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Scott Webb: Atrial fibrillation or AFib is an irregular heart rhythm that can lead to stroke if it goes untreated. And joining me today to discuss the causes, symptoms and treatment options for AFib, including the Watchman procedure is Dr. Shivang Shah. He's a cardiologist at Franciscan Health specializing in electrophysiology.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, thanks so much for your time today. We're talking about atrial fibrillation also known as AFib. So let's start up front here. What is AFib?

Dr. Shivang Shah: Atrial fibrillation is an abnormal rhythm in the heart. It's one of our more common abnormal rhythm we see. There's four rooms in the heart, two on the top and two on the bottom. This is a top chamber abnormal heart rhythm. Now, this is an abnormal rhythm that can go fast, inappropriate, meaning you could be going at a fast heart rate of 120 when you're sitting still and you don't need that.

Scott Webb: And so doctor, what are the symptoms of AFib?

Dr. Shivang Shah: Symptoms of AFib can kind of vary from patient to patient, meaning from no symptoms at all too common symptom is palpitations or a racing heart feeling to even getting worsening shortness of breath or shortness of breath with activities that you could easily do earlier or even chest discomfort.

Scott Webb: And I'm assuming that untreated AFib can be dangerous, right?

Dr. Shivang Shah: Yeah. So with atrial fibrillation, the most important danger part about it is that it is associated with a stroke risk. How do we estimate that stroke risk? Well, when you come and see us based on your current risk factors, we have a way to calculate what your stroke risk is. We use a score system called CHA2DS2-VASc score system. And basically, if you have a score of two and above, we recommend strong blood thinners, like the ones you probably heard on TV, the common ones, Eliquis, Pradaxa, Xarelto or Coumadin. All of these will kind of lower it by 70%, more or less.

Now if you have a very low stroke risk, you may get by with just an aspirin. That can lower it about 22%. So that's the most important thing, is that this is associated with stroke risk and a blood thinner can lower that stroke risk. So that's the first thing we want to make sure we always address with this rhythm.

The second aspect is going to be with the symptoms and those are going to be more of a quality of life thing. And we have lots of ways of kind of managing that as well. But again, the most important thing with this specifically on how it will affect the longevity of the patient is the stroke risk. So that's why we really want to always address that right away.

Scott Webb: Yeah, definitely. And so let's talk about some of the treatments. What are the treatment options? You mentioned a little bit there, but let's go through the treatment options and if there's any new treatments or new advances in treating AFib.

Dr. Shivang Shah: First off, with the stroke risks, we talked about the blood thinners going route. Now, we do have a procedure called the Watchman procedure. Now, that's an option for patients that can't tolerate being on a blood thinner. Again, with blood thinners, it thins the blood to decrease the chance of forming blood clots and that's how it lowers the stroke risk. But it also causes a bleeding risk, not directly but indirectly.

So what do I mean by that? If you get a cut on your arm or a cut in your stomach line, like an ulcer, you can bleed longer on it. And if you're having big bleeding issues with it, that's where we can talk about the Watchman option as a way of trying to keep your stroke risk as low as possible without being on a strong blood thinner. That's something when you come in, we can always talk more detailed about that. But that's all regarding the stroke risk with atrial fibrillation.

The second aspect is where we talk about the symptoms. You know, like we talked about from palpitations, shortness of breath, those we have ways to manage and treat those. Now, with atrial fibrillation, in the beginning, you kind of go in and out of it by yourself. At some point, these episodes last longer and longer to some point you're always in it. It always progresses that way. It's just a matter of time and it's unpredictable. It could be a couple months. It could be a couple of years.

But there's ways we can manage as far as using two strategies. One is try to keep you into a normal rhythm as long as possible or the other option is let you stay in this rhythm, but try to prevent your heart rate from getting fast. Generally speaking, the main reason to go one versus the other is from a symptom improvement. But nowadays, you know, especially younger patients, especially if they're going in and out of the rhythm, we like to favor trying to keep them in the rhythm as long as possible. And we have ways of doing that by stronger medicines, what we call anti-rhythm medicine as well as we have options, a procedure called an ablation procedure.

With medication options, you know, with these stronger medicines, there are some side effects that are accompanied with it. So depending on the patients, there's a few we can offer and some are attractive and some are less attractive given the patient's age, meaning if there's a lot of side effects, it's not the most attractive medication beyond it long-term when you're on the younger side. But depending on your age, if you're older, it might be okay. And that's where the ablation procedures come into play.

Now, it's advanced a lot in the last, 20 years it’s a procedure that is there strictly just to help decrease symptoms of atrial fibrillation by trying to keep you in normal rhythm as long as possible.

Now, this is a procedure we do with general anesthesia. So your patients are completely asleep with it. While they're asleep, we do a camera procedure where we go through the feeding tube to look at the backside of the heart to make sure there's no blood clots, because that's where blood clots can form with this. As long as there's no blood clots, we take that probe out of the feeding tube and we can go ahead with the ablation procedure at the same time.

The goal of this atrial fibrillation ablation procedure is to electrically isolate the lung vein. And the reason we do that is the data shows that if we do that, that's how we increase our success rates of keeping them in normal rhythm longer. Now, there's a couple ways of doing it. We do it with freezing technology or with heating technology to create those lesions around the lung veins. So the goal is that blood flow is just fine between the lung brain to the heart, but no electricity.

And then once we do those lesions, we check to make sure that electricity is blocked from both directions, from the lung veins to the heart and the heart to the lung vein. There are risks behind this procedure. And the risks are going to be bleeding, infection, damage to the blood vessels or damage to the heart.

Despite doing all of the stuff we do, the chance of any of this to happen generally is in the order about 1% to 2%. It's overall low, but then that's not 0%. In addition, anytime we deal with atrial fibrillation, there's always a risk of stroke, heart attack, and sudden death. Those are well below 1%. Now, this is a procedure that myself and a lot of my colleagues, we do it on blood thinners, so we don't hold the blood thinner for this procedure to help kind of decrease the stroke risk.

After the procedure, they're going to have bedrest for the groin site to heal. It's usually in the range about four to six hours. Usually, we ask our patients to plan on staying the night. But there are a lot of patients that we do let go home that same day after the bed rest is done if it's a convenient time for the patient, not too late in the evening.

To do this procedure, there is some restrictions afterwards and the main restriction is all about the groin site to heal. It's going to be about no heavy lifting or a strenuous physical activity or any sexual activity for about one to two weeks after the procedure. Walking flat the next day is fine. And then after those one to two weeks, there's no restriction.

Now, the success rates can vary, but generally they're about double the stronger medicine success rate of maintaining normal rhythm. Now, at the end of the day, there is no cure for this rhythm. So we're not talking success rates in the 90%. Generally speaking, it's about 70% for someone that's going in and out of the rhythm by themselves for about one to two years out. If they're in the rhythm all the time and they've been in it less than six months or so, success rate is about 60%. And if they've been in the rhythm all the time for over a year, the success rates go down to about 50%. So the longer you're in the rhythm, the harder it is to get you back into a normal rhythm. But that being said, if people are symptomatic, we still take on those because there's still a chance to help improve the patient's symptoms.

Scott Webb: You know, I've known a few people that have had AFib, and they've said that that's really the hardest part for them, that even though they've reduced their risk of stroke is that when the abnormal rhythms come, it's difficult for them kind of not to panic a little bit.

Dr. Shivang Shah: Absolutely. Yeah, it is. First of all, the most important thing is always, you know, educating the patient because anything new is always scary, especially when it's unknown and you don't know what's going on. And the symptoms can vary. Oftentimes, the faster the heart rate goes, that's when they tend to be more symptomatic, but even then symptoms can kind of vary.

But once we kind of educate them, you know, there is a chance they can have recurrence going forward. Small things that they can do, they definitely help. It's really working on all those risk factors, meaning that we strongly recommend everyone to get a sleep study because our data shows 80% of people that have atrial fibrillation have sleep apnea. And sleep apnea is the concept of people stop breathing at night without them realizing it, so they're not getting good quality sleep. That puts stress on the body and that can increase the atrial fibrillation burden and to cause it. It also causes high blood pressure. It also causes to be tired during the daytime. So that's something that I refer all my patients to get a sleep study done because that's one of the, you know, 0% risk modifiable risk factor we have control over. So we really want to do that, to give the success rates the best possible chance we have for the patient.

After that, there's also hypertension or high blood pressure. So we really want to be strict control on that because uncontrolled high blood pressure causes that AFib to come back sooner. The other big risk factor is obesity and cardiovascular exercise. Getting people's BMI below 30, if possible, and also performing regular cardiovascular exercise and then alcohol and caffeine in moderation. All that goes a very long way to help manage it. So we strongly recommend all those lifestyle modifications whether we do these advanced therapies or not.

Scott Webb: Doctor, as we wrap up, anything else you want people to know about AFib?

Dr. Shivang Shah: If you have concerns about it, just come and talk to us, you know, set up appointment with us. A lot of this stuff, we address at the appointment, because again, a lot of it's education. But then after that, there's a lot of range of therapies. And even if you're late in the stage, it doesn't matter. I mean, if you're feeling bad enough, we still offer everything because at the end of the day, our job is to make patients feel better. Even if the success rate is on the lower side are not, if there's a chance to make them feel better, we're willing to go that route.

So most importantly, if you have atrial fibrillation, come and see us so we can talk about it and try to, you know, develop a strategic plan that's best suited for that particular patient, because everyone's a little bit different. So sometimes we have to tailor the plan slightly different.

Scott Webb: Well, it's been really great having you on. Your expertise is amazing. So much information today. Doctor, thank you so much for your time today and you stay well.

Dr. Shivang Shah: All right. You too. And thanks so much.

Scott Webb: For more information on AFib, go to FranciscanHealth.org/restoretherhythm. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.