Transcription:
All About AFib

Bill Klaproth (host): So what is atrial fibrillation or AFib? How do you know if you have it? What are the symptoms? How common is it and how is it treated? So let's find out what Dr. Vivek Iyer, co-medical director of electrophysiology at Marin health. This is the healing podcast brought to you by Marin Health. I'm Bill Klaproth. Dr. Iyer, thank you so much for your time. We appreciate it. Before we get into eight-figure. Can you give us a little bit of background on yourself?

Dr. Vivek Iyer: Yeah. Thanks Bill. It's great to be with you here today talking about AFib. I'm Vivek Iyer I'm a cardiologist and a heart rhythm specialist, so we deal with all kinds of electrical problems with the heart. I've been an electrophysiologist for approximately eight, nine years now. and started out my training in medical school, in Harvard Medical School. Graduated in 2006. did the rest of my training actually in New York City, in Columbia University. Stayed on in New York for a few years as faculty there in the heart rhythm division of Columbia University. And then, my wife got a job out here in the Bay Area, so I followed her. And, now I'm with a private practice here in the North Bay, cardiovascular associates, of Marin, where I'm the co-director of electrophysiology. And happy as a clam, treating patients with heart rhythm disorders.

Bill Klaproth (host): Yeah. Well, welcome and we're glad you're here. So, Dr. Iyer, our podcast today is on AFib. To start off, can you tell us what AFib is or the real name atrial fibrillation? Can you tell us what that is?

Dr. Vivek Iyer: Sure. Well, I'll start by saying that it is a heart rhythm disorder and it's actually the most common heart rhythm disorder that we encounter in clinical practice. Affects millions of Americans. So it's quite a common, condition to run into. And, it is a disorder where the electrical activity of the heart is abnormal. So the heart is a pump. It pumps blood to all of the organs in our body. Somewhat miraculously actually. When we're born, we're born with a pacemaker that sets the rhythm of the heart electrically.

So there's like a little spark plug. that's the pacemaker that we're born with, and it sets the ticker at 60 beats a minute, and that pacemaker responds to our activity so that if we're running or, you know, watch a scary movie or something, our heart rate does race a little bit, which we've all seen. The problem with AFib is that sometimes people have clusters of cells that fire too much and fire abnormally and those clusters of cells can trigger the heart to actually go way faster than it should be. So if a normal heart rate at rest is 60 beats a minute, then the top chamber of the heart or the atrium.

Goes at 60 beats a minute, and the bottom chamber of the heart, or the ventricle goes at 60 beats a minute. But in atrial fibrillation, extra beats can cause the top chamber of the heart to go into chaotic activation. So believe it or not, the top chamber can go at 350, 400 beats a minute. So really outta control. And the bottom chamber of the heart, it follows suit, but not in a one to one fashion. So what happens is that the bottom chamber of the heart, which controls your pulse, that you could feel on your wrist or in your neck.

That might go faster than it should. Like 130, 150 beats a minute sometimes, but the real problem is that uncoordinated activity, electrical activity of the top chamber of the heart, which can cause a lot of symptoms and, a lot of morbidity in patients, which we can get into.

Bill Klaproth (host): So that upper chamber of the heart is really beating fast. So that's where that fluttering comes in. What are the traditional symptoms of AFib?

Dr. Vivek Iyer: That's exactly right. So fluttering is probably the most common thing that patients report to me when they're diagnosed with AFib. Sometimes that goes by the word palpitations. If you're talking to a doctor, they may use that word. Feel like, you know, something's popping outta your chest, or awareness of the heartbeat, that's the most common. Other people will have just a sort of a more, we have a lot of active people here in the Bay Area that are out biking and hiking and climbing, and they find that they're just level of energy and their ability to get after it is really compromised when they're in atrial fibrillation.

That may manifest as lower energy or shortness. More rarely, some people will have some chest pain or, you know, just a sensation that something's off that's difficult to put the finger on. But, just a feeling of being off.

Bill Klaproth (host): So one of the concerns with AFib is the possibility of a blood clot. Can you explain more about that and how untreated AFib relates to stroke?

Dr. Vivek Iyer: Yeah, sure. And this is the big worry because we talked about the symptoms, but only a fraction of people with AFib will even have symptoms. So sometimes people can have AFib and maybe not even know about it. And human nature being what it is. Sometimes we don't know something is abnormal until we're told it's abnormal. So that's the other thing where we don't really know what's abnormal or what a symptom is. And what makes it so troubling is that risk of clot because left untreated, Atrial fibrillation does predispose towards strokes. And the way that is felt to happen is, we talked about that top chamber going at 350, 400 beats a minute.

At those really fast activation rates that chamber is, we're really asking a lot of that chamber. It's not really pushing blood very well. And so the blood can really stagnate and kind of layer, and when the blood isn't moving very much, then it tends to form. those clots, sitting in the heart are a dangerous thing. They can move to different parts of the circulation, and most commonly, where it tends to travel is to the brain, where the brain can really be deprived of blood flow, and that is the cause of strokes in atrial fibrillation.

Bill Klaproth (host): Are there people that have certain risk factors or are there risk factors pertaining to AFib?

Dr. Vivek Iyer: Yeah. And there are two ways that this manifests. So there's certainly risk factors for developing AFib, and some of these are genetic. You're just kind of born with it. And sometimes I'll see a patient who's diagnosed with AFib and they're 40, 45 years old. And there we really think that there is a genetic or a familial basis to the reason they have AFib. The other sorts of risk factors are similar to risk factors of other forms of heart disease. so the older we get is, that is the most common risk factor is, advancing age. And indeed the prevalence or the chances that you have AFib really skyrocket, in your sixties, seventies, and particularly in your eighties, where there's something like a one in 10 chance that you might be diagnosed with AFib at your 80th birthday.

So, quite common in that age range, things like high blood pressure or other types of heart disease, certainly can stretch out the chambers and, predispose towards atrial fibrillation. Also not living the healthiest lifestyle. So, being at a less than ideal body weight or being inactive. Those kind of things have been linked to atrial fibrillation as well. So those are some of the risk factors towards developing atrial fibrillation. The second half of it is, certainly the risk factor for developing clots and stroke with atrial fibrillation. certainly, not everybody is at the same risk of forming clots and stroke with atrial fibrillation.

So it stands to reason, right? If you have a 35 year old who has AFib, they're not gonna be at the same risk a stroke as perhaps a 90 year old who's had a stroke before and diabetes and so forth. So, one of the great things, is in the cardiology field, we've been able to do a lot of research to figure out who's at risk and who we really need to treat more aggressively. And by studying thousands of patients, we've been able to distill the risk factors for stroke formation, atrial fibrillation, which we can get into.

Bill Klaproth (host): Okay, so let's continue with that thought, Dr. Iyer. So then what are the risk factors for stroke?

Dr. Vivek Iyer: The research has studied thousands of patients with atrial fibrillation to figure. between the patients who ended up having a stroke and patients who didn't have a stroke, what are the factors that determine the predictability of having a stroke? And so we have a scoring system called the Chad's VASC Scoring System, and it's really just an acronym, with each letter standing for one of the risk factors. C stands for congestive heart failure, which is a form of heart disease where the heart is not pumping blood effectively. And people tend to have shortness of breath and retain fluid. that has been linked to atrial fibrillation. Each is for hypertension, which is, the infamous high blood pressure.

So, if we're not at goal or you're taking medications to control your high blood pressure, that ends up being a risk factor. A stands for age and you can actually get up to two points for age, one point for being above the age of 65 and one point for being above the age of 75. So those are two risk factors boiled into one. D is for diabetes, s is for a previous stroke, and that one is another one that counts twice. So if you've had a previous stroke, it's twice, as big a deal as say, having hiper tension. V is for vascular disease. Those are things like blockages in the leg arteries or having had a previous, heart attack or myocardial infarction.

And SC stands for sex category. And this is kind of a newer, thing that's been unasked by the research. Pound for pound, being biologically female gender, seems to impart a higher risk of stroke than being biologically male gender. So we factor that in, particularly when there's another risk factor at play like hypertension, the scoring system ends up being that if you have zero of those risk factors, you end up being at relatively low risk of stroke. If you are at two risk factors or above, you end up being at high risk of stroke where we're typically pretty aggressive about protecting you against having a stroke or having another stroke. And one is intermediate. And then we sort of have a discussion about the options and see whether an aspirin or if the treatment forms might make sense for you.

Bill Klaproth (host): So this is where we don't want points. We want less points in this system. Right. We want less points is better. So you were just mentioning treatment at the end there. Let's talk about treatment options. I know one of them is called cardioversion or resetting the rhythm. Can you talk about what type of treatment options there are when treating AFib?

Dr. Vivek Iyer: So there are two forms of AFib, actually early on in AFib, typically people will have an episode and then it'll stop on its own, and we call that parasysmal. It occurs in parasysms or fits. They're very concrete and they, they kind of limit themselves. People can have multiple parasysms that start and stop on their own, and that's typically an earlier form of the AFib. Over time, unfortunately, AFib tends to progress. people tend to have more episodes and longer episodes. And this eventually culminates into a form of AFib that we call persistent AFib. And that's when you have an episode of AFib and it just doesn't stop on its own.

And seven days have passed and you're still in atrial fibrillation for seven days continuously. The treatment that you mentioned, cardioversion is often kind of a temporary fix and it basically, you come into the hospital and get some sedative and just like the paramedics resuscitating someone with electric shock, it is that same kind of treatment, but it is a much more measured and controlled kind of circumstance where an anesthesiologist gives you medication, you go off to sleep and totally unaware. Then we apply electricity via paddles or patches on the skin, and it jolts the heart and gives some electricity and it resets, the rhythm back to normal. Now it almost always works in restoring the rhythm back to normal.

The question is just, does the AFib end up coming back? And we've had patients where it comes back the next day or even that later, that same day. But we've also had patients where the rhythms sticks, for several months or even longer. So the cardioversion has that role of a temporary reset. The other two tools in our toolbox, apply equally for the paroxysmal or the start and stop version, as well as the persistent version. And those are medications that you could take basically on a daily basis, and they tend to calm the electrical activity of the heart, so that it tilts the balance back in favor of normal rhythm.

And then the last option is the technology assisted option, and that is using procedures. Typically minimally invasive procedures, to go in the heart, identify the cells that are not working right, and typically cauterize them or freeze them or use some kind of energy source. so those, cells are quiet and they don't cause a mischief in your heart.

Bill Klaproth (host): So you mentioned medications. What are the specific medications that someone would go on to help control AFib?

Dr. Vivek Iyer: There are two basic categories of this. So one type of medication is purely to control the heart rate in AFib. So if you're one of these individuals who has a lot of start and stop AFib or are in persistent AFib sometimes will give a heart rate slowing medication, and the goal there is not really to fix the AFib, it's just to minimize its impact on you in terms of the symptoms, because typically someone who's at a heart rate of 130 at rest. Feels a lot more lousy than someone who's on medications and have a heart rate of 90 or a hundred.

It's not perfect, but it's better. So we call those medications, rate control medications. just a descriptive term, but basically just trying to control the heart rate in AFib. The Second type of medications medications, and those are called antiarrhythmic medications. And again, kind of a descriptive term, we prescribe those medications. Usually patients take it twice a day, and these medications are about five or six different kinds of them. But they all work in different ways to calm down the electrical activity of the atrial cells themselves.

So basically they calm them down, make them fire less, and unfortunately these aren't. A hundred percent cure for AFib, if they were 40% of the time or 50% of the time. Those are the kind of numbers we've come to expect. But if a patient is in that 40 or 50% category, then that can be a really good option. Sometimes partial successes good to at least get symptoms under check while folks are coming to terms or figuring out what their options are. So that would be antirrhythmic medications. And then the procedure I mentioned is called an ablation procedure. That would be the third option that we typically discuss.

Bill Klaproth (host): Right. Okay. So let me ask you this, if someone does have the resetting the rhythm or the cardioversion as it's known as, is it typical then for that person to go on medication afterwards?

Dr. Vivek Iyer: Yeah. Commonly. So we do the shock or the cardioversion, and then we either talk about you. Crossing our fingers and hoping it doesn't come back. And sometimes if it's the first episode and we don't know what pattern it's gonna take, that might make sense for somebody. But more commonly, we are at least having that conversation about medication so that we maximize the chances that, that shock or cardioversion, sticks and takes hold.

Bill Klaproth (host): And another procedure I want to ask you about and get more information on is the catheter ablation. Could you go more in depth on that as well?

Dr. Vivek Iyer: Sure. Yeah. I mean, we've talked about some, scary consequences of AFib and I just wanted to say that there's probably never been a better time to have AFib because we have such great treatments now. Particularly technology assisted treatments and, the catheter ablation, is now a very mature technology and a mature procedure that we can reach for earlier and earlier in the disease state, because it's that much more effective and that much more safe and, minimally invasive. what we do in the catheter ablation is, in a minimally invasive procedure we use kind of needle pokes typically in the leg.

And we thread up what we call a catheter. It's a tiny, instrument that is, probably in dimension the size of your coffee stir. Just to give you an idea or the, the ballpoint pen filler. And we follow the bloodstream from the leg all the way into the heart. And basically the technology allows us to reconstruct a three dimensional cartoon or map of what atrium looks like, those top chambers that are fibrillating or basically chaotically activating. And we can identify the problem areas where the AFib is being triggered from. Now in early stage AFib, anatomically the site where those cluster of cells live, typically is in a structure called the pulmonary veins.

Which are these veins that drain the blood from the lungs into the heart. There's something about the embryology or where we were kind of formed as human beings, where the transition from a blood vessel into heart muscle leaves behind these little sleeves of muscle cells that, end up being bad actors in this process. And so what we do in this, ablation procedure is we build a map of where those pulmonary veins are what the atrium quote unquote looks like. We're really looking at where there's scar or abnormal areas of activation electrically. And then we can use that same instrument to deliver energy to basically cauterize, burn a blade, all kind of synonyms, or sometimes freeze that tissue.

We're currently participating in new research about ways to do ablation as well. So I think you'll find in the next year or two that the types of energy sources we use are gonna be different as well. Currently at our center we're, participating in a clinical trial using pulsed field ablation, that instead of using burning energy or freezing energy, we're using high voltage electricity to treat the cells. And there's a lot of promise about how that might durably treat that tissue and do it in a safer way. So we do this ablation. Can take anywhere from maybe an hour, hour and a half to three hours, depending on how much, work we need to do and how many areas we need to treat.

And most of the time patients can go home the same day or maybe they spend the night, in the hospital for monitoring, and then we tell them to sort of lay low for a week before doing any heavy duty exercise. Mainly outta caution. But it ends up being a pretty safe and very effective way for treating, atrial fibrilation. We get success rates in early stage AFib exceeding 85, 90% for selected patients, so we can reach for it pretty early in the disease process, although it doesn't necessarily a hundred percent fix the stroke risk that a patient might have. It ends up being really good for controlling the symptoms that come with AFib.

Bill Klaproth (host): Right, So that's a good point. there still is potentially a stroke risk even with this, so I know you have a way to try to address that with the percutaneous left atrial appendage occlusion, how does that work? How does that help reduce stroke risk?

Dr. Vivek Iyer: The mainstay historically of treating stroke risk has been to give medications. And, the tried and true one from decades old is the infamous rat poison, right? We call it coumadin or warfarin. And it was developed really as a rat poison. Lay around the coumadin in the area where your grain is stored. The rats eat it, and they, tend to bleed to death. And so that has been sort of, the power has been harnessed and it could be used therapeutically to minorly thin the blood. But that, medication was the tried and true. And because the window of therapeutic value is so narrow and we don't want to turn human beings into rats and bleed too much.

There have been newer medications, called novel oral anticoagulants that are, maybe a little bit more favorable in terms of the bleeding profile. But unfortunately bleeding is always gonna be a risk with blood thinners. Whether you're using the rat poison or the newest me. And so sometimes patients just don't tolerate those medications because they've had bleeding or they have side effects on the medications, or they lead an active lifestyle. We have a lot patients in the North Bay that are mountain biking and, they fall down a lot or what have you.

And so there are reasons to seek alternatives to the blood thinners, and that's where that treatment that you mentioned, has a role. The percutaneous left atrial appendage oclusion. This, again, is a procedure. So it's a minimally invasive procedure. We're not, cutting through skin or going through the, breast plate. Again, it's through a needle poke in the leg and we follow the bloodstream and we can deliver, a device that looks a little bit like an umbrella. It's like a miniature umbrella that collapses on itself. And we put this device in a spot in the left atrium, one of the chambers.

Where it's kind of like a blind alley, and that's where most of the clots form and the stagnant blood flow occurs. And so that umbrella kind of sits in that area as a scaffold. And then your body does the rest of the work. Your body, over a period of six weeks to months can kind of grow a skin over top of that scaffold and effectively exclude or occlude the left atrial appendage that, that structure in your heart. So basically it's a procedure that replaces the blood thinner and it does a really good job at that. And it goes by two other terms sometimes we call it the Watchman procedure, because that's one of the brand names of the devices.

Sometimes we call it the amulet procedure because that's another brand name of the device. but the percutaneous left atrial appendage occlusion is referring to those kind of devices that sit in the heart and protect you.

Bill Klaproth (host): So you mentioned earlier, this is a good time to have a fit because all of the treatment options available and then looking forward, are there new technologies that are coming for atrial fibrillation as well?

Dr. Vivek Iyer: Absolutely. So we in our center, mentioned are participating in clinical trials for the next generation of ablation technology, and it's really exciting. I think I mentioned there are millions of folks in the US alone, who suffer from atrial fibrillation. So, thankfully, the technological advances are coming along quite well to service this population and get them the latest treatments. This pulse failed ablation is something that we're very excited about and I'd be kind of surprised if over the next, two to three years isn't having a major role in our ablation, sort of options, moving forward. Our initial experiences in the clinical trial have been very favorable, and think gonna be here to stay.

So on the ablation side, lots of new developments including new energy sources and catheters and mapping systems that help us do our job. We just talked about with the left atrial appendage occlusion. That is also an area where folks are really tired of taking blood thinners a and having issues with them, and so getting new devices that fit better in the left atrial appendage and, cause fewer problems and are easier to put in, are being developed month by month it feels, or year by year. And so there are gonna be new devices that help us do that job, safer, quicker, and more effectively as well.

Bill Klaproth (host): Right. So for patients in the North Bay who are concerned they might have an arrhythmia or who may have been diagnosed with AFib, what steps should they take to make sure they're getting the right diagnosis and treatment?

Dr. Vivek Iyer: Yeah. I think it starts because of the implications of AFib and stroke and CLO formation. No surprise that I would say, get to your doctor. I mean, I don't think you need to go to the emergency department necessarily, but certainly arrange a, an appointment with your doctor and I wouldn't be surprised if the next step would be a referral, to someone like me, a cardiac electrophysiologist. Or a cardiologist to go through this in a little bit more detail. We always, when we see patients in the office, like to really individualize to a patient and see what's going on with you.

What are your symptoms are, like what is your risk, what are the risks and benefits of the different treatments? And have a nice discussion about it. And then we tailor something and then, life changes, right? So, we periodically check. With patients and say, Okay, what's working? What isn't? Is AFib changing? Is it getting worse? And then we kind of fine tune from there. But a visit to a cardiology office, is definitely advised and, we got a good group of folks up here in North Bay that are happy to help.

Bill Klaproth (host): All right. Very good. Well, thank you so much for your time today, Dr. Iyer. This has really been informative. We appreciate it. Thanks again.

Dr. Vivek Iyer: Oh, you're more than welcome. Happy to be here.

Bill Klaproth (host): And once again, that's Dr. Vivek Iyer. And to learn more, please visit my mymorinhealth.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is The Healing Podcast brought to you by Morin health. I'm Bill Klaproth. Thanks for listening.