Transcription:
AFib & Stroke: Get the Facts to Lower Your Risk

Melanie Cole (Host):  Welcome to Bryan Health Podcast. I’m Melanie Cole and today, we’re discussing atrial fibrillation or AFib. Joining me is Dr. Michael Kutayli. He’s a cardiologist and electrophysiologist with Bryan Health. Dr. Kutayli, it’s a pleasure to have you join us today. I’d like you to kind of give us a little working physiology lesson to begin. What is atrial fibrillation? Tell us a little bit about how common it is. What’s happening?

Michael Kutayli, MD (Guest):  Sure Melanie. Thanks for having me on. Atrial fibrillation is the most common heart rhythm disorder that we see in clinical practice. It affects around three million people in the United States in terms of prevalence. About 160,000 new cases a year. Essentially what atrial fibrillation is, the atria which are the top chambers of the heart, start to fibrillate or quiver. They are beating very rapidly and chaotically leading to a disorganized and rapid heart rhythm. The atria are beating at 300 beats a minute or more which makes the bottom chambers, the ventricles speed up as well.

Patients experience a very rapid and irregular rhythm that can be associated with all sorts of symptoms including shortness of breath, and fatigue, palpitations, weakness, fainting, chest discomfort and sometimes even symptoms of stroke which we’ll talk about here shortly. It’s a very, very common rhythm problem and one that unfortunately tends to affect people as they get older. We don’t understand why people get atrial fibrillation with one hundred percent certainty and we know there are lots of associated risk factors, age of course, hypertension, high blood pressure, obesity, lung disorders, obstructive sleep apnea, thyroid disorders, alcohol use. So all sorts of things contribute to atrial fibrillation.

Host:  Well thank you for that excellent definition. Now, as we’re talking about the risks of untreated AFib, and since some people really don’t even know they have it. Everybody can’t feel it, right. And you’ve mentioned the risk factors, now talk about the risk of stoke and how that is increased if somebody does have AFib.

Dr. Kutayli:  Yes, that’s actually a very good point you made Melanie. I talked about some of the symptoms that patients can feel when they are having atrial fibrillation but you’re right, oftentimes atrial fibrillation can be silent or asymptomatic without symptoms. Atrial fibrillation because the top chambers aren’t contracting normally, the blood inside those chambers doesn’t move very well and when blood doesn’t move, it can clot. And so, the main concern that we have with atrial fibrillation is the risk of stroke that’s associated with it. Patients with atrial fibrillation have five times an increase in their stroke risk because of that clot that could form and if a clot forms in the heart, it can dislodge and go to the brain and cause a stroke.

So, one of the first things we have to do when patients have atrial fibrillation is to address that stroke risk. Now in terms of the patients who have silent atrial fibrillation, they may have atrial fibrillation and not know it and sometimes patients will present with strokes to the hospital and one of the things we have to figure out is did this patient who had a stroke have atrial fibrillation as a potential cause.

Host:  Well then let’s talk about some of the main goals of treatment. Are they symptomatic? Are they curative? And speak about some of the new guidelines for the use of blood thinners and even aspirin has been touted as something that can help reduce that risk of stroke. Tell us a little bit about some of the things that you might try as a first line of defense and why.

Dr. Kutayli:  Sure so, in terms of treatment of atrial fibrillation; the very first thing we have to address is the stroke risk. Because although atrial fibrillation itself usually doesn’t put you at higher risk of death. A stroke of course could. And so, the first thing that needs to be protected is the brain in patients who have atrial fibrillation. So, we look at patients with atrial fibrillation and try to determine is this patient at high risk of having a stroke. The general feeling is, that the younger you are, the less likely that atrial fibrillation is to cause a stroke. Of course there are exceptions to every rule. But generally, if you are above the age of 65, your risk of stroke from atrial fibrillation goes up. We use age as well as other risk factors to determine who is at the highest risk and who needs to be treated more aggressively.

So, there are risk scores that we look at primarily something called the CHADS-VASC score that goes over the most common risk factors that increase the risk of stroke with atrial fibrillation. We talked about age as being the primary one, 65 and up. If you are above the age of 75, your risk goes up even higher. Congestive heart failure, which is a condition where there’s overload of fluid, hypertension, diabetes mellitus, if you have already had a stroke, that increases your risk having another one potentially from atrial fibrillation. Vascular disease like coronary artery disease or carotid disease and female sex category also increases the risk to some extent.

So, if you have more than one risk factor of the ones that I just mentioned, you are someone who would be a candidate for blood thinners. Blood thinners are the primary way we treat stroke risk with atrial fibrillation. The most common blood thinner and the one that’s been around the longest is a blood thinner called warfarin which is taken on a daily basis and which can thin out the blood and what I mean by that is that when you’re on this blood thinner, it takes you longer time to clot. There are other newer blood thinners that are on the market now in the last ten years. These more direct oral anticoagulants that people can take. And these are drugs that you may have seen on television commercials for like rivaroxaban, also known as Xarelto, apixaban or Eliquis, dabigatran a drug called Pradaxa. We use these newer blood thinners in patients who are diagnosed with atrial fibrillation who do not have significant valvular disease. As long as their heart valves are okay, they don’t have replaced heart valves or prosthetic valves we can use the newer blood thinners.

The newer blood thinners are easier to take and multiple studies have shown that they lower your risk of stroke even more than warfarin does. In terms of aspirin, the general feeling is that aspirin isn’t really a great way to lower your stroke risk with atrial fibrillation. Historically, we used to use aspirin in people who we felt were at low risk. But if you have a significant risk of having a stroke and you have one of those CHADS VASC risk factors that I mentioned, the feeling is that aspirin isn’t going to do you a whole lot of good, that you are better off taking either warfarin or one of the newer oral anticoagulants.

For patients who are unable to tolerate blood thinners there are other options that we could talk about including the Watchman device which is a device that we use occlude the left atrial appendage. The left atrial appendage is an area on the left atrium, the top chamber on the left side where most of the clots form. So, when you put in an occlusion device, you basically block off the areas where the clots can form and therefore lower the patient’s risk of having a stroke.

Host:  Isn’t that fascinating? And as you mentioned, some people don’t tolerate those oral anticoagulants. And as an important therapy that they are, they come with risk factors, limitations; so what else besides the Watchman might you try if that – and also, please mention if they do have a procedure like the Watchman, do they still have to be on their blood thinners afterwards? What is their life like if they have an interventional procedure such as that?

Dr. Kutayli:  Yeah, so, when we talk about a left atrial appendage occlusion device; we’re talking about usually patients who are at too high of a risk to take blood thinners or who haven’t tolerated blood thinners. So, an example would be someone who has had a bleeding problem either in the GI tract from say diverticulitis or some other disorder or who has had a history of intracranial bleeding from falls. So, these are people that we would feel are too risky to stay on blood thinners long term.

So, the left atrial appendage occlusion devices like the Watchman are a nice alternative. The Watchman device is implanted in the Electrophysiology Lab. Basically, the patient is under anesthesia. We go in from the right femoral vein in the patient’s groin. We introduce a catheter inside the vein that drains into the heart. We cross over from the right atrium to the left atrium where the left atrial appendage sits, and we then implant the device under echocardiographic guidance or ultrasound guidance. You’re right, to get the Watchman device, you do have to be on blood thinners at least in the short term. So, in the initial few weeks before the procedure and then about six weeks after the procedure we have to have patients on warfarin or one of those newer oral anticoagulant agents.

But the hope is that if we can get a good location, a good seating of the device; over time, we can get the patients off of those blood thinners in the long run period.

Host:  So, tell me a little bit about lifestyle and what this is like for patients with AFib. If they’ve had an interventional procedure, what is their life like afterwards and wrap it up with your best advice about atrial fibrillation and the many treatment options available.

Dr. Kutayli:  Well, we’ve only addressed one aspect of treatment of atrial fibrillation here which is the risk of stroke. We haven’t yet touched on how you treat the atrial fibrillation itself in terms of improving the patient’s symptoms. One of the main symptoms that people experience when they have atrial fibrillation is very rapid heart rates. So, we use common blood pressure medicines like beta blockers which also lower the heart rate to help alleviate those symptoms by slowing the patient’s heart rate down. Sometimes patients with atrial fibrillation can have very slow heart rates particularly if they’re on medications like beta blockers and they may require pacemakers for adequate treatment of their atrial fibrillation.

If we’re trying to maintain normal rhythm in a patient who keeps having recurrent atrial fibrillation despite medical options with commonly used drugs like beta blockers; we have other medications, we can use, and these are drugs called antiarrhythmic drugs which work on the heart’s sodium and potassium channels to help regulate the rhythm. For patients who have atrial fibrillation refractory to all antiarrhythmic drugs and beta blockers; there’s a catheter ablation and catheter ablation is an invasive procedure where we try to regulate the rhythm by ablating or cauterizing inside the left atrium in the areas where the atrial fibrillation tends to start, namely the pulmonary veins, the veins that drain the lungs back into the heart. So, we have a lot of different modalities that we can use to treat atrial fibrillation in that regard.

The catheter ablation procedure, we can use cautery or radiofrequency and that can be done with manual catheters or robotic procedures, and with freezing technology or cryoablation. Here at Bryan Heart, we provide patients with all sorts of different modality options in terms of treatment and ablation of atrial fibrillation, including all of those three options that I just mentioned.

Host:  Thank you so much Dr. Kutayli. What a fascinating topic. And thank you for sharing your expertise with us today. And thanks to our Bryan Foundation partners, Sampson Construction. That concludes this episode of Bryan Health Podcast. Please visit our website at www.bryanhealth.org for more information and to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Bryan Health Podcasts. Until next time, I’m Melanie Cole.