Atrial fibrillation is an irregular heartbeat.
Dr. Mikhael El-Chami discusses treatment of afib for those who need more than diet and lifestyle changes to live with the condition.
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AFib Treatment
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Learn more about Mikhael F. El-Chami, MD
Mikhael F. El-Chami, MD
Dr. Mikhael El-Chami is a cardiologist in Atlanta, Georgia and is affiliated with multiple hospitals in the area, including Emory University Hospital and Emory University Hospital Midtown.Learn more about Mikhael F. El-Chami, MD
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Bill Klaproth (Host): So what is atrial fibrillation or afib and how is it treated? Here to answer those questions and more is Dr. Mikhael El-Chami, a Cardiac Electrophysiologist at Emory Healthcare and Associate Professor of Medicine at Emory University School of Medicine
Dr. Mikhael El-Chami (Guest): Yeah thank you for hosting me on this podcast. Atrial fibrillation is an abnormal heart rhythm. It’s the most common arrhythmia encountered in clinical practice and currently there’s around five million people in the US who have afib and we are seeing an increasing number of patients who suffer this abnormal heart rhythm.
Host: So it sounds like it’s fairly common. What puts you at risk of developing afib?
Dr. El-Chami: That’s an important question. There are multiple risk factors for atrial fibrillation. The most important one in my opinion is age. Aging predisposes you to have atrial fibrillation. Obviously that’s a risk factor that you cannot modify, but there are other risk factors that you can actually modify. Number one, obesity or being overweight. That’s an important risk factor. Having common conditions like hypertension and diabetes, if they are not treated in a good manner, they might predispose you to atrial fibrillation. And last but not least having sleep apnea, obstructive sleep apnea is an important risk factor for afib, and as we will talk later, treating or modifying these risk factors might help prevent atrial fibrillation or minimize the occurrence of afib episodes. There are also other risk factors such as having structural heart disease, meaning have valve heart disease or heart attacks or weak heart muscle, all of these are potential risk factors for atrial fibrillation.
Host: Gotcha, so before we get into treatment, let me ask you this, are there different types of afib?
Dr. El-Chami: Right now we divide afib into three different types. What we call paroxysmal atrial fibrillation. It’s an afib that goes and comes. It usually lasts for a short duration time. For the purpose of definition we consider it an afib that lasts less than seven days. We have a persistent atrial fibrillation that’s an afib that lasts continuously longer than seven days. And we have the term long term persistent atrial fibrillation, which is an afib which has been present continuously for more than one year, and this is the afib that usually a little bit difficult to treat. Also some people use the term permanent atrial fibrillation. It’s an afib that’s present all the time, but after the physician and the patient agree to treat afib in a way, what we call, rate control, just staying in in afib all the time since some patients, as we will talk later, might not be very symptomatic when they have atrial fibrillation.
Host: Very interesting. So let’s talk about the first one, short term afib. That’s the afib that you said is characterized by lasting less than one week. How do you treat that?
Dr. El-Chami: So the paroxysmal afib, or the afib with short episodes that comes and goes could be treated in a different manner. For people who have an episode once a year or once every couple years and really short stays – stays for a short duration of time and subsides on it’s own, we might not need any treatment per se to prevent the afib. The only thing we focus on, as we’ll discuss later, is whether these patients need blood thinners to prevent stroke and patients who have frequent episodes of atrial fibrillation, meaning they have an episode maybe once a month or once every couple months or maybe even more once a week, we would need to use a specialized medication called anti-arrhythmic drugs to minimize the occurrence of these episodes. Another way to treat afib in those patient is an ablation procedure where we go inside the heart, it’s an intervention procedure. We go inside the heart and we try to burn or freeze the area where the afib comes from, and we can discuss this later during this podcast, and sometimes when some of these episodes last longer, they don’t go away by their own. For example, let’s say the patient has an episode of afib that lasts for 48 hours and the patient is very symptomatic, we don’t wait for it for seven days, we just bring the patient to the hospital and perform a procedure called cardioversion, which basically consists of using anesthesia to put the patient to sleep and shocking the heart back in normal rhythm.
Host: And how about that middle one you were talking about. What did you call the middle one again?
Dr. El-Chami: The persistent atrial fibrillation. Really the persistent atrial fibrillation by definition is an episode that lasts more than seven days and in my mind it is a continuum with paroxysmal atrial fibrillation. These patients who have persistent afib, the way I think about treating these patients is number one, are they symptomatic? And number two, does their heart function normal or not? For example, if you have no symptoms at all and if you’re afib, if your heart rate is controlled, you’re not going at 150 or 120 beats per minute or 110 beats per minute and you don’t feel anything. There’s really – we could offer the patient the approach of rate control and the use of blood thinners or anticoagulation. We don’t really need to be aggressive in treating afib, in those patients in particular except if we see evidence of weakening of the heart muscle. Sometimes afib is associated with weakening of the heart muscle, but in patients who have no symptoms at all and their heart function is strong, then we might elect not to aggressively treat afib except by using simple medications such as beta blockers and using blood thinners, but for patients who have symptoms, some patients really struggle when they have afib or for patients who have progressive weakening of the heart muscle that we believe is related to afib, then those are the patients that we need to be more aggressive in treating atrial fibrillation. Number one, to improve quality of life, and number two to prevent damage to the heart muscle, and the way we could treat those patients either using anti-arrhythmic drug, a rhythm medication to try to keep them in normal rhythm or go the route of an ablation. Typically in my practice and the practice of a lot of my colleagues, we go the route of the ablation, which is the invasive procedure if the medication does not succeed in doing the trick or the medication causes significant side effects, then we go the route of the ablation.
Host: Okay, and you said people who have permanent afib, treating that can be tricky. Can you tell us about that?
Dr. El-Chami: The patients who have what we call long term persistent atrial fibrillation, typically have an enlarged upper chamber of the heart at the left atrium, and we know from multiple studies that the longer you are in afib, the harder it is to get you out of afib, and in those patients, if again, I go back to the theme of symptoms. If patients are symptomatic or have weakening of the heart muscle, a lot of the time we see in our practice patients who have been left in afib for a long time and the patient has really been complaining of fatigue or tiredness that most likely is related to afib, but for some reason the afib was not treated, they come to us and they’ve been in afib for two years or three years. These are the patients that’s it’s a little bit tricky to get them out of afib. They need a combination of medications and often ablation procedure, and sometimes they might be offered a more invasive kind of ablation called the conversion procedure where we can do both – have a cardiac surgeon do the ablation in the sac surrounding the heart and we do the ablation – the typical ablation. So we do what we call a conversion or a combined ablation. But these are the patients overall that are a little bit more difficult to treat and might need multiple different approaches or combination of approaches to try to succeed in maintaining normal rhythm.
Host: So let me ask you this, is it possible to treat or manage afib through lifestyle, diet, and exercise changes?
Dr. El-Chami: Yeah, that’s a very important question, and recently there has been multiple studies, and I also mentioned in the beginning of this podcast that some medication conditions such as hypertension, diabetes, sleep apnea, or even weight loss are very important risk factors for afib and recently there has been multiple studies, especially studies coming out of Australia, showing that in patients who are obese and lose significant amount of weight, their afib becomes much easier to manage, and actually just the loss of weight itself reduces the burden of atrial fibrillation. So that’s something we encourage our patients. I know that sometimes it’s easier said than done but really weight loss I think at this stage of time should be cornerstone of treating atrial fibrillation, and you will see that when you lose weight, afib is better controlled, hypertension is better controlled, even sleep apnea might be better controlled, so this is an important risk factor or lifestyle modification that could improve the control of atrial fibrillation. Also we tell patients you need to focus on treating your high blood pressure, your diabetes, you need to be compliant with wearing the mask, the CPAP mask that’s used to treat the sleep apnea, and this is one of the cornerstone of treating atrial fibrillation is focusing on modifying the risk factors that could lead to afib.
Host: So it sounds like through treatment options and lifestyle changes, that afib can be managed for a lifetime. Is that correct?
Dr. El-Chami: That’s correct and manage is a key point. I tell my patients with afib is that it might take several steps to control the atrial fibrillation but patients need to be ready to be involved in their treatment. They might be ready to accept that okay we tried this approach but it didn’t work, let’s try the second approach, but eventually we are usually able to manage atrial fibrillation and get it under reasonable control. What I didn’t maybe stress during all this is that when I talk about treating atrial fibrillation, I think about three main things. Number one, the lifestyle modification that we just discussed. Number two, preventing the occurrence the afib or minimizing the occurrence of afib with medication or drugs, but I want to stress the importance that preventing stroke is a very important aspect of treating afib, and that’s something we stress with all of our patients because afib carries significant risk of stroke and part of the treatment of afib is the use of blood thinners to minimize the risk of stroke.
Host: Really good information and great advice so thanks for sharing that with us Dr. El-Chami. I appreciate your time today. For more information, please visit Emoryhealthcare.org/afib, that’s Emoryhealthcare.org/afib. You’re listening to Advancing Your Health with Emory Healthcare. I’m , thanks for listening.
Bill Klaproth (Host): So what is atrial fibrillation or afib and how is it treated? Here to answer those questions and more is Dr. Mikhael El-Chami, a Cardiac Electrophysiologist at Emory Healthcare and Associate Professor of Medicine at Emory University School of Medicine
Dr. Mikhael El-Chami (Guest): Yeah thank you for hosting me on this podcast. Atrial fibrillation is an abnormal heart rhythm. It’s the most common arrhythmia encountered in clinical practice and currently there’s around five million people in the US who have afib and we are seeing an increasing number of patients who suffer this abnormal heart rhythm.
Host: So it sounds like it’s fairly common. What puts you at risk of developing afib?
Dr. El-Chami: That’s an important question. There are multiple risk factors for atrial fibrillation. The most important one in my opinion is age. Aging predisposes you to have atrial fibrillation. Obviously that’s a risk factor that you cannot modify, but there are other risk factors that you can actually modify. Number one, obesity or being overweight. That’s an important risk factor. Having common conditions like hypertension and diabetes, if they are not treated in a good manner, they might predispose you to atrial fibrillation. And last but not least having sleep apnea, obstructive sleep apnea is an important risk factor for afib, and as we will talk later, treating or modifying these risk factors might help prevent atrial fibrillation or minimize the occurrence of afib episodes. There are also other risk factors such as having structural heart disease, meaning have valve heart disease or heart attacks or weak heart muscle, all of these are potential risk factors for atrial fibrillation.
Host: Gotcha, so before we get into treatment, let me ask you this, are there different types of afib?
Dr. El-Chami: Right now we divide afib into three different types. What we call paroxysmal atrial fibrillation. It’s an afib that goes and comes. It usually lasts for a short duration time. For the purpose of definition we consider it an afib that lasts less than seven days. We have a persistent atrial fibrillation that’s an afib that lasts continuously longer than seven days. And we have the term long term persistent atrial fibrillation, which is an afib which has been present continuously for more than one year, and this is the afib that usually a little bit difficult to treat. Also some people use the term permanent atrial fibrillation. It’s an afib that’s present all the time, but after the physician and the patient agree to treat afib in a way, what we call, rate control, just staying in in afib all the time since some patients, as we will talk later, might not be very symptomatic when they have atrial fibrillation.
Host: Very interesting. So let’s talk about the first one, short term afib. That’s the afib that you said is characterized by lasting less than one week. How do you treat that?
Dr. El-Chami: So the paroxysmal afib, or the afib with short episodes that comes and goes could be treated in a different manner. For people who have an episode once a year or once every couple years and really short stays – stays for a short duration of time and subsides on it’s own, we might not need any treatment per se to prevent the afib. The only thing we focus on, as we’ll discuss later, is whether these patients need blood thinners to prevent stroke and patients who have frequent episodes of atrial fibrillation, meaning they have an episode maybe once a month or once every couple months or maybe even more once a week, we would need to use a specialized medication called anti-arrhythmic drugs to minimize the occurrence of these episodes. Another way to treat afib in those patient is an ablation procedure where we go inside the heart, it’s an intervention procedure. We go inside the heart and we try to burn or freeze the area where the afib comes from, and we can discuss this later during this podcast, and sometimes when some of these episodes last longer, they don’t go away by their own. For example, let’s say the patient has an episode of afib that lasts for 48 hours and the patient is very symptomatic, we don’t wait for it for seven days, we just bring the patient to the hospital and perform a procedure called cardioversion, which basically consists of using anesthesia to put the patient to sleep and shocking the heart back in normal rhythm.
Host: And how about that middle one you were talking about. What did you call the middle one again?
Dr. El-Chami: The persistent atrial fibrillation. Really the persistent atrial fibrillation by definition is an episode that lasts more than seven days and in my mind it is a continuum with paroxysmal atrial fibrillation. These patients who have persistent afib, the way I think about treating these patients is number one, are they symptomatic? And number two, does their heart function normal or not? For example, if you have no symptoms at all and if you’re afib, if your heart rate is controlled, you’re not going at 150 or 120 beats per minute or 110 beats per minute and you don’t feel anything. There’s really – we could offer the patient the approach of rate control and the use of blood thinners or anticoagulation. We don’t really need to be aggressive in treating afib, in those patients in particular except if we see evidence of weakening of the heart muscle. Sometimes afib is associated with weakening of the heart muscle, but in patients who have no symptoms at all and their heart function is strong, then we might elect not to aggressively treat afib except by using simple medications such as beta blockers and using blood thinners, but for patients who have symptoms, some patients really struggle when they have afib or for patients who have progressive weakening of the heart muscle that we believe is related to afib, then those are the patients that we need to be more aggressive in treating atrial fibrillation. Number one, to improve quality of life, and number two to prevent damage to the heart muscle, and the way we could treat those patients either using anti-arrhythmic drug, a rhythm medication to try to keep them in normal rhythm or go the route of an ablation. Typically in my practice and the practice of a lot of my colleagues, we go the route of the ablation, which is the invasive procedure if the medication does not succeed in doing the trick or the medication causes significant side effects, then we go the route of the ablation.
Host: Okay, and you said people who have permanent afib, treating that can be tricky. Can you tell us about that?
Dr. El-Chami: The patients who have what we call long term persistent atrial fibrillation, typically have an enlarged upper chamber of the heart at the left atrium, and we know from multiple studies that the longer you are in afib, the harder it is to get you out of afib, and in those patients, if again, I go back to the theme of symptoms. If patients are symptomatic or have weakening of the heart muscle, a lot of the time we see in our practice patients who have been left in afib for a long time and the patient has really been complaining of fatigue or tiredness that most likely is related to afib, but for some reason the afib was not treated, they come to us and they’ve been in afib for two years or three years. These are the patients that’s it’s a little bit tricky to get them out of afib. They need a combination of medications and often ablation procedure, and sometimes they might be offered a more invasive kind of ablation called the conversion procedure where we can do both – have a cardiac surgeon do the ablation in the sac surrounding the heart and we do the ablation – the typical ablation. So we do what we call a conversion or a combined ablation. But these are the patients overall that are a little bit more difficult to treat and might need multiple different approaches or combination of approaches to try to succeed in maintaining normal rhythm.
Host: So let me ask you this, is it possible to treat or manage afib through lifestyle, diet, and exercise changes?
Dr. El-Chami: Yeah, that’s a very important question, and recently there has been multiple studies, and I also mentioned in the beginning of this podcast that some medication conditions such as hypertension, diabetes, sleep apnea, or even weight loss are very important risk factors for afib and recently there has been multiple studies, especially studies coming out of Australia, showing that in patients who are obese and lose significant amount of weight, their afib becomes much easier to manage, and actually just the loss of weight itself reduces the burden of atrial fibrillation. So that’s something we encourage our patients. I know that sometimes it’s easier said than done but really weight loss I think at this stage of time should be cornerstone of treating atrial fibrillation, and you will see that when you lose weight, afib is better controlled, hypertension is better controlled, even sleep apnea might be better controlled, so this is an important risk factor or lifestyle modification that could improve the control of atrial fibrillation. Also we tell patients you need to focus on treating your high blood pressure, your diabetes, you need to be compliant with wearing the mask, the CPAP mask that’s used to treat the sleep apnea, and this is one of the cornerstone of treating atrial fibrillation is focusing on modifying the risk factors that could lead to afib.
Host: So it sounds like through treatment options and lifestyle changes, that afib can be managed for a lifetime. Is that correct?
Dr. El-Chami: That’s correct and manage is a key point. I tell my patients with afib is that it might take several steps to control the atrial fibrillation but patients need to be ready to be involved in their treatment. They might be ready to accept that okay we tried this approach but it didn’t work, let’s try the second approach, but eventually we are usually able to manage atrial fibrillation and get it under reasonable control. What I didn’t maybe stress during all this is that when I talk about treating atrial fibrillation, I think about three main things. Number one, the lifestyle modification that we just discussed. Number two, preventing the occurrence the afib or minimizing the occurrence of afib with medication or drugs, but I want to stress the importance that preventing stroke is a very important aspect of treating afib, and that’s something we stress with all of our patients because afib carries significant risk of stroke and part of the treatment of afib is the use of blood thinners to minimize the risk of stroke.
Host: Really good information and great advice so thanks for sharing that with us Dr. El-Chami. I appreciate your time today. For more information, please visit Emoryhealthcare.org/afib, that’s Emoryhealthcare.org/afib. You’re listening to Advancing Your Health with Emory Healthcare. I’m , thanks for listening.