Caitlin Whyte: There are a number of treatment options when it comes to AFib. So in this episode, we are joined by Dr. Arjun Mehta to go over some of those choices. He is a cardiac electrophysiologist at Ascension Saint Mary - Chicago.

This is “Vital Signs”, a podcast from Ascension Illinois. I'm your host, Caitlin Whyte. Kick us off here, doctor, is AFib easy to diagnose?

Arjun Mehta, MD: Well, AFib has a variety of symptoms that can present themselves in the patient, including shortness of breath, palpitations, or rapid heartbeats, skipped or irregular heartbeats. Some of these patients come in to see us because they feel unusually fatigued. They used to be able to walk or run three miles, let's say, and now they can only do half of that. So these are some of the symptoms that patients describe to us.

In terms of patients who have no symptoms or who are asymptomatic, we can usually diagnose that based upon an EKG or with all the wearable technology now available to us like Apple Watches and Kardia Bands, Fitbit monitors and such, people are coming into us and telling us that, "Hey, my wearable device told me that I had an irregular heartbeat" and many times that can represent atrial fibrillation, but it also can represent a normal heart rhythm and just extra heartbeats. So it's always best to get evaluated when your monitor at home, your Apple Watch, for example, tells you you have an irregular heartbeat or possible AFib.

Caitlin Whyte: And then when should a provider refer a patient for an evaluation with an expert?

Arjun Mehta, MD: Yeah, that's a great question. So before, we used to treat atrial fibrillation as a rhythm only if the patients were symptomatic. Now, there's a little caveat to what I'm saying here. We always treat atrial fibrillation or most often treat atrial fibrillation for the component of the stroke risk. So people are put on blood thinners because the top chamber of the heart, which is usually squeezing vigorously is instead quivering. And when the blood just sits there in those chambers of the heart, it can form a blood clot. So people, especially people who have certain characteristics, high-risk characteristics, they need to be on a blood thinner. So that treatment has been established. And we've been doing that for, you know, decades and decades.

Before, in terms of the treatment for the rhythm itself, meaning to get someone who's in atrial fibrillation back into a normal rhythm and the fancy term that we use for that is a normal sinus rhythm, we used to only offer that to people who had symptoms. However, more and more, there's increasing data that shows that people who have no symptoms, but are in atrial fibrillation, tend to do worse in terms of cardiovascular outcomes. There was a study in the New England Journal of Medicine approximately a year ago called EAST-AFNET 4, which showed that people who have early rhythm control tend to have better cardiovascular outcomes at five years when they compared them to usual care or usual care was controlling the heart rate, giving blood thinners and not changing the rhythm back to a normal rhythm.

Things have changed. Now, even patients that don't have any symptoms, but they're in atrial fibrillation, you know, we should definitely have a discussion about possibly getting them back into a normal rhythm. And we should do that as early as possible because the data shows us the earlier you get someone back in a normal rhythm, the better they're going to do and the less AFib that they'll have in the future.

Caitlin Whyte: Okay. So then tell us about some of the treatment modalities and when they might come into play, when they might be indicated.

Arjun Mehta, MD: Yeah. For atrial fibrillation, like I was saying for the stroke risk, especially the stroke risk for those who have high risk characteristics, we have been giving blood thinners. Previously, that was Coumadin. Coumadin is a little bit tedious for the patient because they have get blood sticks all the time. They have to watch their diet. Now, we have newer medications called the DOAC medications like Eliquis and Xarelto and those medications can be taken once or twice a day and there's no monitoring needed, and those treat the stroke risk element of the atrial fibrillation.

Now, for the heart rate control, which is another component of atrial fibrillation that causes people's hearts to get weak, the heart rate if it's going over approximately 110 beats per minute for a prolonged period of time, which often occurs in atrial fibrillation, the heart rate just is high for no reason, those people we give medications to slow the heart rate down and we've been doing that for a very long time. An example of one of those medications is metoprolol.

And then the third component of treating atrial fibrillation is just like I was talking about before, just being in the rhythm itself and trying to get you back into a normal rhythm where sort of the normal quarterback of the heart is telling the heart what to do or the normal coach of the heart is telling the heart what to do. And so the treatment modalities that are available for that include medications and those medications have been around for a long time. They're called antiarrhythmic drugs. These medications usually need to be started by an expert and closely monitored because they have side effects. They can cause sometimes even life-threatening heart rhythm problems. So these rhythm medications should be started by either a cardiologist who's well seasoned and has been doing that or a cardiac electrophysiologist, that's the fancy term for a heart rhythm specialist.

And outside of the medications that we can use, you may have heard of catheter ablation. So ablation is a technology, which we use quite often now and is actually becoming more and more studied to be a first-line therapy, meaning you can use it before you even give medications. A lot of people are starting to publish data on that, but it's a procedure where we go into the heart and we basically use a balloon or a heating-tipped catheter to stop the electricity that triggers atrial fibrillation from getting out to the rest of the heart. So even if that area called the pulmonary veins, even if that hyperexcitable area that starts atrial fibrillation is trying to send a message to the rest of the heart, after the ablation procedure, it cannot. The communication, the electrical communication is completely cut off. And so then the atrial fibrillation doesn't start.

And this procedure has about, in somebody who's coming in and out of atrial fibrillation or we call it paroxysmal atrial fibrillation, approximately an 80-ish percent success rate, and that's by pretty strict criteria. Usually, we see even more than 80% of people at least have a reduction in how much AFib that they're having. A lot of people tend to feel better from a quality of life perspective as well. But these medications and this ablation procedure, I will also reiterate that even in patients who don't have symptoms, we're starting to see data that says that maybe getting them back into a normal rhythm, in the rhythm that you're born with when you're a baby, getting them back into that rhythm is better for you in terms of your heart health.

Caitlin Whyte: Now, what are the latest guidelines for rhythm control of AF and atrial flutter?

Arjun Mehta, MD: Yeah. So I've been through some of this with the atrial fibrillation component of things. Right now, the guidelines still say you get a shock procedure first if you're stuck in atrial fibrillation and we see how you do, then we start some medications and try the shock again. And then if the medications don't work and you still go back into the atrial fibrillation rhythm, that we can then become a little bit more aggressive with a procedure and do a catheter ablation procedure, like I was describing before.

However, like I stated before, there's people eagerly studying whether doing ablation upfront or offering it at least to the people who don't want to be on medications is a good strategy. And a lot of those studies have shown that there's been increased quality of life, reduction in hospitalizations for people who get the ablation before even trying the medications and such, so reduction in going to the hospital, an increase or improvement in quality of life and similar side effects and negative outcomes. And that's not in the current guidelines, but a lot of the newer studies, you know, these guidelines come out and sometimes they're years apart from each other. So some of the newer data is telling us, you know, number one, let's get people back into normal rhythm to help their heart health. And number two, maybe using these procedural interventions, like an ablation procedure might be beneficial even before the medications, but that's not currently in the guidelines at this time.

For atrial flutter, which is a similar rhythm to atrial fibrillation, our ablation technology has gotten so successful, meaning we can usually in 95 to 97% of people with the typical atrial flutter rhythm, we can get them out of it into normal sinus rhythm. And they will never see that rhythm ever again in their life in about 95-ish percent of people. So for that rhythm actually, the flutter rhythm, we say go straight to the ablation procedure because it's so safe and it's so effective that we should just jump straight to that and do that procedure first.

Caitlin Whyte: So what can physicians caring for atrial fibrillation patients do to lower the risks for patients undergoing these complicated and multi-faceted treatments?

Arjun Mehta, MD: Yes. So I would say for somebody who's referring the patients, I'd say the one thing is refer early. The earlier we get to them, the earlier we make an intervention, the better the patients tend to do, because there is a notion that AFib begets AFib. The atrial fibrillation rhythm causes more scarring, causes more remodeling of the heart, and then that remodeling and that scarring causes more atrial fibrillation. So for a primary care doctor or for a general cardiologist, getting these patients to us as soon as possible so that we can at least evaluate and talk to them, have a patient doctor discussion about the risks and benefits of all these different procedures, I'd say that's important. And then second, you know, in general is just being educated, going online, reading about these procedures, reading about AFib and learning more as a patient, even as a doctor, and what the current data kind of says, that's incredibly important.

Caitlin Whyte: And I understand, doctor, you hit a pretty big milestone recently. Can you tell us about that?

Arjun Mehta, MD: Yes, we recently did a procedure called an epicardial VT ablation, and it was a milestone because it was the first done, I believe, in the entire Ascension Illinois, but definitely in the Chicago Metro four hospitals that we work at. And this is a procedure where patients who have another heart rhythm, which is often more dangerous than atrial fibrillation called ventricular tachycardia. When those people have scar on the outside or in the middle of the tissue of their heart, and the only way to access it is rather than, you know, these IV-type sheets that we can put into people's legs where we usually do our procedures, we have to go on the outside of the heart. And so basically, we were able to successfully go on the outside of one of our patient's hearts, who was unfortunately suffering from cardiac arrest over and over again, every hour was basically having to receive shocks, like you can see on TV when you see a patient pass out and they have the paddles and they shock the patient and they come back to life, that was happening every hour for this patient. And so we were able to go on the outside of the heart with this procedure and we were able to basically zap that area and he's been free of that rhythm now since that procedure.

Caitlin Whyte: That is incredible.

Arjun Mehta, MD: Yeah, yeah, definitely. It was very exciting for our team and, you know, we keep looking for new opportunities to grow and to offer our patients the full university-level service that can be offered.

Caitlin Whyte: Well, doctor, thank you so much for joining us today on the podcast and for sharing more about AFib treatment with us. This has been “Vital Signs”, a podcast from Ascension Illinois. I'm your host, Caitlin Whyte.

To find care in the Chicagoland area for AFib and other heart rhythm disorders, visit ascension.org/ILheartbeat [Ascension dot org slash I-L heartbeat].