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This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host, Melanie Cole.

Melanie Cole (Host): Welcome to Expert Insights with the Carl Foundation Hospital. I'm Melanie Cole. And joining me today is Dr. Benjamin Rhee. He's an electrophysiologist with the Carle Foundation Hospital, and he's here to highlight advanced treatment for atrial fibrillation. Dr. Rhee, thank you so much for joining us again today. I'd like you to start by telling us a little bit about AFib, the prevalence, and really the scope of the issue that we're talking about here today.

Dr Benjamin Rhee: Certainly, thank you for having me. Atrial fibrillation is the most common rhythm disturbance we see. It is seen in about 3% of the population overall. It unfortunately is expected to increase significantly in the foreseeable future with the prevalence anticipated to increase and triple by 2050. Another way of answering the question might be to say that one-quarter of people over age 40 are expected to develop atrial fibrillation in their lifetime.

Melanie Cole (Host): Wow. That's some incredible statistics. So, I guess the main thing we worry about with AFib, I mean there's plenty to worry about, but the complications and the risk of stroke. Can you explain a little bit about why that happens? And since some people don't even know that they have it, and it may not even be detected on a normal well-visit, for other providers, what would you like to tell them when they're counseling their patients about this particular condition?

Dr Benjamin Rhee: We have collected an enormous amount of information regarding atrial fibrillation. There are two elements we manage with regards to atrial fibrillation. One is the risk of stroke, and second are symptoms associated with atrial fibrillation. We do know that atrial fibrillation is not a life-threatening illness in the traditional sense. It is not something where people develop it and then pass away immediately from it. That allows us to focus on symptom management. And again, the area where people do have early mortality is if they happen to develop a stroke.

The calculated risk of stroke increase due to atrial fibrillation ranges from 1% to about 12% in patients. And so, it is a big deal to see your physician and have that risk assessed and the appropriate therapy determined for the stroke risk, which again does cause people to pass away prematurely. The second element, the symptom risk does not cause people to pass away early and, while important, is not as acutely alarming for most patients.

Melanie Cole (Host): Well then, tell us what's exciting. You and I have done a previous podcast on this. I'd like you to update it. Tell us what's exciting in the world of treatments. What problems are you trying to solve as we're curing the AFib, or are we just reducing that risk of stroke, or both? We're talking rate control and anticoagulation. First start with medication intervention, Dr. Rhee, and then we can get into some of the interventions that could possibly be curative.

Dr Benjamin Rhee: Sure. In the few years since we last spoke, our understanding of atrial fibrillation has increased significantly. Regarding medication management, I think the biggest elements are that we are much more focused on preventing atrial fibrillation from developing at all. So, that means being aware of the modifiable risk factors of atrial fibrillation, which can include high blood pressure, diabetes, weight, cholesterol, things like that. We are acutely aware that for patients who can reduce their weight, for example, by 10%, they experience significantly less atrial fibrillation throughout the course of their lifetime. So, the management involves primary prevention, managing sleep apnea, and those other diseases that we discussed to try to overall keep the heart healthier before any atrial fibrillation develops.

Regarding specific medications for atrial fibrillation, we continue to use beta blockers and calcium channel blockers as our first line therapies. Those are very safe and well tolerated and help to keep people feeling better from atrial fibrillation, but don't primarily keep them in normal rhythm. If someone is symptomatic despite those medications, there are more potent medicines that are available for electrophysiologists generally to use, and they work pretty well at helping control symptoms of atrial fibrillation.

Melanie Cole (Host): Dr. Rhee, when the AFib discussion becomes interventional, tell us about some of the interventional procedures that you might look to. Why don't you start with ablation, and tell us about any that you are very interested in right now.

Dr Benjamin Rhee: Ablation has been a boon to atrial fibrillation patients for about 20 years now. We are experiencing a tremendous improvement in treating atrial fibrillation through the catheter. We have developed ways to use radiofrequency energy and cryoablation to dramatically reduce episodes of atrial fibrillation in the future for patients who suffer from atrial fibrillation. The ablation seems to work about 85-90% of the time at keeping atrial fibrillation patients free of atrial fibrillation at the two-year mark. In comparison, the medications I mentioned earlier seem to keep them free of atrial fibrillation around 45-50%. The complication rate of the procedures have dropped enormously. And so, the overall summary I would say about ablation is that it continues to increase in the recommendations and guidelines as an earlier and earlier recommendation for patients with atrial fibrillation because of the outstanding outcomes and the continued reduction in risk of the procedure.

Melanie Cole (Host): What are some others that are looking right now, as we see that there are so many coming down the pipeline and so much happening in your field right now? It's really an exciting time. Tell us what else is going on out there.

Dr Benjamin Rhee: I think the most exciting area we're looking at is the possibility of a new type of ablation called pulsed-field. It is very promising, but not certain that it will deliver as promised just yet. So, it's in the experimental phase. But we are hopeful that we can get even higher success rates at reducing atrial fibrillation than the traditional radiofrequency ablations and cryoablations.

I guess I would like to mention that some of the success rates might be viewed differently by patients. Because atrial fibrillation is not a life-threatening rhythm disturbance, sometimes a reasonable goal might be symptom relief through the ablation. And frequently, we see an additional 10% or even 15% of people feel significantly better with the ablation, even if they continue to have episodes of atrial fibrillation. So again, how you perceive the success rate of atrial fibrillation may depend on what you define as success.

The catheter ablation is also getting safer, to answer your question more directly, because of better ways of monitoring the energy delivery and the risk of damage to non-cardiac tissues during the procedure. So, the procedure is getting better and better through engineering enhancements in our monitoring technology.

Melanie Cole (Host): That's a great point. And I'm so glad that you brought that up because radiologic advances now are really adding to your armamentarium of available therapies and making them, as you say, a little bit more safe and with better outcomes. Before we wrap up, what would you like other providers to take away about the options available for atrial fibrillation. And as we're, you know, looking at not only the medications, but the interventions, I'd like you to just speak to them now and speak about the current thinking surrounding all of these different options and how, with shared decision-making, you're deciding which of these options to use when you're with patients.

Dr Benjamin Rhee: One additional therapy that patients may be aware of is the Watchman. It is a device that is a plug for a part of the heart called the left atrial appendage and is used for stroke prevention. The anticoagulation that most patients are recommended to utilize for prevention of stroke reduces their risk of stroke by about 60%. In patients who cannot tolerate anticoagulation because of risk of bleeding, side effects from the medication or other reasons, the Watchman is something that can serve as a replacement for oral anticoagulation and help prevent stroke in patients, again, who cannot tolerate anticoagulation. The device is in its second generation. It is being implanted across the world. It is reasonably safe at this point, and is something that should be considered for patients who cannot tolerate anticoagulation.

We'd like all of our patients to be educated in the illness that they have and understand the treatments and options that they have available to them. We welcome shared decision-making in all of our patients. We discuss side effects of medications, the pros and cons of medications. And similarly, we discuss the rationale why a procedure might be recommended or why we might discourage any individual patient for a procedure. But certainly, all of the decisions we face with non-life threatening illnesses are discussed carefully with each patient.

Melanie Cole (Host): Great information. And thank you so much for telling us, Dr. Rhee, about all the advances going on in your field right now. Thank you again. And for more information and to get connected with one of our providers, you can visit carle.org. Or for a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.