Maggie McKay (Host): How much do you know about electrophysiology and technology? Today, we're going to find out what it is, what it's used for, and who can benefit from it with Dr. Matthew Hakimi, cardiologist with subspecialty training in Electrophysiology at Community Memorial Healthcare.

Welcome to Wise and Well, presented by Community Memorial Healthcare. I'm your host, Maggie McKay. Welcome, Dr. Hakimi. So good to have you here. Could you tell us a little bit about your journey into electrophysiology and what excites you most about this field?

Matthew Hakimi, MD: Thank you so much for having me. This is my first podcast professionally and personally. So, I'm especially excited, and I'd love to speak about my specialty and what led me to here. I was always interested in the heart, specifically prevention of heart disease. So, it's interesting that I've ended up on the intervention side of heart disease where we treat patients, but I think they're very much connected. And my journey started with being interested in risk factors that develop heart disease, specifically hypertension. I did fellowship training in hypertension and Vascular Biology, and then went on to do General Cardiology training. And in those years, I was very interested in the role of technology in Cardiology. And the perfect field I thought was electrophysiology that truly marries these two healthcare and biotech technologies that really use each other to treat patients.

And it's such an exciting time to be in electrophysiology because the treatments are really exploding, and they're becoming much more efficient, much safer, much shorter. So, the specialty that I have focuses on treating arrhythmias, which are anything having to do with the patient's heart rate or heart rhythm. And we can do anything from implantation of devices to performing procedures that are called ablation to try to fix the arrhythmia itself. So, it's an exciting time and I've learned a lot. And there's a great deal still to be learned and improve on the field.

Host: So, what are some of the biggest advancements you've seen in electrophysiology since you began your career?

Matthew Hakimi, MD: You can divide the field into two different categories. We implant devices like pacemakers and defibrillators, and those have really improved and become smaller and much more efficient, longer battery life. We are doing what's called leadless pacemakers, which the field is really moving towards universally adopting that. And there are pacemakers that actually instead of having to do surgery on the chest, they can be implanted through the groin transfemorally, meaning going through the femoral vein. And these are very exciting devices that can really help improve patient's lives in a much more minimally invasive way.

And then, on the ablation side, so not devices, but actually doing catheter-based procedures, again, we go through the femoral artery in the groin. And the reason we do this is because the way to access the heart, you have to access a vein and our vessels are much larger and much more accessible on the groin. So, that's why a lot of cardiac procedures are done sort of transfemoral, we call it, or on the groin. And then, we access the heart with catheters. And these catheters go and sit inside the heart and they listen for signals. They create these beautiful 3D maps of the heart, and they find where the arrhythmias are coming from and we can go after them.

The way to go after them has really changed. We have a variety of ways to create these maps of the heart and make a very efficient, sort of diagnostic platform to operate on and use different kinds of energy to deliver these lesions that basically eliminate abnormal cells that are producing arrhythmias. We've had traditionally radiofrequency, which is very targeted heat lesions that you can apply. We've had cryotherapy and those are still very much widely available, and we use them quite frequently.

The new kid on the block is pulsed-field ablation, which also has great promise to make it a shorter and safer procedure. And there's lots of developments. Literally, every week, there's a new piece of information added. And the equipment that we use keep improving. So, lots of developments in both ablation front and also device implantation front.

Host: Let's talk about wearable technology. We've seen a surge in the popularity of wearable devices like smart watches and rings. How often are you seeing patients with AFib that was first detected by these devices? Can you give us a sense of the numbers or percentages vaguely?

Matthew Hakimi, MD: It's definitely a very interesting time to be practicing medicine. Not just limited to my field, but in general, patients have great access to their own health information, and the wearables are a big part of being able to detect their heart rhythms and coming to us with questions and really being involved in their own care.

So, I would say a good 40%, just under half of the patients that I see do have some sort of wearable, and sometimes the diagnosis really does start there. They're not excellent in terms of their specificity, which means if they detect something, is it truly an arrhythmia or sensitivity? They might miss something because they're not truly continuous monitoring devices. It's really a series of snapshots throughout the day, and they're not worn all the time. But it does sometimes help. I mean, at the very least, it might trigger someone to then come see a doctor and then we can really build on that and give them another monitor that's a true continuous monitor. And we might detect something that we would not have thought about if they hadn't come to us with that very first question. "What is this that I'm detecting on my wearable Apple watch?" Or some of the other wearables that they have.

So, I think, overall, they are helpful. They definitely are not a substitute for other diagnostics that we use, but they can be a good start for patients. And it's becoming more and more common that we see that.

Host: Dr. Hakimi, have you noticed any trends in the demographics of patients who are wearing wearables for AFib detection? Are certain age groups or populations more likely to use this technology?

Matthew Hakimi, MD: Yes. I think it started for younger patients just because Apple watches and things like that are tech devices. And I think it was a feature that was being used sometimes by the typical demographics, which tend to be younger people. But I think we've seen a good spread into people above their 60s and 70s. And it keeps improving in terms of detection of falls or having an oximeter on it, or really having a good monitor, even after someone gets an ablation. And the ablation patients sometimes tend to be on the older side. So yes, the demographic is changing. And I think the ease of use is there. And we are seeing a shift from sort of a bimodal shift. Younger patients or older patients are both having it, yes.

Host: What are some of the most common misconceptions that people have about AFib?

Matthew Hakimi, MD: I think AFib can be very scary when someone is diagnosed with it because arrhythmias are difficult to really describe or understand. And my job when I first see a patient that has had AFib and they go through this shock, is to really bring some clarity to the diagnosis that. "This is a lot more common than you think. It's not something you've done. It may be genetic. It might have to do with some risk factors like sleep apnea or high blood pressure that's out of control or other risk factors." but for the most part, we're not good at predicting who gets AFib. So, they should be reassured in that it wasn't something that necessarily they could have come to me earlier, but we are where we are and we need to make sure that you're protected against potential bad outcomes like stroke. And then, we can talk about treatment options, which include medications or ablation.

But it is not a per se deadly disease by itself. It's hard to imagine how someone can have a fatal AFib. I want them to really not think about terrible outcomes. But it is important to manage AFib. It is important to protect them against stroke. It is important to manage their symptoms, and talk about options that might be invasive, but it would go a long way to eliminate or at least lower their burden of symptoms from AFib and prevent sometimes what we see as cardiomyopathy, meaning weakening of the heart muscle that can happen with AFib, but not everyone gets that. So, there are potential consequences of AFib.

But overall, I would say the misconceptions have to do with is "This a terrible thing that I have, there's no cure for it, and can I be really hurt by this?" Those things really need a good conversation with the doctor and I think we can do a good job of bringing clarity and making them feel better and helping them manage it by controlling some of the risk factors as well.

Host: And so, you mentioned treatment. Let's talk a little bit about that. What are the latest advancements when it comes to AFib treatment, both procedural and pharmaceutical options?

Matthew Hakimi, MD: I sort of compare the two fields of interventional and electrophysiology in that they deal with the blockages of coronary arteries and opening them up, stenting, bypass surgeries are extremely helpful. In our field, we deal with arrhythmias and they are much more micro. Yes, they can be a consequence of an ischemic event, meaning if there was a blockage, then the tissue that the blood supply was supplying and it's not there anymore, that can form a scar and can cause arrhythmias. But overall, arrhythmias are a separate thing from interventional.

And in our field, medications have not traditionally been very helpful. And when it comes to intervention, at least considering a patient for a catheter ablation sometimes can do a lot more and be more definitive in terms of therapy for a patient than medications such as antiarrhythmic therapies that may not be well tolerated.

So, I would say, for the treatment of arrhythmias, ablations are becoming more and more first line. So, it's a good idea to refer patients to an electrophysiologist when there's an arrhythmia, because these arrhythmias tend to recur and the earlier you catch and treat the arrhythmia, the better of a long-term arrhythmia-free survival you're going to have.

Host: And lifestyle changes. What do you recommend for patients with AFib? How do these changes complement medical or procedural interventions?

Matthew Hakimi, MD: We know that weight loss, treating sleep apnea, treating high blood pressure, getting the diabetes under control if there is diabetes, and make sure that what we call a volume status is optimized. And so, if somebody has heart failure, that there aren't good diuretic medications, that just overall the stress on the heart is as little as possible so that a heart that has had AFib, the progression of AFib is slowed down. And if they get a treatment, like an ablation or a medication to control the AFib, the sort of breakthrough recurrences of AFib are minimized. Those are extremely important.

I think the challenge is sometimes we think that there's now AFib and we just have to focus on AFib. But if the blood pressure is not controlled, if there's sleep apnea that's not controlled, and if there's overweightness, obesity, those things can really affect not just the progression of AFib and make it more common, longer episodes, more symptomatic episodes, but also really interfere with the success of procedures or antirrhythmic therapies. And it's hard to make an asymptomatic patient feel better. I always say that when it comes to hypertension and some other comorbidities, even sleep apnea sometimes, you'd be surprised how many patients might have sleep apnea and not know it. There's really no clear demographic or that textbook picture of a sleep apnea patient with overweightness or sleeping all the time. So, I think it's a good idea to screen for that, with a sleep study when somebody's diagnosed with AFib. So, the challenge is to get those things under control, and then also focus on the AFib itself.

Host: Dr. Hakimi, thank you so much for sharing your expertise with us today. Where can our listeners go to learn more about you and your work?

Matthew Hakimi, MD: Thank you so much. I'm happy to be speaking and the patients are welcome to go to mycmh.org/heart to find out more.

Host: Thank you again. This has been fascinating.

Matthew Hakimi, MD: Glad to hear that. Thank you for having me. 

Host: That's Dr. Matthew Hakimi. And again, to find out more, you can go to mycmh.org/heart to learn more about heart and vascular care at Community Memorial Healthcare. 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. I'm Maggie McKay. Thanks for listening to Wise and Well, presented by Community Memorial Healthcare.