Maggie McKay (Host): Welcome to Meaningful Medicine, a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm your host, Maggie McKay.

Today, I'm sitting down with Dr. Lai Chow Kok, and we're going to be talking about a new type of treatment for atrial fibrillation. Before we get started, I would love to know how Electrophysiology became a passion of yours and what made you want to become a cardiologist?

Lai Chow Kok, MD: Well, let me answer the second question first. I guess when I was going through medical school, I've always found Cardiology interesting and fascinating. It fits my personality, my temperament, because it's one of those few subjects in Medicine where there are clear, measurable parameters, and there are good explanations to how the disease comes about. And because you understand what causes the problem, therefore, you can tailor treatment to solve the problem. So, I guess I am a pseudo-engineer by default.

And, as I entered the field of Cardiology and I found out that it's really fascinating to try and understand the electrical system of the heart, it seems like it requires more of a lifelong learning just to understand the intricacy of heart rhythms and heart rhythm abnormalities, as well as it allows me to use my hands because I like to work with my hands. So, I think it's like a merger of just different interests of mine that somehow led me into this field of Electrophysiology.

Host: Well, lucky for your patients, that's what you chose. What is atrial fibrillation and what are the symptoms?

Lai Chow Kok, MD: Atrial fibrillation, it's probably the most common rhythm problem. The word atrial indicates it's a problem related to the upper chamber of the heart. And fibrillation just is a word that means that your heart is beating very fast and very chaotically. So, atrial fibrillation, in short is when your atrium, which are the upper chambers of your heart, It's just beating very fast and very irregular. It can cause significant symptoms. Surprisingly, there's a small percentage of patients who may have atrial fibrillation and they hardly have any symptoms at all. They will not be aware of it unless the doctors happen to do a 12-lead ECG on them.

Host: Can it be prevented?

Lai Chow Kok, MD: That's a very good question. In some cases, oftentimes atrial fibrillation does not have a known cause, a known direct cause. Rarely, there could be conditions like hyperthyroidism that may cause atrial fibrillation or certain particular kind of heart valvular disease, in particular mitral stenosis, that may cause atrial fibrillation. But unfortunately, most of my patients that have atrial fibrillation does not have a known cause and therefore is very hard to prevent. And atrial fibrillation also, it's more common as we get older and that's something that's not preventable. So in a sense, there's no real prevention apart from just healthy living, healthy lifestyle. And minimizig risk of having heart disease, that would be one good way to prevent atrial fibrillation.

Host: What type of heart doctor should you see if you have a heart arrhythmia? I know sometimes you hear about the plumbers and the electricians.

Lai Chow Kok, MD: Well, that's a very good question. Yeah, sometimes it's just easier. I actually introduced myself as an electrician because electrophysiologist is such a mouthful. Most people just get lost with that big word. And the plumbers are some of my colleagues that actually deal with blood flows to the heart. And so, I'm like the electrician of the heart.

And so in the past, when electrophysiology was a fairly small discipline, so to speak, it will be difficult for just the small number of electrophysiologists see a lot of patients with atrial fibrillation. And over the decades, as we understand atrial fibrillation better as electrophysiologists, we feel like we can provide better care for people who have AFib. So, I think it would be best if patients who have AFib, they start of by seeing so-called the electricians of the heart. But AFib being so common, I think most cardiologists are able to handle the simple, straightforward AFib before referring them to us to handle the more complex ones.

Host: Doctor, when it comes to AFib, what's the most common question you receive from patients?

Lai Chow Kok, MD: It varies from, "Is this something life-threatening? Can I get off my medication? Is there a chance for me to get off my blood thinners?" to "I feel fine and I don't feel like I need to do anything about it." It all depends on where the patient is coming from, what stages of life they are in, and all the other variables. So, I guess there's no one common question.

Host: And are there many different types of treatment for AFib? Can you explain a little bit about your approach?

Lai Chow Kok, MD: Well, before I go into the approach of treatment, I'll just give a quick overview about the types of atrial fibrillation. So, when atrial fibrillation starts, it usually self-corrects on its own. And so, we call those paroxysmal AFib, which means patients can have AFib that lasts for minutes to hours, sometimes to a day or two, and it corrects on its own.

And over time, it becomes more frequent to the point where the patient will stay in what we call persistent AFib, where we need to do something to get the patient out of AFib. And following that, if we let persistent AFib alone, it will eventually become permanent AFib, which means no matter what we do with our current state of medical technology, patients will stay in AFib permanently. So, the best time to treat people with atrial fibrillation will be in the initial stages of atrial fibrillation, either in the paroxysmal stage or in the early persistent stage.

So, there are broadly two ways to treat them. One is to use medication and the other one is the approach of what we call ablation where we actually literally use tools available to us to create scar tissues inside the atrium to prevent AFib from happening. So, those are the large two groups of approach to people with atrial fibrillation. And sometimes you need a combination of both types of treatment to maintain normal rhythm.

Host: You mentioned ablations. They've been around for a while, but what's new or different about pulsed-field ablations?

Lai Chow Kok, MD: Well, I think pulsed-field ablation is a very exciting technology, and you're right that ablation has been around for I think close to 40 years now. I mean, for the longest time, while we talk about ablation, it's a big word, it just means creating scar tissue. We use temperature to create scar tissue. Initially, we use energy called radio waves or radiofrequency to create heat that will then so-called burn the heart muscle, creating a scar tissue. About a couple of decades ago, we started using the reverse, use cold energy to freeze the heart muscle to create scar tissue. Pulsed-field ablation is different in that it does not use temperature, or it's not a thermal effect. What it does is it actually delivers very high-voltage electrical activity that causes the tiny pores in the cells to remain open. As a result of that, those cells become damaged. And In a very simple way, it becomes damaged and forms scar over time.

Host: Are you seeing good results with that?

Lai Chow Kok, MD: Well, I've started using pulsed-field ablation since April.. And as far as I can tell, in the short term, it seems promising to treat people with AFib. I think the more important thing is that between pulsed-field ablation and the other form of energy, radiofrequency or the cold energy we call cryoablation, pulsed-field ablation seems to have much better safety profile. In terms of the longevity of the scar tissue formation, time will tell. So at least from the safety profile, it's a lot better. And also, in terms of the duration of the procedure, it seems to be shorter compared to the other two forms of energy.

Host: And what's your goal when treating someone with AFib?

Lai Chow Kok, MD: A lot of times patients with AFib come to me because their quality of life has been impacted by AFib and a very common complaint is that they feel tired, they feel fatigued. And my goal is to return them as much as possible to the life that they used to have before they developed AFib. So, like I said earlier on, it depends on the overall health status. And so, it will be a combination of medicine, ablation, or one or two of them, or all of them together.

Host: In closing, is there anything else you'd like to add that you think people should know?

Lai Chow Kok, MD: I've been treating patients with atrial fibrillation for as long as I've been in practice here in Winston Salem, which is over 20 years. And from my personal experience, I think, for patients who wonder whether they should see cardiologists for AFib, I think the sooner you have AFib treated, the better would be the outcome. And that would be my message to anyone who's listening to this podcast.

Host: Thank you so much for sharing your expertise and your time on this important topic. We appreciate it.

Lai Chow Kok, MD: Well, thank you for inviting me to share my experience and I hope we'll be able to come back and share further insights.

Host: Great. We love it. Again, that's Dr. Lai Chow Kok. To find out more, please visit nh.team.hvi. And to find a physician, you can visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Meaningful Medicine, a podcast from Novant Health.