ward.
If living in an area close to York this could be a good idea, being hundreds of miles away I think I'll still rely on my hospital.
All in all I think any sudden chest pain needs a 999 call.
I was sent to a ‘Quick access atypical chest pain clinic’ by my GP as an alternative to A&E for my AF/attacks of extreme breathlessness. I think there are many ‘Third Way’ initiatives in the NHS but sadly they are not universal. I belong to a local residents’ online group and NHS info pops up regularly. I wanted a lesion on my nose removed because it was catching on my glasses so I looked up private dermatologists. Next thing I knew a questionnaire on NHS Dermatology popped up on my feed! As it happens I’ve been referred to the ‘Non-Melanoma Skin Cancer Clinic’ so may not need the private appt.
I watched the video with interest as I am learning new things all the time. It made me angry to hear the way the doctor labelled both the NHS and the private system. He is right in his description. Unless you have had to access either, you have no idea how bad health care has become. I have been shocked at how hard it is to see a GP and to be referred for further treatment. We are lucky that we can afford to see a specialist privately but, despite paying, communication with them isn’t good. I have phoned and emailed to ask for an echocardiogram to be included when I see the doctor in April but no one replies. I learnt something new when Dr Gupta talked about a CT scan. I hadn’t heard of it but, as I don’t live that far from York, it might be something for me to consider. Since being diagnosed with AFib I have been helped, guided and advised by the people on this forum when, in reality, I should have received this from the NHS. It’s all very sad.
I'm there with you, my experience was dehumanising both from NHS and private. If I couldn't pay to go abroad I would be in a very bad position now, they would have irreparably ruined my health at 38.
I complained several times to my health board, to Ombudsman for private insurance refusing to cover cardiologist and treatment, and currently trying to bring this to the attention of the Welsh Government as health is devolved.
Wilky: . I learnt something new when Dr Gupta talked about a CT scan. I hadn’t heard of it but, as I don’t live that far from York, it might be something for me to consider.
Please do not rush into getting a CT scan unless your doctor thinks it's medically Indicated. And I'm not talking about the doctor that is promoting it.
I asked my cardiologist 10 years ago if I could CT scan to see what the condition of my heart was. He said, "why are you looking for trouble"?
The point he was making was that unless it's medically indicated it can be a fishing expedition ending up, causing more harm than good.
This is not to say that cardiac CT scans are not important, but they have to be medically Indicated.
Also, a CT scan uses X-rays: a good dose of them. The newest CT scanners use a far smaller dose, so that is a question to ask if you do go for one.
A cardiac MRI scan uses no radiation and is called the "gold standard" as it reveals a great deal of useful information about the heart. But it is not perfect.
I would say that if you get symptoms of concern, and which you doctor agrees are concerning, some sort of scan will be useful. A CT sees differently from an MRI, both have their uses. An ultrasound sees far worse than either, but is far cheaper. A further CT contrast scan might be called for if blockages or similar show up.
The problem with viewing the heart is knowing what matters. Each older person's heart will likely show potential "issues" but the radiologist cannot always know how relevant they are to your health and this can cause anxiety for no reason.
Well Steve I'm waiting for a 3rd scan - re Neck Scan
The ultra-scan showed no single suspicious lymph nodes. But it showed a ring of calcification 77mm!
Surgeon referred me for a CT Dye injected Scan follow up. This was clearer showing 2 lymph nodes calcified a 6mm and another 7mm. But an area behind 19mm x 9mm which had calcified. Surgeon not clear what it is lymph node or some normal material. NEW as this is my 4 Year Check Scan for returning Papillary Cancer (Thyroid). 12 lymph nodes on Right were removed with total Thyroidectomy a 19mm x 7mm? I think carcinoma in Right Lobe. Tiny bit on Left.
This shows how good the pictures are. But the 1st area was especially filmed with no concise result.
The 2nd Radiographist recommended Nuclear as RAI Radio Active Iodine Scan or PET Scan.
Surgeon says that Pet Scans do not give sharp clear pictures.
He wrote referral to NZ largest Hospital Auckland Hospital where they do the nuclear scans and the RAI Treatment.
A friend just had the latter done for a Melanoma Mole on his back. Injected around the mole. In surgery 2 lymph nodes were removed. On the day after at our Base Hospital Whangarei.
I will have a face to face as soon as appointment date given, Scan done and results are in.
So these scans are different in how a cross-section is done to give the surgeon the best images to work on his patient. PET Scans are done in our Base hospital.
I will be Radio Active for 24 hours. following the RAI Scan.
Surgeon marks referral URGENT - Papillary Cancer returned.
I'm sure you are right there. When I had one, though, I was told that the new Siemens CT scanner they used required a far smaller dose of X-rays than did previous machines, so I wonder if it is now much safer?
I agree, very sad state of affairs and unfortunately no hope of things improving any time soon. When we moved my husband was told 58 week wait to see a cardiologist- that was May 2022 and still waiting for NHS appointment. We have seen one privately who picked my husband needed replacement PM - NHS appointment arrived 2 weeks later. Co-incidence? I think not.
This is ONE initiative by ONE doctor - it’s not ideal but at least it’s someone who cares trying to do doing something!
NHS is great for emergencies, acute care and trauma but for chronic conditions 🤷♂️
All I can say is the NHS over the last 12 years have saved my life twice and I will forever be grateful to them.
On this evening’s news 58 Pharmacies closed in my area because drugs are not funded, I rang GP for appointment exactly at opening time and I was 29th in the queue. My husband called 111 who called 999 for paramedics, which I didn’t need, who spent over an hour attempting to call a doctor.
I get very frustrated when simple solutions are apparent but because of beaurocracy, funding shortfalls, staff burnout and strikes nothing happens so more than anything, I applaud the initiative.
I know most who work in the NHS work very hard for very little but they have to be able to pay the rent.
Received a letter today from Local University Hospitals begging for contributions for a Hardship Fund for staff - I think that is shocking and of course I will send donation but they shouldn’t have to!
CDreamer probably thought she was posting for everyone to read and her comment wasn't directed at you. I can tell you her informative comments are valued on this forum. No way would she ever knowingly offend anyone.
You’ve said nothing to offend at all - “can’t please them all” comes to mind - difference of opinions is a great thing - honestly never understand why people take things the way they do
I really should not be commenting on this as I no longer live in the UK but in South Africa where our Medical Aid Societies (not insurance , work very well with private medicine, although the government is trying to change us to a NHS type system)! However, I have to wonder how hard the NHS staff actually work. I am in contact with a friend, who is a senior nurse in the maternity section of a hospital, but it seems to me, from communication with her, that she is on holiday far more frequently than friends who work in the private sector. She has holidays in Australia, here in South Africa and the Far East, long weekends in just about every European capital and country hotels throughout the UK, and that's not counting lectures and study time. Maybe I've just got the wrong impression, but I have to question when she is actually at work!!!!!!
Perhaps she works as a contactor and gets paid way more for it and also dictate her times away. Anybody I know on the NHS is very bound to a strict and very demanding schedule
Thank you Jean, I do comment on various things and enjoy and learn from everything everyone has to say, but I just felt that perhaps it was wrong of me to comment on the NHS given my knowledge is basically limited to one employee !!!!
I see what you mean now, it's not too bad here in Devon. A doctor will still either call and talk through a health worry with you, or give an appointment for the same day if they think you need to be seen.
Devon was MUCH better run Jean, we had our moans but on the whole RD&E was 5* compared with Sussex - every other night on local news there seems to be something awry with Royal Sussex which is a nightmare to visit, find your way to a clinic and where waiting room for Cardiac Day Surgery was a corridor next to the main entrance with doors opening and closing constantly so freezing. Staff worked their socks off with no breaks, were incredibly apologetic and did their job well but there wasn’t even a working toilet on the same floor, had to go down 2 flights of stairs to get to a toilet and obviously climb back up again, not enough beds in the day ward, no beds in main ward to discharge to so every bay had 2 beds on both sides and you could only walk down between them sideways. It was a shock to both of us.
Thankfully the surgery (replacement Pacemaker) went well and we were out of there by early evening.
Glad your procedure went well. Why did you need a pacemaker change? I thought you were pleased with the one you had inserted a few years ago.I'll count my blessings I'm in Devon now after what you've said.
Nurses are expected to work 12 hour shift systems, are not paid for overtime if shift runs late but that means 4 shifts = 48 hours which will explain quite a lot. Most nurses I know who are still working tend to have 2/3 jobs - 1 clinical on ward, 1 office based & 1 research based. It’s a very weird system. It used to be 3x8 hour shifts, now 2x12 hour shifts.
What area are you in and is the acupuncture available in the NHS? I live in the Lancashire and South Cumbria NHS Trust and was very recently told by a consultant from the Pain Management Team that acupuncture is not offered in this Trust.
East Anglia. Mind you it was a few years ago. You could try acupressure or trigger point therapy which you can easily do on yourself or a friend. Trigger point.net is a resource I use often. 🙏
Thank you. I have actually paid to have acupuncture privately (and many other therapies) which, unfortunately, has not really helped this particular issue although did help with other things. I was particularly trying to find out what was on offer in my local Pain Management service and acupuncture was just one thing I was interested in knowing if they offered. Hiwever, it seems that medication is all they have to offer for my condition at least. I have used acupressure in the past but not for this so will look at the website you suggest.
Not impressed. What it all comes down to is a very narrow offer of a cardiac CT scan and a consultation for 1199 pounds.
First anyone in real chest discomfort should go to the A&E or call 911.
Second, if it's not of an emergency nature, how do they know they really need a chest Cardiac CT scan? He emphasizes you don't have to go through your GP, just email him -- not sure if this is even wise advice,
Personally, I never had a cardiac CT scan until prior to my ablation, which was a prerequisite to get a better look at the pulmonary veins.
What I see is a lot of people getting a lot of unnecessary, cardiac CT scans, and spending a lot of money for it. It could also be a gateway for a lot of other unnecessary and expensive testing depending on the results.
Before you go get cardiac CT scan make sure that it is medically indicated and not that it's some kind of promo on a YouTube video.
I don’t think you have any idea of the disastrous state of the NHS, difficulty of contacting a doctor to speak to or lack of general monitoring many of us endure.
Dr Gupta is known to many of us, not just a video on YouTube.
No its not impressive but gives me hope that someone, somewhere who works in BOTH systems is willing to speak out and do something tovert change the status quo!
I don’t, I had private practice but all my family worked all their working lives at all levels in NHS from GP, Architect, ICU Manager, software writers, nurses, nurse educator and admin so always a dinner time topic! All but one either left or retired.
At my sister's GP surgery in Devon you can still go along when you feel unwell and make a sit and wait appointment! I've often talked about how good those days were, but I was with my sister there yesterday and two people were coughing all the time and I couldn't wait to get out!
Absolutely, true.I'm quite saddened by Dr,Gupta encouraging vulnerable people looking for answers down this route.
No matter what state the health service is in , or what medical care is open to you in the country you live in , going elsewhere to get a CT scan at an inappropriate moment or when an event isn't occurring isn't a good medical option. It's not going to bring the revelations implied especially if nothing is active at the time of scanning.
There is a Third Way to better healthcare , but this isn't it.
As an aside to all readers , not just in reply to mjames1, before any people berate me for my opinion , or assume I don't understand the state of the NHS , I will say I not only have relatives and friends that work in both public and private health care , I'm also working with a physiotherapist whom works in both NHS and Private Care ( within their own time too) to try and create a better way to exercise and use lifestyle changes to improve the symptoms of cardiac and chronic health conditions as well.
I've been a patient in the NHS system and tried private care similar to that discussed experiencing the work of various Departments because of chronic illnesses for the majority of my life.
I've experienced the best and the worst of care , paying was never a way to avoid the worst.
I've learned that I had to do my own research into most of my conditions to get the right support , not because of the strain on the system , nor the lack of cash, facilities or caring of medical professionals in the most part , but because most doctors and specialists had little experience of treating the things I have.
With some conditions, aFib and Arrhythmias included, there aren't always easy causes simply seen on scans or simple cures to deliver so you can go back on your way.
The conditions are there and even after Ablations or Cardioversion for many they require us to manage our risks in the long term and there aren't any guarantees that they won't become active again no matter how good we are . And , although that is hard to hear we need to accept it and think positively about ourselves and the life we have with a health issue or we won't get the best we can out of life with the health problems we have.
Giving people false hope that everything can simply be reversed by using a Third Way with many chronic health conditions by implying that just getting the scan you think you need , or, trying a certain less used treatment is the way forward is just as bad for the patient as not doing certain tests or trying certain things and not explaining why you aren't doing them.
More doctors need to learn that we need honesty and they need to be brave enough to have the conversation that they as doctors may not be able to find out exactly why something has happened and that in some cases it isn't caused by an easy to see fault that's easy to fix, and admit treatment could be for life and require much trial and error along the way, as well as confessing they don't know which self care or complimentary care could work best either and that they may occasionally need guidance from others to help get things right.
I know Dr.Gupta gives a lot of help to many people looking for answers which they feel they aren't getting elsewhere but this isn't the answer.
Well said Blearyeyed. I completely agree with you. I know I’m getting old and cynical but, having seen the video, I’m sorry to say that fear this is rather more about self-promotion than anything else.
I agree with everything you have said, I’ve worked with NHS employees and heard the best and the worst of both Private and Public care.
My question is really - Why do we not care enough about our Health Care Systems to invest in them?
I want to make this clear - I do NOT see this as an answer for AF - I’m not ‘against’ the NHS - it’s not even about AF. I see this as Dr Gupta responding to the loss of his friend by offering an alternative. I don’t see it as self promotion, although I understand that it could be taken that way and think it so sad that we now automatically distrust motivation. I understand that we are also open to manipulation so it is always a judgement call and not everyone makes good judgement calls all of the time.
The best doctors I ever encountered were those who recognised the limitations of the NHS and worked in both systems.
I do hope that something soon changes to create ‘A’ Third Way as I have always thought that the original concept of the NHS - free at the point of delivery - was the flaw we now live with but seems impossible to reverse. We care about our health when we also take response ability for ourselves and family and although there are some who cannot, most can but choose not to.
I was just heartened that someone is trying to offer a mid, third way because I am concerned when access to expert doctors is so difficult yet technology that can help in so many ways is not fully utilised and was reminded of the Paradoxical Commandments - Do It Anyway.
Well, we’ve had health insurance for many years with husbands job, mind you it wasn’t FREE, paid and taxed. Private gas it’s own problems and it manned by those who also work in the NHS! Been waiting since before Christmas for an ablation, told 3 months 🤣
2nd opinion was same as the private. Had ablation privately luckily insurance paid most, total was - hold breath - £16.5k
I think we all recognise that both NHS & Private Healthcare in UK needs radical rethink!
I’m also lucky that my ex-employer pays my private health insurance which includes GP appointments but transferring between the 2 systems is a nightmare.
Well, are you going to put the 3rd way out there CDreamer?
At a guess it is the patient being interested in their way forward and becomes a part of their journey. Control of AF being the forward move.
I understood that Dr Gupta doesn't actually in ablationing the heart.
I've always been involved with my journey but I was niaeve in not knowing full knowledge of types in meds, different blockers etc what I could try to control my heart beat.
But I have had to carefully check that appointments promised are given, waiting is monitored etc.
I check all blood tests and demand special tests - one the thyroglobin result was helpful in the latest result of scans for return of my papilary thyroid cancer.
I fought our ACC for removal of the jagged Johnson & J Mesh.
We know our bodies and we need to convey that our health is important. We should have choices too.
I'm interested in Dr Gupta's 3rd way. Simply tell us.
oh dear. Yes the NHS can be terrible in certain areas - poor Northern Ireland. But my experience has been good. I have a chronic genetic condition that is assiduously monitored and treated. I had two years of sight problems following a detached retina - well treated by an excellent but overworked specialist eye hospital. The AF team in local cardiology is excellent, prompt ablation and good arrhythmia nurse . GP practice excellent but horribly overworked.
Why would I accept the advice of a clever private doctor suggesting I bathe my heart in radiation of a CT scan which may not be needed, needs a specialist to read, and ongoing treatment unsure or expensive?
Older populations are a challenge. Apart from childbirth i hadn’t used much health care until the last decade. I now understand why a health economist once said you used 98% of your health care costs in the last decade of your life.
I won’t even start on my adventures with private healthcare- especially in USA…
Patchy problems in both, but I don’t honk there are simple solutions.
One local GP practice runs sessions in church halls and pub social rooms and toddler groups to reach the families who rarely venture off their estate.
Running a health care system is a vast undertaking and I advise with caution!
Locally I helped set up a scheme allowing access to exercise for those whose GP or other medical practitioner feels they would benefit (which is basically everyone 🤣,). This now funded by the NHS and we have amazing results in all conditions mental and.physical. there are very innovative ideas out there.
NHS would be a whole lot better if it was funded to the same level as France or Germany. You get what you pay for. Except in private medicine which definitely is a cash cow 🤣
Unfortunately successive governments here in France have been running down the health service , closing beds , local maternity services and A&Es . However it is still miles better than the NHS. There is also the possibility of accessing private hospital care at a clinic by paying a higher rate in the private part of health insurance . We pay around €3000 a year for a policy that is nowhere near top of the range but which allows us to see specialists and have operations at a private clinic. This is usually quicker than at a public hospital and you have the option of a private room . I have had three major ops at our local clinic and been very happy with treatment . I was able to choose when I wanted them though first hip op had a 4 month wait due to covid backlog. I was able to bring my second hip op forward from the date I had originally chosen because my pain deteriorated a lot with a phone call to my surgeon's secretary. There is no nonsense like prior conditions not eligible like there is with private health insurance in the UK but contributions do rise a little with increasing age. Any tests that are done provide results rapidly - often at the end of the visit. Blood test results are available the next day - this is standard in the public sector too. I have also been treated at public hospitals - again much better than the reports one hears of the NHS . I refuse to go to the UK anymore- too worried about falling ill there.
I have just watched the whole video - and it is instructive. It is self promotion based on stirring fear, any offer which includes a 99 at the end of a fee is trying to put a gloss on a price - £1199! And any promotion that says “grab” and act quickly is also suspect. I have heard so much about this cardiologist and only seen a couple of videos before but this does not endear me. I am pretty sure any local private cardiologist would arrange scans for that price …
Yes , you are right , available across the UK from reputable groups and hospitals and a lot cheaper too. Even when you include an initial consultation and follow up with a recommended cardiologist in the field that your illness is most linked to .It's whether it's really worth it necessary to do at the time you are considering that counts , otherwise you are just putting a burden on your body at an inappropriate time.
If your cardiologist has suggested a scan but there will be delay then fine , but again the options are available nationwide and at a lesser cost.
It’s basically self pay, and as you say, available from many other providers at a lower cost. I’m not against the doctor or his private practice, but I certainly wouldn’t call what is effectively self pay any kind of ‘third way’. For some it will be an appropriate investigation but for others it might be the wrong test and won’t make any difference to their healthcare or how they manage their condition.
I suppose arrhythmia would cover that. My chronic conditions treatment plan with my Medical Aid Society calls mine that, although the ICD10 code they attribute to it is Atrial Fibrillation!
I don't think he has to be, in the Province in South Africa where I live there is only one EP, so most cases of AF are handled by Cardiologists or GPs. Most people if they want to see an EP or have an ablation, travel to Cape town where there are several, including a specialised AF clinic run by an EP who according to another member of this group, was the top graduate on his course conducted by a professor at a London hospital. These are of course private practices and hospitals where they operate.
I agree but I was taken to A&E buy ambulance in February and sat in a plastic chair for 5 plus hrs so I feel my visit in April to Dr Gupta for a echocardiogram and consultation is peace of mind in todays NHS problems and it is priced at a lot less than 1999 and thanks for your informative reply
When A&E had finished with you, either they or you should have asked for a Heart Specialist. He/she would have done an ECG & ECHO before seeing you publicly. FREE.
Then 24-hr Heart Monitor to see how new change was making.
In 2021 I had 2 March & May. Then February following directions from Private Heart Specialist discharged back to Public Heart Specialist.
Once on to it everything went cautiously and I became finally AF controlled H/Beat and BP.
For a start a referral from your GP to Dr Gupta would reduce your bill from PRIVATE.
Considering that this is the AF forum and the video relates to an event that was clearly life threatening it is maybe not so appropriate for persistent AF sufferers to view this as a way forward.
I had chest pains around the time my persistent AF was diagnosed and went through every scan in the book via the NHS (who were brilliant even during the covid period)
My cardiologist had to beg the NHS CT scan specialist to do that scan on me because he said that the persistent AF would impact the accuracy of the scan. He was right, it did invalidate the scan. It was eventually a pressure wire angiogram that detected a blocked LAD artery. He told me that the pressure wire used as part of that investigation costs £4000 alone and it was a one-off usage.
I simply don’t believe that Dr Gupta’s motives for seeking a 3rd way are anything other than altruistic, based on his previous videos he is clearly a man of principle to me. The first consultation with him on his scheme would surely identify whether the CT scan was medically indicated or not.
Well I finally asked the right ? on Google ad got Dr Sanjay's Gupta's suggestion.
Um, perhaps helpful in York!
I'm in NZ but I have been to York staying with relatives in 1990s.
$1199.00 sorry pounds.
Whow.
But the prerequisites are 1. Suffering Chest Pain.
Most of us suffering Chest Pain would be ringing for A&E. I for 1 have a St John's Home Alarm and would be seen immediately at hospital.
Stroke in 2019 I was taken to Taipa Beach area where we waited for a helicopter. Then helicopter stopped off at Bay of Islands Airport to refuel but eventually I arrived on the rooftop of our Base Hospital.
I was given BB Metoprolol which I said NO to, but given regardless - made breathless as I said. No follow up! AF with it. Consented to a biopsy of my thyroid - possible cancer which I had. So thyroid problems undiagnosed caused AF gave me a stroke. Left 1 year 3mths 186bpm, 47avge at night with pauses. I demanded H/Specialist changed to 156bpm 47avge at night on Bisoprolol which was upped dose till 10mg still no control.
Under Locum DR who has had AF directed me to a private specialist. Who introduced CCB Diltiazem 180mg too high then 120mg AM Bisoprolol 2.5mg PM.
At 2 years 3 months controlled AF rapid h/rate & BP.
That's NZ system for you. Heart left distressed so damage shows in my ECHO done 2 years 10 months ago.
But Private Specialist quickly referred me back to Public so I did not pay for ongoing ECG and Heart 24-hr monitors.
Was discharged last November 2023. Only symptoms were always uncontrollable sweating and stopping on exertion.
I personally can't see why NHS (I have an NHS number and NZ number) patients can't ring emergency for chest pain and immediate treatment.
If patients are silly enough to go down the long road and pay !,199 pounds or not they put their live at risk.
I had to pay 1760 pounds to have my wet belt changed on my Ford if I did not the engine would pack up it’s called preventative maintenance so 1.990 pounds not bad if it saves your life 😊🏴
He is basically saying that unless you are actually having an MI A&E will just send you home because Troponin is negative and the ECG is OK.
That is not really my experience of A&E. If you are having chest pains every day, I believe they would admit you for more tests. That is my experience.
Also, if you have had an MI and phone a GP with chest pains , our practice will send you to A&E. They even got an ambulance for me
As far as having to either use the NHS or private, in my experience, that's not true. I have on more than one occasion seen a cardiologist privately, and subsequently had appropriate scans via the NHS. The cardiologist was happy to facilitate this. Subsequently I had phone calls to the cardiologist for which he did not charge
BTW I paid around £250 for an initial consultation not £400.
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Dr Sanjay Gupta..Some Clarification...
Calcium channel blockers no good for vagal AF - Dr Sanjay Gupta
Initial AF advice please
