Transcription:
All About Atrial Fibrillation

Melanie Cole: According to the Centers for Disease Control and Prevention, up to as many as six million Americans may have atrial fibrillation and many people don’t even realize that they have it. My guest today is Dr. Rodrigo Bolanos. He's the medical director of electrophysiology at Baycare’s Winter Haven Hospital. Tell us first what is atrial fibrillation.

Rodrigo A. Bolanos, MD: Thank you for having me on the podcast. Atrial fibrillation is a very common arrhythmia, perhaps the most common arrhythmia that patients suffer from. It's basically an irregular heartbeat that affects the upper two chambers of the heart, also known as the left and right atria. This results in poor blood flow within the heart itself and can result in a constellation of symptoms. These symptoms may include an irregular heartbeat, sensation of palpitations which patients sometimes characterize as rapid, fluttering or pounding sensations in their chest. Patients can be lightheaded, they can complain of fatigue, shortness of breath and chest pain even.

Melanie: Tell us about untreated atrial fibrillation. Are there certain risks or comorbidities that are associated with it? What do you tell people about the things that could go wrong if they don’t get it treated?

Dr. Bolanos: Atrial fibrillation can result in a variety of complications and can also worsen any coexisting conditions. Atrial fibrillation is often associated with other comorbidities such as diabetes, coronary artery disease, chronic kidney disease, obesity, high blood pressure and so forth. We know there's a synergistic effect between atrial fibrillation and these conditions and that patient who have heart failure and have atrial fibrillation, for example, have worse outcomes. Likewise, patients who have high blood pressure are at increased risk for stroke in the presence of atrial fibrillation. I focus on these patients and explain to them the importance of them working on these other risk factors and attempting to modify them and get the best control they can usually with the help of their primary care physician or other specialists that they see and I then focus on the atrial fibrillation itself.

Melanie: Are there certain triggers that would bring it about or bring it on and do people even sometimes realize that they have it? Can you feel it?

Dr. Bolanos: Some people can feel it. Not everybody feels classic symptoms of an irregular heartbeat in the form of palpitations or their fluttering. Some people feel that their chest is just not quite right. As far as triggers are concerned, some people are very sensitive to alcohol, so some people might binge drink and they may bring on an episode, but truly the factors that contribute the most are really genetics. If one of your siblings or parents had atrial fibrillation, you have a pretty good chance of getting it eventually.

Melanie: Tell us a little bit about if someone comes to you and you're diagnosing it. First of all, how do you diagnose it, and once you do, let's about some of the treatment strategies.

Dr. Bolanos: When patients come to me, they have already often been diagnosed, but when a patient gets diagnosed either by the referring physician or myself, it’s usually picked up on auscultation. When you're listening to the patient’s heart, the heartbeat is all over the place. There's no particular irregularity. It is irregularly irregular by definition. One confirms that with an EKG because there can be irregular rhythms when one listens to a patient’s and that does not mean that it’s atrial fibrillation. Atrial fibrillation is one of those irregular rhythms.

Melanie: Once it’s diagnosed, then what? Tell us about some of the treatment. Let's start with the role of rate control, medicational intervention, rate versus rhythm control and then people have heard about these things to prevent clots and blood thinners that they might have to go on for their life. Explain a little bit about these different classes of medication and what they're intended to do.

Dr. Bolanos: When a patient is first diagnosed with atrial fibrillation, there are two things that we focus on immediately. The first is risk stratifying that patient for the risk of stroke. Atrial fibrillation regardless of other risk factors for stroke increases your risk of stroke. We calculate something called a Chad’s VASC Score and that takes into consideration age, diabetes, the presence of peripheral vascular disease, coronary artery disease, history of heart failure, prior TIA or stroke. Based on that, we make a decision as to what kind of blood thinner the patient should be put on. Patients can be on one of the newer agents or they can use the traditional therapy which has been Coumadin. What is very important and emphasize to patients is aspirin does not protect patients who otherwise meet criteria for a blood thinner against stroke. It is not much better than a sugar pill. The second thing we focus on is treating a symptom. Once we have appropriately risk stratified that patient and have determined if they need a blood thinner or not, we focus on their symptoms and symptom relief often involved controlling the heart rate. Atrial fibrillation most commonly when first diagnosed results in too rapid of a heartbeat which then causes a lot of the symptoms for the patient. We focus on controlling the heart rate that's a rate control strategy and then often we give the patients when it’s first diagnosed a chance at rhythm control meaning to get that heart back to normal sinus rhythm which is the physiologic rhythm of the heart. There’re several ways to do that. They can be done pharmacologically with medications that can put the heart back into rhythm, otherwise we often proceed to what's called a cardioversion where we shock the heart back into rhythm and there's often the need for something called an ablation procedure where we actually go into the heart in a minimally invasive fashion and target the abnormal areas of the heart that are causing it to go out of rhythm.

Melanie: What are those kinds of procedures like? When we were talking about medications, if someone goes on these medications, are they a lifelong situation?

Dr. Bolanos: That’s a long answer and I’ll try to make it as short as possible. As far as the medicines to control the atrial fibrillation, the ones that keep you in rhythm often will work for a while and it varies from person to person. It just depends how they're doing. Some people do very well long-term on the medication and some of them have recurrent atrial fibrillation almost right away and require more aggressive treatment such as an ablation. As far as the blood thinners are concerned, typically once it’s recommended that you're on a blood thinner, it’s usually for life with some small caveats.

Melanie: What are the procedures like do people feel what you're doing and what's life like afterward for them?

Dr. Bolanos: These procedures are done with sedation. Sedation can range from conscious sedation or light sedation as you would have for a colonoscopy or something like that. That’s what is given for a cardioversion where the patient is brought in as an outpatient to the hospital. Two patches are places across the chest and once the patient is temporarily asleep, we give a quick shock to the heart which the patient does not feel and puts the heart back in rhythm. The challenge is will the heart stay in rhythm and that’s where we often use medications to help maintain the rhythm to better access the patient’s symptoms. As far as the ablation is concerned, that’s a more involved procedure and it’s an invasive procedure. It’s not open heart surgery but it’s invasive in that we have to go into the body and place some catheters in various positions in the heart and then we target with a catheter that heats up the abnormal areas in the heart specifically the left atrium most commonly, sometimes the right atrium, and cauterize the abnormal areas where muscle fibers that have cells that trigger the heart to go out of rhythm. That's often performed under general anesthesia and those procedures are longer and last anywhere from two to five hours and the patient usually stays overnight. They usually don't have much of a recovery period, but sometimes they can have some residual chest discomfort for a day or two.

Melanie: Does it go away after a procedure like that or is it something that might have to be redone?

Dr. Bolanos: It depends on the type of atrial fibrillation the patient has. The earlier the atrial fibrillation is dealt with and if it comes and goes and there are not too many other comorbidities in that patient, then the patient is more likely to have a successful procedure on the first time around. Sometimes a procedure has to be performed a second time or even a third time in rare instances. The goal overall though is to improve the quality of life and the symptoms of the patient and that can often be accomplished through a combination of procedures often if need be what they use of what we call an antiarrhythmic, which is a medication specifically meant to keep the patient from going back out of rhythm. Through a combination of these procedures and medications, we can often have the patient attain their goal of a better quality of life.

Melanie: Tell us a little bit about what the future holds for stroke reduction in afib patients and where do you see this field going. You're an electrophysiologist and people don’t even always know what it is you do for a living. Speak about where this field is going and what you see for afib patients.

Dr. Bolanos: It’s an exciting field and it’s changed so much just in the last few years and it’s continued to change and it will continue to change. Where we need to go as far as atrial fibrillation I believe is we need earlier diagnosis and treatment. We need to better identify which patients will benefit from which type of treatment modality, which patients are likely to benefit from ablation earlier than later, which patients may respond better to some antiarrhythmics more than others, and that's where genomics comes in, connecting what's called a genotype, meaning the genetic predisposition of the patient, to the phenotype, meaning how the disease is expressed. We got a little bit of time to go on there before we’re there on that, but I think that’s what the future holds. New procedures are being developed. The goal would be to try to develop procedures that are more effective the first time around with less comorbidity.

Melanie: What best advice do you have for afib patients and for the people that love them about making sure that you adhere to whatever prescription your doctor has discussed with you so that you can keep control of your afib?

Dr. Bolanos: The first thing I would say is don't lose hope. Know that your condition can be improved, but it's a team effort between yourself, often your general doctor and cardiologist and I would recommend an electrophysiologist. If you're not sure exactly which way to go, don't hesitate to go and get a second or third opinion. That's what we're here to do. I always encourage patients to get another opinion or to seek appropriate medical advice. I usually advise patients not to get on Google or the like.

Melanie: Such good information. Thank you so much for being with us today and it’s important for people with afib to hear this great information about the treatment options available at Baycare Health. Thanks again for joining us. You're listening to Baycare Health chat. For more information, please visit baycare.org. That’s baycare.org. This is Melanie Cole. Thanks so much for listening.