Joey Wahler (Host): It can help save lives. So we're discussing preventing stroke for A Fibrillation patients. Our guest is Dr. Jared Salvo. He's a Cardiac Electrophysiologist with Dignity Health. This is Hello Healthy, a Dignity Health podcast. Thanks for joining us. I am Joey Wahler. Hi there, Dr. Salvo. Welcome.

Jared Salvo, DO: Thank you very much. Good morning to you. Thank you for having me.

Host: Good morning to you. Thanks for being with us. So first in a nutshell, what does an electrophysiologist like yourself do?

Jared Salvo, DO: In the shortest terms, I tell folks that, I'm an electrician of the heart. My counterparts are plumbers, the ones that deal with blocked arteries and heart attacks. But the heart is a rhythmically active organ, and it needs a specialist just to manage the heart rhythm.

Host: A great way to put it. Certainly brings it into much clarity. So what exactly is atrial fibrillation and how common is it?

Jared Salvo, DO: The heart, like I said, is an electrically active organ, and it has to beat in a synchronized fashion from top to bottom. And there's a series of checks and balances and natural pacemakers that the human body is born with. But it is prone to having errors and degeneration and disease.

And when that synchrony is lost and what, what I'm talking about is the top chamber in particular, instead of squeezing and beating in normal rhythmic fashion, it starts to quiver and shake and vibrate instead of pulsating. This sends a very erratic signal to the bottom chambers of the heart. Now, the bottom chambers are your pump.

They're the workhorse. Those are what your body depends on. So it tries to keep up with this erratic signal. Thankfully, it doesn't keep up with it in total, but that top chamber going frantic and haywire like that really can cause a lot of problems that can cause symptoms. It can make the patients feel bad, but one of the worst things it can do is when the blood is not pumping through those top chambers; it actually can stagnate in there, if that makes sense. And as it stagnates, it can form small clots. Because you know, blood that's not moving that sits around, tends to clot and thicken. And if those clots break loose, the first place they're going to go out the heart is to the brain and cause a stroke. And that's why atrial fibrillation is one of the most common causes of stroke in America. But the rhythm of atrial fibrillation as a disturbance is extremely common and is estimated that about 45% of all Americans will have some brush with atrial fibrillation at some point during their lifetime.

Host: Wow. And does that risk of that happening rise as we get older?

Jared Salvo, DO: Absolutely. So you took the words right outta my mouth. Atrial fibrillation single and without any other description, is a disease of aging. The older you get, the more likely you are to have it. The longer you're on this planet, the more likely you are to have it. If you look at the studies that have been done; and the graphs that have been done based on aging, the rate of atrial fibrillation as you get older, just skyrockets. Now, some people will have it once in their life. Maybe you're hospitalized with a bout of bad pneumonia, and it puts a strain on your heart, and that may be the only time you ever have it.

Or maybe someone goes on an alcoholic binge, that they wouldn't normally do, and they go into atrial fibrillation. We call that holiday heart. They may never have it again, but the real problem is when it recurs, and in most folks, it will be a recurring problem. And the more you have, the more you get. Meaning the more AFib you have, it sort of becomes a self-fulfilling prophecy that you're going to have more and more and more.

And there are become changes at the cellular level of the heart muscle that make it so, that you get more prone to having atrial fibrillation.

Host: And actually when you have a stroke, it typically makes you prone to having more in the future as well, right?

Jared Salvo, DO: Absolutely, you're hitting all the salient points. So as you age, if you have a stroke and you have atrial fibrillation, your risk for having a recurrent stroke down the road actually now goes up astronomically and we have this calculation system where we look at the risk factors of a particular patient, and it's called the CHA2DS2-VASc score, and it has various components to it.

Medical history, age, sex, diabetes, some other things. And as that point tally goes up, we can estimate that someone's risk of stroke if they have atrial fibrillation starts to go up remarkably and we make decision choices on how to manage those patients to prevent stroke based on that calculation score.

And you can imagine that aging is one of the top scores. And the same thing with having had a prior stroke, as you mentioned.

Host: And so having said that, generally speaking, how much higher is the chance of stroke for someone with AFib compared to those without it? If you take age and et cetera out of the equation.

Jared Salvo, DO: So some of the people that are at highest risk of stroke we look at it as an annual risk, and it's somewhere in the order of probably 10 to 15%. Now those odds may not sound terrible because that means, oh, well there's a 90% chance I won't have a stroke every year that I live with AFib.

But I would tell you that if you knew what the consequences were of having a stroke, you would bet against those odds all day long because nobody wants to be debilitated or in a locked in position where they can't speak or half their body can't move or they're in a wheelchair or have to have a feeding tube.

So, although 10 to 15% annually may not sound like a high risk, in medicine it is an absolutely astronomical risk.

Host: And so one more question about this piece. Is the risk of stroke from AFib constant, if you will, or can it change over time depending on a patient's progress?

Jared Salvo, DO: Well, there are things that can be done to mitigate the risk. For example, if somebody is on an anticoagulant, blood thinner; the studies have shown that the risk of stroke, if you have atrial fibrillation now drops below 1%. The problem is a lot of folks don't like taking blood thinners because they get bruising and they get a bloody nose.

But I will tell you that they're quite effective. That is a pharmacological way to change your risk. We have structural ways to change the risk. There is a particular side pouch of the left atrium, as you will. It's an anatomical pouch that we're all born with. That little side pouch is where the clots seem to form the most when the person has atrial fibrillation.

And so somebody came up with the bright idea, well what if we close that little pouch off? Then clots are less likely to form. And you know, 30 years ago you would have to do open heart surgery to do that. And sometimes they did do open heart surgery to close off that little side pouch to deal with stroke risk. It's pretty rare. Now we have a percutaneous, meaning less invasive way, where we can go in through the groin, deliver an umbrella that is collapsed, position it in that little side pouch, and deploy the umbrella to close off that side pouch, thereby reducing the risk of stroke as if you had done open heart surgery and the studies have borne out that doing that umbrella deployment, you may have heard of a device called the Watchman, for example.

The other one is the Amulet. They can reduce your risk of stroke to less than 1%, just like blood thinners can. So the pharmacological and the surgical options that we have can really lower someone's risk. But aside from that, once you carry the risk of diabetes, high blood pressure, aging, sex, these are things that you really can't control. And as you get older, the risk would otherwise become increased unless you did something about it.

Host: So let's talk about those treatment options. You mentioned blood thinners. Is that typically the most effective way to go about this?

Jared Salvo, DO: Yes, the blood thinners are going to be absolutely your first line agent. They're effective. They've been well studied. The ones that we have now are remarkable. I remember in the days of my training, we only had warfarin, which is a medicine that goes back to, you know, the 1950s. It's difficult to manage. It has a very narrow therapeutic window, meaning you have to calculate the dosages and check blood tests. So up until about 10 to 15 years ago, that's all we had. Now we have newer oral pills that are predictable, reliable, and do not take a lot of dose changes or adjustments and the patient can just take them and go, they're really effective.

You can encounter some bruising with them and bleeding if you're shaving. But most folks do okay on them. And I would say as a first line agent, it's your go-to. The one downside that I hear is they can be a little bit costly. And so sometimes the pocketbook is the determining factor of whether a patient, chooses a medication versus having the surgical option that we talked about.

Host: Once on AFib meds, how important is a doctor to take them regularly? Because slipping up even slightly can cause a stroke, correct?

Jared Salvo, DO: It can, there's a little bit of grace built in them. The half life of most of these medications are about 24 hours. So, one of them, for example, is twice a day. If you forgot one in the morning and then picked up again in the evening, you'd probably be okay. But, yeah, compliance is extremely important, because it doesn't take very long for these medications to get out of the bloodstream, and then you're in theory not protected.

Now, I will tell you, sometimes we have to tell someone to intentionally interrupt the blood thinner. They're going to have a tooth extraction or a knee replacement. And those are supervised and monitored by the doctors. And we tell them when to stop it exactly, and then determine which is the safest time to resume them after your procedure.

So there are times where you have to interrupt them.

Host: But that's of course under professional supervision with someone like yourself, you don't want to, for instance, give into some of those side effects that you mentioned a bit earlier and say, boy, I need a break from these. Just gimme a day or two, because that could be the difference between life and death, literally, right?

Jared Salvo, DO: Absolutely, you hit the nail on the head, and I'll tell you that I have many patients who will come to me telling me that they're taking it every other day because they feel more comfortable doing that. And I have to try and educate them and tell them, Hey, listen, I know you feel like you're doing the right thing but really your risk of stroke is not being adequately met, in terms of stroke risk reduction, if you're not taking the medications as prescribed.

Host: Absolutely. Couple of other things here. Any lifestyle factors that can increase or reduce the risk of stroke for AFib patients.

Jared Salvo, DO: The risk of atrial fibrillation goes up with certain lifestyles. Morbid obesity, which is really something that I'm seeing more and more of every day is a risk factor for atrial fibrillation, which will then be a risk factor for stroke. Diabetes, which in some cases is a lifestyle, dietary indiscretions. Which, so if you've eaten high sugar content and developed diabetes, that would be an increased risk of stroke there. Untreated sleep apnea would be another risk factor. So if your significant other notices that you snore or stop breathing while you're sleeping, we know that untreated sleep apnea is absolutely a risk factor for developing atrial fibrillation.

And I would tell you that treatment of sleep apnea is one of the most important things, and you could argue then that it would be in a domino effect reducing the risk of stroke. But I always get the question, and I think this may be what you're asking about, it's probably alcohol. That's probably one of the biggest questions we get.

And we do know that alcohol does increase the risk of atrial fibrillation, which in then could turn and result in increased risk of stroke. The studies on caffeine actually didn't bear out, but we thought that, oh man, if someone's drinking a lot of caffeine and stimulants, they're going to put themselves into AFib, and, and that can happen, but it doesn't seem to be quite as strong of evidence as it does with alcohol.

Host: And so in summary here, you've done a great job of going through all the different details to be considered. What's your most important advice, Doctor for AFib patients overall help reduce their stroke risk. What's the mindset they need to have here?

Jared Salvo, DO: I think for me is getting checked out is one of the biggest things to see if you have atrial fibrillation. It may not take a lot, but just seeing your regular doctor and having a checkup and listening to having the provider listen to your chest and maybe do just a basic EKG and a careful history, those can lead to prevention of stroke.

 I can't tell you the value of that. And the reason being is because I would say about 15% of people don't feel their atrial fibrillation, meaning there's no symptoms. They didn't have racing heart. They didn't have any other indicator. And the first manifestation is a stroke, and those are always the worst stories and I've seen them time and time again.

So in some folks who don't feel it as they get older, you just need to be checked and make sure you're seeing your provider on a regular basis to determine if you might be at risk. Family history can be helpful as well because if it runs in your family, you may be more prone to it. And we know that to be true.

Host: So in short, don't wait until it's too late, right?

Jared Salvo, DO: That's absolutely right. Do not wait, get checked out. If you think that you might have an irregular heartbeat, it could be a number of other things, it might be nothing, but it cannot hurt to get checked out because if you do in fact have atrial fibrillation and you have some of those risk factors that I mentioned, you can absolutely do your best to prevent stroke and reduce the risk and, it's very valuable.

Host: Valuable indeed to say the least. Well folks, we trust you are now more familiar with preventing stroke for AFib patients. Dr. Salvo, great information for everyone, whether they've had their heart checked out recently, or particularly if they haven't. Thanks so much again.

Jared Salvo, DO: Thank you. You know, the old saying, an ounce of prevention is worth a pound of cure, right?

Host: It's a saying that's been around for a long time with good reason, right.

Jared Salvo, DO: Absolutely. Thank you very much.

Host: You got it. And for more information folks, please visit Dignity health.org/bakersfield/stroke. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler and thanks again for being part of Hello Healthy a Dignity Health Podcast.