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Dr. Andrew Wilner (Host): Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm your host, Dr. Andrew Wilner, I invite you to listen in, as we discuss convergent therapy for atrial fibrillation and the spectrum of care. My guest today is Dr. Cynthia Trailer, Professor of Medicine at the George Washington School of Medicine & Health Sciences and she's affiliated with The George Washington University Hospital.

As a neurologist, I'm very interested in today's topic of atrial fibrillation because it's one of the causes of ischemic stroke, a diagnosis that I see all too often. I'm looking forward to learning about treatment approaches for AFib at The George Washington University Hospital, that might help prevent these strokes and other complications from atrial fibrillation. Thanks for joining me. To get started, what is atrial fibrillation and how common is it?

Dr. Cynthia Tracy: Atrial fibrillation is an extremely common cardiac arrhythmia. In fact, It is the most common sustained arrhythmia that we see. It is very rapid irregular rhythm in the atrium where the sinus node is no longer in charge of the electrical impulse, and various foci typically originating from the pulmonary veins become active and fire at extremely high rate with variable amounts of that passing through the AV node and down into the ventricle, gives rise to the characteristic irregularly, irregular rhythm that we see with the atrial fibrillation. And how common it is, well, it's extremely common as I mentioned. Probably by the time people are in their 60s, 70s, 80s, and above, it is seen in a very high percentage of people. The older we get, the more likely you are to see atrial fibrillation. Of course, we look for underlying structural reasons for it, but a fair number of people will have it independent of any other underlying pathology.

Dr. Andrew Wilner (Host): That's great, Dr. Tracy. You answered my second question, which was who gets it? And I guess the next question is, why is it important to control?

Dr. Cynthia Tracy: It's important to control atrial fibrillation because of the associated things that can happen with it. In the process of treating the patient with atrial fibrillation, we're looking for any modifiable things and understanding that the underlying substrate is often related to underlying structural heart disease or kidney disease, hypertension, those types of things. So of course, we treat those things. But by the time the patient has developed the atrial fibrillation, it's probably too late to eliminate those risk factors. So what we're looking at is reducing the risk of the atrial fibrillation.

The main things that we are concerned with in atrial fibrillation are the possibility of stroke or other embolic events. And the other thing that we're always concerned about is a possibility of a tachycardia-mediated cardiomyopathy, where the heart rate is simply too fast and depletes the high energy stores of the heart muscle resulting in a cardiomyopathy.

Dr. Andrew Wilner (Host): You know, one thing I always wondered is do patients know whether they have atrial fibrillation? Can they tell?

Dr. Cynthia Tracy: It's pretty variable. It's not unusual to see people who have no symptoms whatsoever. And in a way they're kind of the unfortunate people, because they may not pick it up, or it may not be determined that they have AFib until they see you for management of their embolic event or their stroke. A fair amount of people will not have any symptoms. They may not be aware of the irregular heartbeat, but they may be aware of the sequelae or the consequences of the AFib. They may feel tired. They may feel breathless. They may have problems concentrating or some of the other things that are associated with the AFib rather than actually being aware of the palpitations.

Dr. Andrew Wilner (Host): So we've talked about what it is and why it's important to control. What do we do about it? Do we use medications? Do we use surgery? Are there any new gadgets?

Dr. Cynthia Tracy: Well, I think I like to think that we have the best gadgets of any fields medicine. Just thinking through what it is that we're trying to do, we're trying to prevent strokes. So we have to go through a quick checklist with the patient to see at what risk they are for having a stroke or other type of embolic events. So we quickly run through the CHADS-VASc score, looking at parameters like have they had heart failure? Did they have hypertension? How old are they? Are they diabetic? Any vascular disease? All of the factors that with each yes to those questions, put them at higher and higher risk.

For a patient who has a risk of stroke, of course, we want them anticoagulated if it's at all possible. So that's our step number one, is trying to prevent the embolic events with anticoagulation and there's a whole separate podcast on what type of anticoagulation you could use. But suffice it to say that in the current therapies, we tend to use the direct oral anticoagulants, like apixaban or rivaroxaban, things like that that are easy for the patient to manage.

Then sort of the next step is trying to decide if the patient is symptomatic, why they are symptomatic. Is it something that's related to rate? Is it something that's related to the rhythm? And what do you do in either of those events? So kind of have to make distinction as you're talking to the patient. "What is making you feel bad? Is it because your heartbeat is irregular or is it because it's too fast or exactly what?" And that'll drive you down the different treatment arms of either rate control or rhythm control. And again, within each of those strategies, there's a ton of different options.

Dr. Andrew Wilner (Host): But it sounds like the ideal solution would be to get rid of the atrial fibrillation altogether. Is there a way to do that?

Dr .Cynthia Tracy: Well, you would think that, but there's a lot of studies that really show that, in many patients, particularly patients who are asymptomatic or very minimally symptomatic, their prognosis with the AFib is really very good. It does not do a lot in terms of their overall prognosis or their longevity. So you have to be careful. For many patients, we are treating them to eliminate symptoms. There's a subset of people, heart failure patients, where you may actually be doing something that would dramatically or hopefully significantly improve their longevity. But it is a decision that you have to make with each patient. And yes, of course, there are tons of things that we can do. If our goal is to achieve rhythm control, then of course there are lots of different treatments that we can use, starting on my side of the equation with medications, sort of the lightweight stuff that might suppress PACs and perhaps eliminate the arrhythmia. But if not, then we consider antiarrhythmics or ablation. And where you cross over to the ablation treatment is very much individually derived and very much derived by what the underlying substrate is.

Dr. Andrew Wilner (Host): Now, back when I was a medical student, which I confess was quite a while back, I remember that all the patients with atrial fibrillation, it seemed to me, where I was on the totem pole, went for a cardioversion. Now, is that still part of what we do?

Dr. Cynthia Tracy: It certainly is. It's part of what we do. Determining whether a patient gets the cardioversion, again depends on where you're picking them up. If somebody walks into your office and they have no recollection of any symptoms whatsoever, and you dig through their chart and you realize, "Oh, gee, you've been in this rhythm for four years," well then of course there's no point in doing a cardioversion because, at that point, the left atrium has had so many even cellular level changes that the cardioversion is very unlikely to be successful. The more typical patient that we'll cardiovert is somebody who's presenting with newly recognized, presumably a fairly short duration atrial fibrillation.

Dr. Andrew Wilner (Host): Oh, okay. Well, thanks for that clarification. Dr. Tracy what would you like to add so that physicians listening know what to do with their patients with AFib?

Dr. Cynthia Tracy: I would just add that this really is a topic or an area where shared decision-making is very critical. I think it's important that the patient understand realistic goals of the treatment and understanding what those goals are. It's always our first goal to prevent stroke and to make the patient feel better. This is a situation where we're not always able to make the patient live longer. Not that that's necessarily a bad thing because the prognosis for many people with AFib is excellent. So we really have to tease out with the patient, what are we treating? Why are we treating it? And what route are we going to go down? And also set up realistic expectations that this is step one. We have step 2, 3, 4, 5, and so on and so forth, so it's a journey that you have to take with the patient. Everybody has to be involved. This being a multidisciplinary approach.

Dr. Andrew Wilner (Host): Dr. Tracy thanks very much for this informative discussion. It's great to know that there are proven techniques for atrial fibrillation control, which can decrease the risk for stroke and help patients live healthier lives. Thanks for joining me on GW Doc Pod.

That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. To refer your patient, please call 1-888-4GW-DOCS. That's 1-888 the number four GW Docs. And if you have questions for one of our specialists, please email physician relations at  physicianrelations@gwu-hospital.com. Thanks for listening.