Scott Webb (Host): This is the St. Joseph's Health MedCast from St. Joseph's Health. I'm Scott Webb. And today, we're discussing how atrial fibrillation, AFib, is being treated using ablation, the Watchman device and more with Dr. Ali Al-Mudamgha. He's a clinical cardiac electrophysiologist at St. Joseph's Health.

Doctor, it's nice to have you here today. We're going to talk about protecting the heart and the brain through ablation, the Watchman device, a whole bunch of good and worthy things for listeners. So, let's start there. How common is AFib? What is it exactly? And why does it seem like more people are being diagnosed?

Dr. Ali Al-Mudamgha: I appreciate the intro, Scott. And atrial fibrillation is the most common heart rhythm disorder we see in adults. To give you a perspective, in 2021, it was estimated that over 52 million people worldwide had atrial fibrillation. If you then try to extrapolate that to the US population, that translates anywhere from about 13 to 15 million people will have atrial fibrillation at any given time.

Atrial fibrillation is really an abnormal heart rhythm of aging. So as we get a little bit older, there are these changes that occur in the heart, these electrical changes, and even some mechanical changes where heart muscle in the upper chamber is sort of replaced with some little scarring, and that can trigger atrial fibrillation.

Host: Okay. Yeah. So as you say, it is very common, especially in America. And I think I've heard this right before, Doctor, but you're here and you're an expert, like, what are some of the common symptoms of AFib? And the part that I've heard that is anecdotal at best, but it seems like a lot of folks don't have symptoms per se, and wondering why that is for something that's so common. That sounds alarming to me that we don't know we have it.

Dr. Ali Al-Mudamgha: Yeah. So, that's actually true. Symptoms vary from patients to patients. Many patients will feel palpitations. The definition of palpitations is the awareness of the heart beating. So, many patients will come and say, "You know, I feel my heart beating irregularly or erratically," or, "I feel it pounding."

But also, just as common or very common is what we call decreased exercise tolerance. Patients will say, "No, Doc, I don't feel the AFib. But, you know, by the way, when I try to do my housework, I feel tired and I feel short of breath." So, day-to-day activities get harder and harder. It's estimated that maybe up to a third of patients have no symptoms at all. And it's always hard to know why somebody has symptoms and somebody doesn't. But a frequent scenario is a patient might be getting ready for a procedure like a colonoscopy, and then they show up on the day of the colonoscopy and they say, "Hey, did you know you had atrial fibrillation?" And the patient looks at the doctor, you know, kind of stunned, and that's how the diagnosis can be made in many patients.

Host: Yeah. Yeah. And I'm sure, Doctor, a lot of us just kind of chalk that up. They just say, "Well, you know, I'm getting older, and therefore I get tired faster." Is that, do you think, what happens to some folks?

Dr. Ali Al-Mudamgha: That is absolutely what happens. Many of my patients will say, "Well, you know, Doc, I'm 68, right? So, I should be tired." And the answer that I always tell them is, "No, that's not the case." And it might be very subtle. You know, the patient will say, "No, I'm doing everything that I normally do." And you'll ask them, "Do you," for example, "mow your lawn?" "Yeah, I mow my lawn." "Last year, when you mowed your lawn, how long did it take you?" "Oh, it took me a half hour." "Well, how about now?" "Well, now it's 40 minutes because now I have to stop and take a little bit of a rest."

Host: Catch my breath, right. Yeah.

Dr. Ali Al-Mudamgha: "But I'm a year older." Right? So, you're right. So, a lot of patients will kind of just attribute these subtle symptoms to their age.

Host: To age. yeah. Doctor, is there a connection between AFib and increased risk of stroke?

Dr. Ali Al-Mudamgha: Absolutely, there's a correlation. The risk of stroke is based on what we call a CHADS2 vascular score. It is a scoring system, and you get one to two points depending on certain risk factors, whether you have congestive heart failure, your age, whether you have high blood pressure, diabetes, whether you've had a previous stroke or a TIA, whether you have a stent in your body.

And then, there's a point, an additional point given for if you're a woman versus a male. And that risk of stroke, if you have a score of 0, your increased risk of stroke from atrial fibrillation is zero, right? It doesn't mean you can never have a stroke. And then, if you go all the way up to a score of 8, that number can increase substantially.

Now, it gets a little tricky. When you get to a score of 6, your risk is 9.8% per year for having a stroke. When you go to 7, it goes to 9.6%. And when you go to 8, it goes to 6.7%. And the reason for that discrepancy is when you look at studies, there are fewer patients that have a score of 7 or 8. So, it's not clearly defined. So, usually, we use the upper range for a score of six as kind of the maximum risk of stroke. But clearly, there is a risk.

Host: Sure. And, Doctor, I think I know what ablation is. I've spoken with other experts. So, I have a sense anyway of what ablation is. But I want to have you tell listeners, explain that, you know, like the process, what ablation is, and how does it work exactly.

Dr. Ali Al-Mudamgha: So, ablation just really means to destroy electrical tissue with some type of catheter in our world, okay?

Host: Yeah.

Dr. Ali Al-Mudamgha: And traditionally, the catheter that we use, this little wire or tube or however you want to describe it, would deliver radio energy waves, and we would, "burn the tissue."

Host: Right.

Dr. Ali Al-Mudamgha: We still do that for certain heart rhythm abnormalities. But for atrial fibrillation, that was the traditional way. We then, many of us, switched from burning to what we call cryo, which is to freeze the abnormal tissue. And the reason for that is that the data on cryo said it was as good, if not better than burning, but also potentially safer. So many of us then switched.

We now have a new technology called pulsed field ablation or PFA, and PFA works very differently. It's an electrical pulse that's really dialed in to the abnormal heart cells. So, what PFA does for us is it really does a couple things. It takes the ablation that was very safe, and it makes it safer. It also allows us to give the patient a more extensive ablation. So, we are seeing routinely as good, if not better results with PFA than we did with what we call radiofrequency burning or cryo, which is freezing.

Host: Yeah. And that's, of course, music to all of our ears. It was already safe. And now, it's even safer. So, that's awesome. Let's talk, Doctor, why or when you put patients on blood thinners and maybe what are some of the common concerns and the risks of long-term blood thinner use?

Dr. Ali Al-Mudamgha: Yeah. So, the need for the blood thinner is really based on that CHADS2 vascular So a male, if they have a score of 2, that obligates or necessitates a blood thinner. For a female, they need to have a score of three to get them to be on the blood thinner. Now, let's say for the sake of argument, the patient has a score of zero or one. Zero means they don't need a blood thinner. One means the patient has the option of a blood thinner or an aspirin. Those patients will sometimes be placed on a blood thinner prior to a procedure to fix the atrial fibrillation. So, a cardioversion is where you shock the heart back to normal rhythm. If the patient was in atrial fibrillation for more than 48 hours and they have a score of 0 or 1, they would be placed on a blood thinner for a few weeks before the cardioversion. And if they're going to have an ablation, we usually start them a few weeks before. Because after the ablation, we want to continue the blood thinner for a couple months, a few months afterwards also. But in general, it's based on their score, their stroke score.

Host: Yeah. Yeah. And you've explained the score to us and how that sort of in terms of diagnosis and treatment is, is really important. And I've heard about the Watchman device, Doctor. What is that? What is the Watchman device, and how does it reduce stroke risk in people with AFib?

Dr. Ali Al-Mudamgha: So in the left upper chamber of your heart, there is this extra piece of tissue called the left atrial appendage. And what I tell my patients is think of the appendage like an appendix. It serves no purpose other than to give you trouble. This extra piece of tissue is where blood can pool and ultimately blood clots can form in patients with atrial fibrillation. These blood clots can then break off from the heart and go to the brain and cause a stroke. And so, the blood thinner is designed to prevent the blood from clotting.

What the Watchman does is it seals the appendage off fully. It looks almost like a little parachute device that we place into the appendage, and it seals the appendage off. And by doing that, it's equivalent to a blood thinner in terms of protecting the patient from a blood clot, stroke. But now, you can remove the patient safely off of the blood thinner and eliminate, one, the cost of the blood thinner for some patients. Two, many of our patients are on a number of different medications. And so, when you talk about compliance, the patient taking the medicine, the more medicine they take, the lower the compliance. And then lastly, you know, when you remove the blood thinner, you potentially remove the bleeding complications that can be seen with these drugs.

Host: Right. Yeah, I want to give you a chance to celebrate a little bit here. Talk about the significance of reaching this milestone of performing your thousandth Watchman procedure. That's a lot. That's a lot of Watchmen. That's a lot of lives, theoretically, you've saved, right?

Dr. Ali Al-Mudamgha: Well, so, that was for our institution. You know, we did a thousand. I think I've done more than half of those total, so more than 500 devices.

Host: That's pretty great.

Dr. Ali Al-Mudamgha: Yeah. We did a thousand. And there are certain things that we do in medicine that are really life-changing for the patient. And a Watchman really is because when a patient—when you tell them, "Listen, you don't have to take another medicine," they're really happy to be honest with you. So, you know, it's a positive result

Host: Yeah. Well, as you say, when it comes to compliance, and I'm guilty of this myself, the more pills I have to take, the less likely I am to take all of them or take them when I should or whatever it is. So yeah, being on one less medication, that's a win, right?

Dr. Ali Al-Mudamgha: Yes, you're only human, right?

Host: Absolutely. So, Doctor, who should talk to their doctor? I'm talking to you, but you're not my doctor. But if we have a doctor or that we have a specialist, you know, that we can go to our primary and then get to a specialist, like, who, when should we talk to a doctor about AFib evaluation or treatment? Is it because we have a family history, a genetic connection to it, our lifestyle? Like, when should we reach out?

Dr. Ali Al-Mudamgha: So, you know, there are certain things that can kind of contribute to atrial fibrillation from the lifestyle. So if a patient's overweight or has high blood pressure or diabetes, you know, you want to talk to your primary care provider and try to decrease the impact of those illnesses as much as you can with weight loss, exercise, taking your medicine, whatnot.

If you have atrial fibrillation or it gets diagnosed, then certainly you want to see your primary care provider right away. Currently, you know, in the modern era, almost every primary care provider is going to then refer the patient either to a general cardiologist or directly to an electrophysiologist like myself. And that depends on, you know, the town and the number of providers and whatnot.

If a patient, though, feels palpitations, okay, they feel an irregularity or, in their mind, they have unexplained shortness of breath or fatigue, they need to see their primary care provider because they may be having atrial fibrillation intermittently, and it's just not getting picked up. And then, you know, the primary care provider will almost certainly get a heart monitor for them and hopefully make the diagnosis.

Host: Yeah. If you're just sitting around watching Netflix, right, and you feel your heart beating or you're, you know, a little bit out of breath and you're not really doing anything, like, that one's hard to explain away, right?

Dr. Ali Al-Mudamgha: Correct. Yeah. You should take your symptoms seriously and reach out to your physician. And if the workup shows you have AFib, then, you know, they'll get you the right individual. If you don't have AFib, then that's great. You don't have AFib, you know. But obviously, you shouldn't just ignore symptoms.

Host: Yeah. Better safe than sorry. And along those lines, I want to give you a chance here at the end. It's been great having you on, great to benefit from your expertise. But I want to have you encourage patients, me, others, encourage us all to advocate for ourselves and to ask questions.

Dr. Ali Al-Mudamgha: You're your best advocate. And if you're not your best advocate, your family's probably going to a better advocate for you. But, you know, if you have symptoms that you can't really explain, you shouldn't ignore them. You should seek out medical care and attention.

And if you are diagnosed with atrial fibrillation, just understand that there are a lot of treatment options available to patients today that we didn't have, you know, years ago. And so, it's not a death sentence, right? It's not an end-of-the-road kind of thing. But it is something that needs to be taken seriously and treated appropriately.

Host: Yeah. And just reading between the lines, it sounds like folks can live with AFib. They live well with AFib. The treatment options are safe and now even safer. But we have to, you know, be diagnosed, we have to seek out the treatment, and we have to take our pills or whatever it might be, right?

Dr. Ali Al-Mudamgha: Yeah. And you're absolutely right. There are millions of people walking around right now with atrial fibrillation that is being managed either medically or post-procedure and are living their lives. And I always tell patients that the purpose here for treatment, in addition, we want to protect you from a stroke, we want to protect you from what we call congestive heart failure. But what we want you to do is we want to treat you so you can live your life. We don't want to treat you to interfere with your life, right? And so, that's the important thing.

Host: Yeah, and that's what's so great about the watchman is it's there, it has a job to do. It's one less pill to take. So, all good stuff. Appreciate your time, your expertise. Thank you so much.

Dr. Ali Al-Mudamgha: I appreciate it.

Host: And for more information about the Cardiovascular Institute at St. Joseph's Health, go to sjhsyr.org/cvi. And for more information, please visit sjhsyr.org. That's sjhsyr.org. And if you found this podcast helpful, please share it on your social media. I'm Scott Webb. Thanks again for listening to the St. Joseph's Health MedCast from St. Joseph's Health.