Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're highlighting newly diagnosed atrial fibrillation, when to treat, when to refer, and when to send to the emergency department.

Joining me is Dr. Joshua Silverstein. He's an electrophysiologist with AHN. Dr. Silverstein, thank you so much for joining us today. So, start by telling us about the Atrial Fibrillation Center of Excellence. Why was it created? Tell us a little bit about it.

Josh Silverstein, MD: Yeah. So, the Atrial Fibrillation Center of Excellence is an initiative that we've started just last January actually, and it comes after Heart Rhythm Society had published a couple of publications in the past two years defining what an Atrial Fibrillation Center of Excellence is and what the criteria are for its establishment, with the goal of being to treat the entire patient with atrial fibrillation, not just leading up to ablation, but making sure that everything associated with that patient is addressed, including from the time of diagnosis until remote follow-up.

Melanie Cole, MS: Dr. Silverstein, very often the first line is the primary care physician. They are the ones who see that patient first. So, what does the Center of Excellence mean for them as they are referring to it?

Josh Silverstein, MD: You're exactly right that the primary care physicians are so key to finding the patients with atrial fibrillation, and they are often the ones treating the patients first. And too often the inclination is to send the patient with newly diagnosed atrial fibrillation straight to the ER. And the reality is a lot of these patients can be managed effectively without going to the ER. And our goal is to standardize the care that patients with atrial fibrillation receive and avoid unnecessary trips to the ER expense to our healthcare system as well as to the patient. So, one thing that we've put a lot of emphasis on is developing a pathway for primary care physicians to standardize the care that they give a patient that they've newly found to be in AFib.

Melanie Cole, MS: Well then, tell us a little bit about that pathway. What happens after the referral is placed?

Josh Silverstein, MD: Yeah. So with the pathway, it first goes over what are the signs that you need to send a patient to the ER? Because that's obviously one of the first major decisions. So, you know, things like heart failure, shortness of breath, heart rates that are extremely high, like over 150. And so, we have that spelled out nicely in the pathway. And so, if those things exist, the decision's easy. You send the patient to the ER.

However, most of the patients don't meet those criteria, and then we address things like rate control, what medications need to be considered first to get the rate under 110 beats per minute at rest. And then, we address anticoagulation, which we actually think that the easiest thing is to put all patients on anticoagulants unless there's a strong reason not to, and we have that defined out in the pathway as well.

And then lastly, it's really important that we get a good handoff to the AF center, and we've enabled a rapid access referral pathway where patients can get referred urgently to the electrophysiology service. And then, they will get a phone call the next business day by one of our triage nurses, and then scheduled to see one of us depending on the triage nurse's assessment. Obviously, if the patient's not doing well, we'll get them in as soon as possible perhaps even the same day. And for those that can wait longer, the triage nurses will decide that.

Melanie Cole, MS: When we're thinking about the referring physician, what do they do while they're waiting for that evaluation? Are they involved with the patient still? How is the communication? Tell us about that back and forth.

Josh Silverstein, MD: The goal is not to necessarily pass the buck to the AFib center, but to share in the care of the patients. We believe that everyone being involved will provide better care than just the electrophysiology service managing the care for these patients. And so, there'll be optimal communication back and forth and addressing secondary risk factors such as obesity as well as sleep apnea.

We know that we can ablate patients all we want. But if those things aren't controlled, like high blood pressure, obesity, sleep apnea, then the patients will unfortunately go back into atrial fibrillation and won't do well in the long run.

Melanie Cole, MS: Dr. Silverstein, while we know that many patients don't end up in the emergency room with atrial fibrillation, and indeed some don't even know that they have it for quite a while, how does the emergency department fit into the center of excellence?

Josh Silverstein, MD: Yeah. So, the ER is also an integral part of the Center of Excellence. And fortunately, we've had two members of the emergency medicine staff who've been part of our committee as part of the AFib Center of Excellence, and they've also helped streamline a standardized protocol for the ER in determining which patients are appropriate for outpatient care and which ones need to be admitted to the hospital. So even if a patient does meet criteria to go to the ER, oftentimes patients will end up in the ER not sent by primary care that they're on their own with rapid heartbeat and thinking they're in a medical emergency.

And so, similar to the primary care pathway, the ER pathway identifies patients who are at risk of complications that will require admission to the hospital. It also helps the ER physicians identify which patients might benefit from an early cardioversion and to be cardioverted actually in the ER and set up with rapid access pathway to the AFib center.

Melanie Cole, MS: Dr. Silverstein, you've mentioned obesity and sleep apnea. And when you were speaking about ablation and saying, you know, we can ablate all we want, but if these factors are still in place, it won't necessarily help the patient quite as much. Speak a little bit about why that is.

Josh Silverstein, MD: And fortunately, atrial fibrillation has many factors that contribute to it. Two of the top ones being obesity and sleep apnea. And if we put a patient through a procedure to try to fix their atrial fibrillation, but don't address the underlying cause, then likely to come back again, unfortunately.

So, that's why as part of this effort, we've also collaborated with our colleagues in sleep medicine and come up with referral pathways for patients with atrial fibrillation. It turns out that the sleep medicine colleagues want to see every patient with atrial fibrillation get a sleep study. And it turns out that most of those patients can start with a home sleep study, and there are some that require in-person sleep studies, which again are defined by our standardized pathways.

For the obesity, it's similar in that those with BMI over 35, it turns out our obesity clinic also wants to see all patients with atrial fibrillation and a BMI over 35. And even with a BMI over 30, if they have a couple of risk factors, would also be appropriate referrals to the obesity clinic. And nowadays, there's a lot more that can be offered. It's not just about bariatric surgery, but there are a lot of medical options for weight loss.

Melanie Cole, MS: So as we're addressing for the patients any of those external comorbidities that could go along with atrial fibrillation, tell us about some of the very exciting treatments that are available now. You have so many more tools in your armamentarium, and you mentioned cardioversion. What else is going on that's exciting?

Josh Silverstein, MD: When it comes to ablating atrial fibrillation, things are rapidly evolving. In the last two years, there's been a new technology called pulsed field ablation, which has been developed. And this type of ablation, instead of using conventional heating or freezing, uses this high-frequency energy that creates scar tissue without the burning or freezing.

And you may say, "Well, who cares?" Well, it turns out that a lot of the complications that we historically have been afraid of with atrial fibrillation ablation are caused by collateral damage to the structures around the heart, such as phrenic nerve injury or atrial esophageal fistula, which is a terrible complication that can happen from radiofrequency ablation, which is burning, or cryoablation, which is freezing of the atrium.

And the atrial esophageal fistula happens when the and esophagus heal together and cause a fistula. That can be a life-threatening complication from AFib ablation. And now with pulsed field ablation, we don't have to worry about that. It's actually not been reported to be a complication with pulsed field ablation.

The phrenic nerve injury is also much less common with this new pulsed field ablation. So, not only that, but the procedure itself has become more predictable and more efficient in that we are able to do more of the procedures in a given day, which means better access to care for patients.

Melanie Cole, MS: And finally, what do you want referring clinicians to remember about the program? What are some of the most important key takeaways or messages that you would like referring providers to remember?

Josh Silverstein, MD: I think one of the main takeaways is the goal of the AFib Center of Excellence is to get the right patient the right care at the right time in the right place. And that means assessing where a patient needs to be treated when they're diagnosed with atrial fibrillation, and ideally getting them into the hands of a specialist sooner rather than later, and then working as a team to help all the patient's comorbidities to make sure that their risk factors for why they developed atrial fibrillation in the first place are addressed.

Melanie Cole, MS: So important. Thank you so much, Dr. Silverstein, for joining us today. And to learn more or to refer your patient, please call 844-MD-REFER or visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.