Understanding AFib, from warning signs to advanced care

Transcript

Maggie McKay (Host): Welcome to Flourish, a podcast from Prisma Health. I’m your host, Maggie McKay. Joining us today is Dr. Paras Patel, board-certified electrophysiologist and cardiologist, to discuss understanding AFib, from warning signs to advanced care. Thank you so much for being here.

Paras Patel, MD: Thank you for having me.

Host: So, what exactly is atrial fibrillation, and why is it something people should pay attention to?

Paras Patel, MD: So, atrial fibrillation, or AFib in short, is the most common abnormal heart rhythm or arrhythmia that we see. Approximately ten million people in the United States have AFib. It’s an abnormal rhythm in the top chamber of the heart. Normally, the top chamber beats, followed by a beat in the bottom chamber. And when people are in AFib, the top chamber starts beating erratically and very fast, often three to four hundred beats a minute, which sometimes causes the bottom chamber to also beat erratically and fast. Ultimately, this results in an abnormal or irregular heart rhythm, which can lead to long-term sequelae in the heart.

Host: How might someone know they have AFib?

Paras Patel, MD: So, AFib is often diagnosed with an EKG, sometimes with a heart monitor, and nowadays even sometimes with things like Apple Watches and Fitbits. But people often have symptoms, things like shortness of breath, feeling like their heart is racing, getting tired, getting fatigued, shortness of breath at rest or when they’re trying to exert themselves and sometimes even like a brain fog. So, the symptoms can be very variable.

Host: Wow. And how is it usually diagnosed?

Paras Patel, MD: So, we generally diagnose patients with an EKG either in the clinic or in the hospital. Sometimes we find out that patients have AFib when they’re wearing a heart monitor at home. And other times things like their Apple Watch or their Fitbits may tell them that they have an irregular rhythm, and patients come to see us in clinic, and we get an EKG and diagnose them that way

Host: Once someone is diagnosed, what are the typical treatment options? Can you walk us through, like, medications and what patients should know about them?

Paras Patel, MD: Sure. So, there are a couple of important things to know about treating AFib, and it kind of falls into three different categories. The first category is stroke risk. So, one of the main complications that we worry about for patients with AFib is having a stroke. And so for patients who are at an increased risk of stroke, which is calculated by their other risk factors, we put them on blood thinners, and that normally entails one of three medicines.

The purpose of being on blood thinners is to help minimize your risk of stroke down to the same level as if you didn’t have AFib at all. So after that has been dealt with, the second two steps that we like to treat are patient’s symptoms and then getting them to a better quality of life. And also deciding whether we want to control their rhythm, meaning getting them back in normal rhythm or just controlling their heart rates. And that is kind of a step-by-step and patient-by-patient approach that we take, and it’s somewhat individualized rather than same thing for everybody.

Host: And what about medications? What do patients need to know about that?

Paras Patel, MD: In terms of medicines, in terms of stroke risk reductions, there are blood thinners that we put patients on. And the purpose of being on a blood thinner is to minimize your risk of stroke. The reason that patients are at increased risk of stroke with AFib is because when the top chamber of the heart is beating three, four hundred beats a minute and very erratically, the blood doesn’t move like it’s supposed to in the heart, and that puts you at risk of developing a clot in the top chamber of the heart, which can then go to your brain and cause a stroke.

So, blood thinners like Eliquis or Apixaban, Xarelto, rivaroxaban, and even things like Warfarin are added to patients’ medication lists to help them hopefully not have a stroke. In terms of medications of treating AFib, the options are medicines that slow down the heart, which are beta blockers or calcium channel blockers or anti-arrhythmic medicines, which the goal of those medicines are to try to keep people in a normal rhythm and preventing them from having AFib at all.

Host: Dr. Patel, at what point do you consider procedures like catheter ablation? And how do those treatments help?

Paras Patel, MD: Catheter ablation over the last ten or fifteen years has come a long way and has become kind of a mainstay treatment for patients with symptomatic atrial fibrillation. And so when patients have symptoms of some of the things that we’ve already previously mentioned, or if they’ve had heart failure or have been admitted to the hospital due to very rapid heart rates that could not be controlled at home, those are great candidates for an ablation.

A catheter ablation for AFib entails us putting catheters in the veins of the legs and running them up to the heart. And then, from that point, we’re able to target areas where AFib generally comes from. And for most people, the first place we start is called the pulmonary veins. And so, we use these catheters with using technology like PFA or pulsed field ablation, sometimes radiofrequency ablation, which is heat, or cryo, which is ice. So, we can use basically electricity, heat or ice to treat these areas of the heart where the electrical abnormalities are. And then, we check to make sure that we don’t see any electrical conduction in those areas to confirm that we have treated it appropriately. And then, after that, we take all the catheters out, and most patients are able to go home a few hours after the procedure

Host: How long has it been like that? Like 10 years, five years, or has that been around for a long time that you could go home the same day?

Paras Patel, MD: So yeah, being able to go home the same day is probably a more recent thing. I think it really became commonplace once the COVID pandemic happened because we really didn’t want to keep patients in the hospital longer than we really needed to. And so, we worked on kind of workflows that helps us take care of patients in a more efficient manner. And we now have devices and tools that we can use to help close the veins, so the risk of bleeding and vascular complications is significantly lower. And so, we get patients up, we let them walk up and down the hall, make sure they don’t have any issues. As long as they’re doing well, we’re able to get them home and walking the same day

Host: That is amazing. Well, for some patients, devices can be part of treatment. What kinds of implantable options are available and who might benefit from those?

Paras Patel, MD: In terms of implantable options, the two major things that patients with AFib end up with either a pacemaker, which is generally the end of the line for treatment of AFib, or something like a left atrial appendage occlusion device. And that’s for patients who cannot tolerate blood thinners or cannot be on a blood thinner safely. And we are able to put a device that closes off the little appendage in the heart called the left atrial appendage, where blood clots tend to form.

So, pacemakers, what we essentially do is for someone whose AFib is no longer able to be controlled, and patients are very symptomatic, we’re able to put a pacemaker in and then disconnect the electrical activity that goes from the top chamber to the bottom chamber of the heart with a simple ablation called an AV node ablation. And from that point on, the patient is paced with the pacemaking wires, but no longer is the top chamber arrhythmia able to affect the bottom chamber, making it go fast. And that’s a great option for patients who’ve kind of exhausted ablation options or medication options, or they have heart failure symptoms that we can no longer control.

In terms of the left atrial appendage occlusion device, that is done similarly to an AFib ablation, where we go through the vein in the leg and enter that area of the heart. And then, we implant this device in the left atrial appendage. And after about six months, that device becomes a part of the heart, and it closes off that appendage, so blood clots can no longer form in the left atrial appendage.

Ultimately, what that does is it’s similar to being on a blood thinner, but you can no longer be on a blood thinner and reduce your risk of stroke similarly as if you were on a blood thinner.

Host: And beyond medical treatments, what lifestyle changes can make a real difference when you’re managing AFib or reducing episodes?

Paras Patel, MD: Lifestyle changes can not only make a difference in terms of managing your AFib burden or amount of episodes you have, but they can also help in prevention of AFib. And so, some of the main things that I try to talk to patients about are things like, you know, your weight. Morbidly obese patients or obese patients, a 10% reduction in weight can reduce significantly the amount of AFib or even chance of recurrence in AFib after an ablation. Managing things like blood pressure, managing things like coronary artery disease. If patients have sleep apnea or if you’re someone who snores or stops breathing in the middle of the night, getting treated for sleep apnea with something like CPAP. And then, also very importantly, reduction in alcohol intake or even abstinence from alcohol, all those things can reduce your risk of getting AFib or reduce your reoccurrence of AFib.

Host: Is it hereditary?

Paras Patel, MD: There is some hereditary component of atrial fibrillation. It is not like some hereditary diseases where you can do a gene test and say, “Well, you know, because of this specific gene, you’ll definitely have AFib or you won’t have AFib.” We often see that patients who have family members that have AFib or siblings that have AFib, they have increased likelihood of potentially getting it at some point in their life.

Host: So, looking long-term, what should patients focus on to stay healthy and lower their risk of complications like stroke, and where can they go to learn more or get care?

Paras Patel, MD: Yeah. If you’re a patient who has a diagnosis of atrial fibrillation, I think one of the most important things you can do is take your blood thinner or the medications that are prescribed to manage the AFib like they are prescribed. If you’re taking your blood thinner, you’re working on some of those things that we kind of previously mentioned, like weight reduction, you know, exercise—I think I forgot to mention that, but exercise is very important. And kind of keeping in track of your symptoms and letting your doctor know when you notice a change or a difference can certainly decrease your risk of complications and also decrease your risk of stroke.

In terms of, you know, learning more about AFib or getting some more information, I think, the HRS or the Heart Rhythm Society website has a lot of good information about AFib, as well as the American Heart Association. And they have a lot of pamphlets and kind of informational documents that can help patients learn a little bit more about the disease and where they fit into the treatment plan.

Host: That’s great. In closing, is there anything else you’d like to add?

Paras Patel, MD: I think the most important thing to realize is atrial fibrillation is different from person to person. Everyone has different symptoms. It affects people differently. And so, the best option for patient A may not be the best option for patient B. And that’s why it’s really important to have a patient-centered discussion when we’re talking about treatment for this condition, because it may be very different. And so, talking to your doctor, letting them know how you feel, letting them what’s going on, what your goals are in terms of your treatment will help guide management and how we take care of folks

Host: Well, thank you so much for sharing your expertise. This has been so informative. We really appreciate your time.

Paras Patel, MD: Yeah. Thank you so much for having me.

Host: Again, that’s Dr. Paras Patel. To learn more, please visit prismahealth.org/podcast. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. Thanks for listening to Flourish from Prisma Health.