Prakash Chandran (Host): Atrial fibrillation, also known as AFib, is a condition characterized by an irregular and frequently rapid heart rhythm, which could result in the formation of blood clots in the heart. In today's episode, we will discuss common symptoms, causes and risk factors, possible complications and healthy lifestyle choices that can help protect your heart. Here with us to discuss is Dr. Vishal Patel. He's a cardiac electrophysiologist with Health First Medical Group in Melbourne, Florida.

Host: This is Putting Your Health First, a podcast by Health First. I'm your host, Prakash Chandran. So Dr. Patel, thank you so much for joining us today. I really appreciate your time. I said your role up at the top, but I'm curious if you can tell us about what you do as an electrophysiologist and the conditions you specialize in treating. And also, tell us how it's different than what a cardiologist might do.

Dr. Vishal Patel: Hi, Prakash. Thank you very much for this invitation. And as an electrophysiologist, there's a lot of conditions we treat, a lot of cardiac arrhythmias. An arrhythmia is basically a rhythm, which is not supposed to be normal rhythm. Most of these are irregularities in how the heart contracts because of the electrical mismatch or the electrical signals to the heart. Now, as an electrophysiologist, I treat a variety of rhythms, rhythms that are sometimes treated or cured in the top room of the heart, such as SVTs, which are supraventricular tachycardia, or other rhythms such as atrial fibrillation, which is what we're going to talk a lot about today. But in general, you know, other rhythms also occur in the bottom room of the heart, the bottom chamber is called the ventricle, you know, lethal rhythms like ventricular tachycardia.

As an electrophysiologist, my role is more specialized in that we can do procedures, catheter-based procedures, in trying to either limit or reduce these conditions, compared to my fellow cardiologists. We all have a role to play. Our general cardiologists or interventional cardiologists help manage some of these conditions that can lead to atrial fibrillation or we often see that coexist with atrial fibrillation, such as heart failure or coronary artery disease, you know, leading to a lot of weak heart muscle function and then causing atrial fibrillation. So, there's an interplay between all the cardiologists and the subspecialists, and atrial fibrillation happens to be a condition which we treat as electrophysiologists, and I enjoy treating patients with them.

Host: Before we get into atrial fibrillation, I wanted to speak broadly about the heart's electrical system that you spoke of. Can you tell us what it is and why it's important?

Dr. Vishal Patel: Yes. So, the heart's electrical system is a very specialized electrical system. You have to think of the heart as a house with four rooms and four doors to them, which are the valves. The heart has its own innate electrical system. The top room contracts first and the bottom room contracts afterwards. Each of these areas of the heart have a specialized electrical supply to them. And if there's any sort of mismatch, for example, if patients have low heart rates, they need pacemakers. We need to supplement their electrical system with additional wires, such as in pacemakers. But with the heart itself, if your heart goes into an irregular rhythm, it could be a variety of conditions. And that's where atrial fibrillation is one you know that you need to be very careful about because it can lead to, you know, conditions such as blood clots, stroke, heart failure or other heart-related complications. So, the heart's electrical system is a very, very intricate system that we need to be taking care of.

Host: Yeah. That's a great explanation. So, let's get into atrial fibrillation. I know it is considered the most common type of heart arrhythmia, but talk to us about what atrial fibrillation is.

Dr. Vishal Patel: So, atrial fibrillation is basically a quivering or an irregular heartbeat, as you mentioned, one of the most common arrhythmias worldwide and probably projected to continue having more patients be diagnosed with it as time goes on. In this condition, the top two rooms, especially the left atrium, it beats in a very chaotic fashion. The electrical supply to it, you know, is very chaotic. And the heart starts beating, the atrium, the top room, starts beating anywhere from 250 beats per minute to possibly 350 to 400 beats per minute. And if the heart is beating that fast, the ventricle, the bottom room doesn't have enough time to let blood get into the system. And when blood doesn't get out of the heart in a timely fashion, blood starts to clot. And when clots happen, they can shoot up, you know, and can cause strokes or can worsen kidney function. So, the atrial fibrillation as an arrhythmia is something that needs to be addressed and needs to be addressed from the primary care physician level all the way to the subspecialist as an electrophysiologist.

Host: So, how does someone know when they have atrial fibrillation, like what are the typical presenting symptoms and how long do they last?

Dr. Vishal Patel: So, there's a few things that happen a lot of times. And this is the unique thing about atrial fibrillation. In some, it can be very silent. That to me is possibly the worst kind of atrial fibrillation you can have. Because if you have other risk factors such as heart failure, high blood pressure, history of stent or so, and you have a silent atrial fibrillation where you are not feeling the sensation or the palpitations, then some patients can end up having a stroke. About 20% of people have strokes because of atrial fibrillation, and that is the concerning thing. And that leads to either a diagnosis done later rather than, you know, a more proactive diagnosis compared to patients that actually feel their irregularities in their heartbeat. Some patients are very sensitive. They know their heart's beating very fast, very chaotic. Some people will be short of breath because the heart cannot keep up with the top room beating in a very irregular fashion. And in some, they end up in the hospital with heart failure because the heart is actually overworked, so to speak, because the atrium has contracted too many times and the ventricle is really struggling at this point.

Host: So, I am curious, like who is most likely to be diagnosed with AFib? Like is there a certain demographic that is at more risk than others?

Dr. Vishal Patel: So in my practice, I see a lot of patients that come in and some of them have AFib picked up incidentally. A lot of patients are getting more savvy and are wearing wearable ECG watches, such as an Apple watch or a monitor of some sort that picked up an atrial fibrillation rhythm. And patients usually come to see me if they're having more symptoms. So often, that's the one subset of patients we see.

Another group of patients, they just know that they've had their heart racing for such a long time. It happens in some for seconds to minutes. Often, they're ignoring that symptom. And then when it's happening for days sometimes, that's when patients can sometimes get very concerned and then reach out to their internal medicine or family medicine doctor. And that often starts their treatment journey or their journey with atrial fibrillation, which sometimes leads to an electrophysiologist.

Host: Okay. But it doesn't necessarily affect someone more based on their age or their sex or anything like that, or family history, right?

Dr. Vishal Patel: So, family history, not really, unless you are very young, there are some genetic conditions. You know, you could be 15 to 25 years of age and still have atrial fibrillation. A lot of those patients, and there's very few of those, those patients have a genetic condition or a mutation or some reason why the muscle properties of the atrium, the top room in the heart are leading them to have a lot of atrial fibrillation, so that's far and few. Majority of our patients are often older. They're in the 60 years of age and above kind of category, and they're having atrial fibrillation get diagnosed. I often joke with my patients, if you've had many birthdays, then you probably will have atrial fibrillation down the road.

Host: Have we found out what causes atrial fibrillation?

Dr. Vishal Patel: I wish we knew what causes atrial fibrillation at present. We best know how to manage it. And even that, you know, atrial fibrillation being broadly a stage of atrial fibrillation called paroxysmal, where the atrial fibrillation comes and goes, and it often happens for minutes to hours. And then if you get into more advanced stage, you have persistent atrial fibrillation, meaning you've been in atrial fibrillation for more than a week. And then, permanent atrial fibrillation where the patient's not wanting to have any medical therapy done for it. And the electrophysiologist or the cardiologist have also said, at this point, there's probably no use in being very aggressive in managing the atrial fibrillation. So again, if you ask me or any electrophysiologist, the sooner a patient gets diagnosed and is symptomatic, the better for the patient because you can offer them treatment therapies, which have more success at that stage of atrial fibrillation than later on when the atrial fibrillation is a little more advanced.

Host: So, we're talking about treatment therapies now. Maybe you can get into that. Talk to us about what the different available treatment options are.

Dr. Vishal Patel: So, atrial fibrillation can be managed in a variety of ways. Medications can be adjusted. You know, some medications such as metoprolol or Cardizem, some of these medications while they're trying to reduce the speed of atrial fibrillation that somebody might perceive or feel can also make you somewhat tired. So, that's one group of medications that we use. And then, there's antiarrythmics, medications that are probably about 30-40% effective in trying to keep the heart out of atrial fibrillation. But every antiarrhythmic is also a proarrhythmic, so they have to be managed, you know, very well by their cardiologist or electrophysiologist. And then, invasive treatments range, and you know we have a modality called radiofrequency ablation where the electrophysiologist goes into the left atrium of the heart and does some point by point ablation. An ablation is, very simply put, creation of an electrical scar. That prevents that electrical rhythm that was causing atrial fibrillation from escaping from the area that it was in and entering the left atrium and causing atrial fibrillation in the whole heart. So, that's one method, is radiofrequency ablation.

Then, there's another modality called cryoablation, which we use and I use heavily. And then, a third one that is still somewhat investigational is called post-frequency ablation, PFA, and I think you're going to hear a lot more about it within the next six months to one year. This field is really picking up. Atrial fibrillation ablations have been more and more successful, you know, reducing hospital visits, symptoms, the burden of atrial fibrillation, the burden to the hospital or to the patient with recurrent admissions. So, as a field, you know, this treatment for atrial fibrillation, we've come a long way.

Host: Now, you talked about a couple different ablation modalities. How does one decide when to use RF versus cryo versus this new post-frequency ablation?

Dr. Vishal Patel: I like to think of it as a horses for courses approach. The cryoablation is an excellent modality in that it covers the outside of the left atrium, we call it the antral area of the left atrium. The pulmonary veins, the lung veins that are connected to the left atrium, that's where about 80% of atrial fibrillation is coming from in a regular heart. Some of it is then coming from the posterior wall, the back of the heart, or other veins in the body called the SVC or coronary sinus. Other sorts of veins can also have triggers for atrial fibrillation, but these are far and few. About 85% of AFib will come from the veins. And a cryoablation modality, I think, does a very good job in causing electrical silence to these signals. Now, if the patient also has a rhythm which coexist with atrial fibrillation, such as atrial flutter, then I will offer them a radiofrequency ablation at that time. And sometimes I do that procedure in the same case,. But overall, my preference is to have a wider amount of electrical silence achieved best by a cryoablation.

Host: We're talking about the different treatment options. But as people listen to this, even though we don't know what causes it, they may be wondering, is there anything I can do to reduce my risk of actually getting AFib. Can you speak to that?

Dr. Vishal Patel: So AFib, as best as we understand it now, is more of a manifestation of, other conditions, your inflammation level, your stress levels, your ischemia levels overall in your body, all of these things are gonna cause a high signal or high amount of atrial fibrillation in some patients. So, the best way to treat atrial fibrillation goes back to the basics. Eat a healthy diet, exercise regularly, lose weight. There's several studies out of Australia, which show that if patients end up losing some weight and also get treated or evaluated for sleep apnea. Their atrial fibrillation burden goes down. And if you combine that with an atrial fibrillation ablation, which like I told you at present for a patient in paroxysmal atrial fibrillation, is probably about 80-85% successful in reducing atrial fibrillation. Nothing can get rid of atrial fibrillation altogether, but it's pretty good when you talk to patients who have been plagued with these palpitations or sensation of fatigue that they often feel when they're in atrial fibrillation.

So, the best thing you could do is, I would advocate for some exercise, weight loss, adding stress relief through yoga. There's trials actually out of Kansas. And those investigators had patients perform yoga and then some that did not and they would measure the amount of atrial fibrillation these patients were having. Patients that often lived a more healthier lifestyle, less stress, often had less atrial fibrillation.

Host: As people listen to this, if they think that they might have an irregular heart rhythm or notice irregular pattern of rapid heartbeats, what do you recommend that they do?

Dr. Vishal Patel: So, one of the most important things is to not ignore it. It could be atrial fibrillation, which in some patients can be very benign, but also needs to be monitored. But it could be other rhythms, which, you know, your heart is racing fast. It could be a lethal rhythm. So, I would recommend that they get checked by their primary care doctor or their cardiologist or even their electrophysiologist.

A lot of patients, like I said, are savvy, have an Apple watch, have a tracing that they bring to their clinic visit. I advocate for that because I've caught that arrhythmia as well as multiple different arrhythmias based on just the tracings that they provide me. I say that because these rhythms are very episodic. You may not have them all the time. So by the time you get to the doctor's office, your EKGs completely normal, and that leads to a little bit of a frustration in patients because they're like, "Well listen, I really feel like my heart was racing." But at that point in time, it's not. So, sometimes I put a monitor on them, a sticker, a patch that will continue to look at their heart rhythms.

And then, just like atrial fibrillation, we can diagnose atrial flutter, which carries the same risk of stroke that atrial fibrillation does, or other rhythm issues such as SVTs, like atrial tachycardias and atrioventricular nodal reentrant tachycardia, for example. Some of these do not need a blood thinner, whereas atrial fibrillation and atrial flutter, the treatment for it may require the patient to be on a blood thinner to prevent a stroke. So, like I said, the first thing to do is to not ignore it, to let your doctor know and to take it from there.

Host: Well, Dr. Patel, this has been a hugely informative conversation today. I really appreciate your time. Just before we close, is there anything else that you wanted to share with our audience?

Dr. Vishal Patel: I wanted to share that the treatment modalities for AFib have come a long way. A lot of patients may have anecdotal experiences or people say that, "I've had five ablations and none of them worked." I think the treatment has been so different over the past four or five years. For example, we've understood the management of atrial fibrillation more, and even not just the symptomatic aspect of atrial fibrillation, but even the therapies of atrial fibrillation involving bleeding risk. Like I mentioned, patients who have AFib or atrial flutter sometimes need to be put on a blood thinner. And some patients have bleeding issues from them, and they resist treatment for AFib, I wanted to mention that we have other modalities of treating that as well through a left atrial appendage occlusion device, something commonly known as a Watchman that can be placed, or surgical management, you know, with a clip with our surgeon.

And also, that at First Health, we have a collaborative approach. Myself, our cardiologist, our heart failure doctors, as well as the cardiothoracic surgeons, we can sometimes, in select patients, offer them combined ablation procedures we call convergence, where the surgeon does his ablation from the outside of the heart, called the epicardium, and I do the ablation from the inside of the heart, through the vein of the leg into the heart. And, you know, we've had good successes and I would urge patients to look around for treatment options and not ignore atrial fibrillation.

Host: Dr. Patel, I think that is the perfect place to end. Thank you so much for your time today.

Dr. Vishal Patel: Thank you very much.

Host: To learn more about Health First's world class cardiac care team, and the minimally invasive procedures offered, please visit hf.org/heart. If you found this podcast to be helpful, please share it on your social channels, and be sure to check out the entire podcast library for topics of interest to you.

Thank you for listening to the Putting Your Health First podcast. My name is Prakash Chandran. Thanks again. And until next time, stay well.