Joey Wahler (Host): It's the most common type of serious irregular heartbeat. So, we're discussing atrial fibrillation, also called AFib. Our guest is Dr. David Pratt. He's a cardiac electrophysiologist. This is Wellness in Reach, a Mount Carmel podcast. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome

David Pratt, MD: Hi, thank you for the opportunity.

Host: Same here. We appreciate the time. So first, in a nutshell, for those unfamiliar, I would imagine most everyone has heard the term, but what exactly is AFib? What's going on there when it happens, and why is it such an important cardiovascular issue these days?

David Pratt, MD: Yeah, atrial fibrillation is an irregular heart rhythm. It affects the top parts of your heart. So, you'll remember your heart has four chambers to it, two upper, two lower, and AFib is an irregular rhythm that affects the upper parts of the heart. It's important. Millions of Americans are living with this worldwide. There's tons of people who have this very important arrhythmia. It's commonly associated with other cardiovascular conditions. And by itself, it's one of the big reasons that people suffer from strokes and a lot of symptoms from this arrhythmia.

Host: And of course, stroke being the leading cause of death in the United States and beyond, right?

David Pratt, MD: Absolutely. It's one of the very common reasons people come to the hospital with stroke. We eventually find they've had atrial fibrillation

Host: No question about that. Well, speaking of common, we mentioned that AFib is indeed very common. Anything you can tell us that illustrates from your experience or the numbers out there just how common is it these days?

David Pratt, MD: Yeah, it's by and large the most common thing that I see in clinic. I'd say about 75% of my practice is comprised of taking care of patients living with atrial fibrillation. We have six electrophysiologists here at Mount Carmel. All of us have very similar practices in terms of the amount of AFib that we treat and take care of.

Host: How do you diagnose it? And even prior to that, are there any symptoms that would bring someone to you for this, or is it just going to come up on a routine exam?

David Pratt, MD: No, that's a great question. And the symptoms may surprise some people. So, many people will have short episodes of atrial fibrillation very early in their diagnosis, and it can be challenging to identify that or capture that on an EKG. Apple Watches and similar technologies have been very helpful in the detection of atrial fibrillation, but the ideal way of diagnosing this is through a 12-lead EKG, one of those stickers that physicians will place on the chest to detect this. And the symptoms vary. So, about 50% of people will have palpitations or heart fluttering that they can feel, but some people have very abnormal symptoms like shortness of breath that comes out of the blue, you know, unexpected shortness of breath or fatigue. Some people feel like when they go exert themselves, it's just not like it used to be. And about a quarter of people don't have symptoms at all, which makes it very challenging to detect in its early phase.

Host: I can imagine. So, how have improvements in mapping and imaging technologies worked to help physicians to treat AFib?

David Pratt, MD: Absolutely, yeah. So, the technology for treating AFib has dramatically changed in the past decade. Historically, we were left with medications, many of which have lots of side effects, are not particularly effective at preventing atrial fibrillation. But ablation has really become the mainstay of treatment for atrial fibrillation.

And the way we ablate tissue has evolved even in the past 20 years since that it first was introduced, which I think we're going to talk a little bit more about, in subsequent questions. But the field has dramatically changed our ability to localize signals within the heart that are abnormal, have dramatically improved as well through the use of catheters with high density mapping.

Host: Well, you set up the next question perfectly, Doctor, because pulsed field ablation, also known as PFA for short, is indeed one of the newest advances in AFib care. So, what is PFA and what's its role in treatment?

David Pratt, MD: Yeah. Historically, ablation was done through thermal injury, so we would heat or freeze tissue to deliver ablation. However, the challenges with thermal energy was always injury to collateral structures. You would heat something up, things in the chest can also heat up alongside it. Pulsed field ablation is a newer technology that has tissue specificity, meaning that the tissue I'm ablating is the only tissue that's being affected. This is dramatic improvements in the risks associated with ablation. It also has been shown to be a much faster and safer procedure for our patients.

And so, typically now, an ablation can be performed in a very simple case within an hour and a half to two hours through the use of pulsed field ablation. The way it's delivering energy is dramatically different. It's not heating or freezing anymore. We're delivering a very short, high frequency field of energy, electrical energy to the tissue, and that ultimately over the course of days to weeks leads to permanent irreversible damage that's therapeutic in nature.

Host: Using electrical energy in that way to help the heart become healthier. It's pretty amazing, isn't it?

David Pratt, MD: It's incredible. It's really incredible technology.

Host: Yeah. I'm always interested to see if the specialists like yourself are as awed by it as those of us that did not go to medical school. But the answer is yes, right?

David Pratt, MD: Absolutely. It's an amazing field. It's changing constantly. It's a real thrill to be able to offer this technology to our patients.

Host: Yeah, that's awesome. So besides those we've already covered, any other innovations, new advances in AFib treatment that you're most excited about?

David Pratt, MD: Absolutely. Yeah. So, when we treat atrial fibrillation, one of the ways I like to talk about it with my patients is really separating out the risk of stroke from the ability to control people's symptoms. And symptom control can be achieved through ablation. But the world of stroke prevention has also been evolving over time. And now, we're seeing more and more technologies emerging that are allowing us to treat or prevent strokes from atrial fibrillation without needing long-term blood thinners.

Historically, we were stuck to using our typical blood thinners like Eliquis, Xarelto, warfarin. But now, we have better technologies out there that allow us to prevent strokes without needing to be on those medications long term. Those are things like Watchman or other technologies that can be placed either from within the blood vessels or at the time of another surgery. And these are great opportunities for us to protect people from stroke, from atrial fibrillation that does not require long-term use of blood thinners.

Host: So, that's got to be great news, at least in part because of the fact that blood thinners need to be managed very closely, don't they? Or things can really go awry, yes?

David Pratt, MD: Absolutely. Yeah, we know that blood thinners do come with risk of major bleeding complications. Especially as AFib has become a very common diagnosis, particularly in our aging population, it makes falls, injuries much more risky when we're dealing with blood thinners in their system.

Host: Switch gears just a little bit, and when we talk about prevention here, how about new evidence that may exist out there regarding lifestyle changes? People know what those are, weight loss, sleep apnea treatment, alcohol reduction, increased exercise and activity, et cetera, to actually reverse or reduce AFib episodes. What's the latest in that area?

David Pratt, MD: Yeah. We're learning a lot about how weight loss and specifically some of the new weight loss medications play a role in atrial fibrillation. We're still learning about that. The preliminary data looks very promising that weight loss in general is extremely important for patients, in managing their atrial fibrillation.

But there's a whole set of lifestyle and comorbidity management that is very important to give the patients the power to be in charge of preventing subsequent episodes of AFib. Not curative, but we know when we assess burden, lifestyle has a huge role iin reducing people's burden of arrhythmia.

So, you're correct, weight loss for people who are overweight, we define that by a body mass index above 25. If they can lose ten to fifteen percent of their body weight, there's dramatic improvements in the overall burden of arrhythmia. For people who consume alcohol or tobacco products, we know that discontinuing each of those things individually have dramatic effects on the overall burden of atrial fibrillation. We know that in terms of comorbidities, managing diabetes with their primary care provider or their high blood pressure with their primary care provider or cardiologist, as well in getting treatment for sleep apnea, all of these things individually and as a composite dramatically affect people's burden of atrial fibrillation.

Host: All right. Couple more questions for you, Doctor. First, how about the biggest misconception patients and perhaps their families too have about AFib? For instance, "My heart feels fine, so there must not be anything serious going on." And how do current pieces of evidence help to address those myths so people are aware of what the truth really is, right?

David Pratt, MD: Yeah. Yeah. I think one of the things that I have to discuss frequently with my patients is that just because I don't have symptoms doesn't mean that I don't have risk. Symptoms don't equate to risk in atrial fibrillation. Many patients are asymptomatic, and they can still have a stroke from atrial fibrillation. I also have to talk about when people have treatment for atrial fibrillation. Because we know treatment is not necessarily curative, it's a way to help reduce overall burden. It doesn't mitigate your risk of having stroke, and we have to really treat those things differently. Prevention of symptoms, prevention of stroke happens simultaneously in the treatment plan of atrial fibrillation.

Host: And in summary here, Doctor, if you look ahead, say five to 10 years from now, what area of AFib research seems most likely to transform how we prevent strokes and manage this condition day-to-day?

David Pratt, MD: Yeah. I think we're going to learn a lot about if options for stroke prevention are actually better than blood thinners. We don't have that data. We know that they are equivalent in terms of their ability to protect people. We don't yet know are things like Watchmen actually better than blood thinners in the long haul. That's going to be a really important piece of information as research comes out about the role Watchman will play in the patients who do fine on their blood thinners, but prefer to not actually be on that anymore. I'm hopeful in the near future we'll have some data to guide us in that conversation.

In terms of ablation strategies, we're learning a lot about how to optimize pulsed field ablation, both in terms of depth of lesions and durability and all these things that me and my partners get to really think about. We also are learning about how to deal with the patients who have AFib even after an initially successful ablation. There's a lot of very interesting AI-based technology that's coming out that we are really excited to learn more about and how we can incorporate it into our practice.

Host: When you think about it, you mentioned terms like AI, Watchman, ablation. Not too long ago, those terms didn't even exist, right?

David Pratt, MD: That's right. That's right. It goes to show that the field advances very rapidly.

Host: Absolutely. Well, folks, we trust you are now more familiar with atrial fibrillation. Doctor, certainly an exciting and interesting field to say the least, with much more on the horizon as you've discussed. Keep up all your great work, and thanks so much again.

David Pratt, MD: Thank you very much.

Host: Absolutely. And for more information about Afib or to schedule an appointment, please do visit mountcarmelhealth.com/campaign/afib.

Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks so much again for being part of Wellness in Reach, a Mount Carmel podcast.