Selected Podcast
Atrial Fibrillation (AFib)
Dr. John Respass discusses what Atrial Fibrillation, or AFib, is, what causes AFib, and how it can be treated.
Featured Speaker:
John Respass, MD, FACC
Dr. John Respass, MD is a Cardiology Specialist based in Poughkeepsie, NY and has over 22 years of experience in the medical field. Dr. Respass has more experience with Cardiac Electrical System Procedures, Cardiac Implantable Device Procedures, and Adult Congenital Heart Conditions than other specialists in his area. He graduated from New York University School Of Medicine medical school in 1999. Transcription:
Atrial Fibrillation (AFib)
Alyne: Heart palpitations, shortness of breath, weakness, these are some of the signs that you need to see a cardiologist.
Our topic today is atrial fibrillation. Here to tell us more about this all too common issue and what can be done about it is cardiologist, Dr. John Respass, an attending physician at Montefiore St. Luke's Cornwall. I'm Alyne Ellis. Welcome to our Health Track podcast
Dr John Respass: Thank you very much. I'm happy to be here.
Alyne: So let's begin with what is atrial fibrillation? And it's commonly called, as we all know it probably, AFib.
Dr John Respass: Yeah, right. So atrial fibrillation is the most common arrhythmia that we deal with in the United States. It can affect up to one out of every 20 people over the age of 70. So we see it in the vast minority of the population. It is fundamentally a disorganized rhythm of the upper chambers of the heart, the atria.
So when you think about the anatomy of the heart, there are two atria at the top and two ventricles at the bottom. The ventricles are the main pumping chambers of the heart. The atria are sort of receiving chambers, but they're also where the heart's natural pacemaker resides. And so when someone goes into atrial fibrillation, instead of organized regular rhythm in the upper chambers of the heart, let's say 60, 70, 80 beats per minute, you end up with more or less continuous electrical activity. And if we were to measure the rate of that activity, it might be 300 times per minute.
So the upper chambers basically ripple and don't really move in a coordinated fashion and that results in the bottom chambers of the heart being bombarded with signals to beat. And those signals get through in an irregular and sometimes quite rapid fashion. So the hallmarks for atrial fibrillation are palpitations, a rhythm that is typically described as irregularly irregular, meaning there's no real rhythm or pattern to it. And that is unpleasant. It can lead to heart failure symptoms in extreme cases, and also is an important risk factor for stroke.
Alyne: And what causes this?
Dr John Respass: That's a tougher question. There's certainly a genetic component. People with high blood pressure are more likely to develop atrial fibrillation. It gets much more common with age. So with every decade, the likelihood that a patient might develop atrial fibrillation goes up. It is heavily correlated with obesity and also very heavily correlated with a type of sleep-disordered breathing called sleep apnea, which people may be familiar with as the condition where you have to wear the mask at night. And then there's a certain component of just bad luck.
Alyne: So when you have this, in addition to feeling uncomfortable, I know it can come and go, at least initially or maybe indefinitely, so that is very disconcerting, too.
Dr John Respass: Yes. So the earliest stages of the disease, we call the rhythm paroxysmal atrial fibrillation, meaning they're episodes that start and stop spontaneously, many times randomly without any clear understanding of why an individual had an episode at any given time. And then with time, those episodes become more frequent, they become longer. And then one day, a patient will have their first persistent episode, meaning they'll go into AFib and simply stay that way until some medical procedure or other intervention is performed to get them back to normal rhythm.
The paroxysmal stage tends to be more symptomatic because it comes out of the blue and tends to be very rapid. Oftentimes when patients are in AFib all the time, their body's sort of gets used to it and it becomes more tolerable. But it is the chronic stage or the persistent stage of atrial fibrillation where you can start to see heart failure.
Alyne: So I'm sure you recommend that at the very beginning, when you start to feel these symptoms, that you go in and see a cardiologist.
Dr John Respass: Certainly because the most important aspect of your care early in atrial fibrillation is to identify whether or not you are at increased risk for stroke. And that is done by scoring patients on a number of risk factors. And if you have a certain number of these risk factors, there is a substantial benefit to taking a blood thinner, an anticoagulant, to lower the risk by as much as 75% for stroke.
So that's the biggest thing we worry about early on. And then the secondary concern, which is often the primary concern for patients, is the amount of symptoms they're having from the AFib, and we would address that as well.
Alyne: So you said that you look for risk factors. What are the risk factors that you look forward to know that the person is at a higher risk for a stroke?
Dr John Respass: There's an acronym that's used to keep track of the risk factors. CHADS2VASC2, C-H-A-D-S two V-A-S-C two. The C is congestive heart failure; H is a history of hypertension; A is age, one point for being 65, two points for being 75; D is diabetes; S is prior stroke and you get two points for that, that's why there's the two in the name. And then VASC simply stands for vascular disease. So patients who have had a heart attack in the past, have had peripheral arterial disease, meaning blockages in the arteries, typically to their legs, that counts as a risk factor.
And then female gender counts as a risk factor. You get one point for that. Because for reasons we don't completely understand, women with AFib have somewhat more strokes than men do.
Alyne: So, how do you diagnosis this?
Dr John Respass: Well, during an episode, it's quite easy. You could diagnose it simply by listening to someone's heart. And certainly, an EKG is diagnostic during an episode. When patients are paroxysmal, oftentimes they'll be referred to us with a history of intermittent palpitations that come and go and last for anywhere from 30 minutes to four to five hours at a time. And that's enough for us to be suspicious, but we really need to capture an episode on some kind of rhythm monitor to make a diagnosis. And that could be a 24-hour heart monitor for frequent symptoms or, for less frequent symptoms, a 30-day monitor that can be worn as a patch on the skin. And there are even monitors that can last for up to three years that are injected under the skin.
Alyne: Now, what can we do about it once we have something like this?
Dr John Respass: Well, the most important thing, as we started to discuss before, is to assess stroke risk. And then when appropriate, take a blood thinner. The most common ones in use today, the generic names are apixaban, rivaroxaban and dabigatran. So those are very effective at lowering stroke risk, as I said before, by as much as 75%.
And then as far as symptoms are concerned, particularly for paroxysmal patients, we might place them on a medication that keeps their heart rate a little bit slower so that it doesn't go quite so rapid when they have an episode. There are several different anti-arrhythmic medications that are useful in certain populations of people that can prevent episodes entirely. And then there is ablation, which is an invasive procedure where someone like myself, an electrophysiologist, would go up into the heart with catheters and basically modify the heart's electrical system, so it's less able to go into atrial fibrillation.
Alyne: And if it were to become more serious, what are the procedures?
Dr John Respass: When you say more serious, you mean?
Alyne: All the time, as opposed to just on and off.
Dr John Respass: So when we're talking about paroxysmal atrial fibrillation, that's when it comes and goes, that's when our interventions are more effective. And so that is when we try to catch people and intervene when appropriate. Once someone becomes persistent, if their heart rates are consistently above a hundred beats per minute, that can lead to congestive heart failure where the heart enlarges and doesn't squeeze as well. That's a serious complication of atrial fibrillation when it occurs. And in that setting, we always try to get that patient back to normal rhythm, either through medications and typically then also the ablation procedure that I outlined.
When we find ourself in a situation where either patients are not safe candidates for procedures or we've tried it and it doesn't work, because ablation does only ultimately work in about 80 to 90% of people, there is a small subset in whom there's nothing we can do to keep them in normal rhythm. We will sometimes implant specialized types of pacemakers and perform a type of electrical disconnect between the upper and lower chambers of the heart, so the fibrillating atria at the top can no longer affect the ventricles, which are the pumping chambers we're worried about at the bottom.
Alyne: It sounds like, in many ways, there's a lot you can do.
Dr John Respass: Oh, there's a lot we can do. It's much better than it was, say, 15 to 20 years ago.
Alyne: Now, what about once this is controlled? What can the patient do? Is exercise safe? Do you recommend losing weight? Of course, I'm sure you do, but what kinds of activities can a person do?
Dr John Respass: Well, certainly the recommendation with weight depends on the point where you're starting. But the whole purpose of our modern atrial fibrillation management is to prevent the arrhythmia from interfering with a patient's life. So our goal is to keep people at completely normal activities without restrictions. That being said, general cardiovascular health recommendations include at least 30 minutes of exercise a day five to six days a week. That still stands for anyone with atrial fibrillation.
Certainly, I assess almost all of my patients with AFib for sleep apnea and treat it if it's present, because we know that untreated sleep apnea makes successful management of atrial fibrillation very difficult. And when patients are clinically obese with a body mass index over 30, we recommend they try to get that down below 30.
Alyne: Well, it sounds like good news in the long run in many cases. And thank you so very much for letting us know. Is there anything else you'd like to add?
Dr John Respass: The only other thing that I think we haven't covered is in patients who are not able to take blood thinners either because they've had serious episodes of bleeding or they have been falling frequently, and blood thinners are obviously risky in a patient who's falling frequently and possibly hitting their head because there's the risk of bleeding inside the skull, there are now alternatives to blood thinners. They're not as effective as blood thinners, but for patients who either can't or won't take blood thinners, they're now a reasonable alternative.
And these are called left atrial appendage occlusion devices, which is kind of a mouthful. But basically there is almost like a pouch off the upper left chamber of the heart and it's called the left atrial appendage. It's about the size of a half of a pinky finger. And when patients are in atrial fibrillation, that structure doesn't really move that well. And since it's a blind pouch, blood in there will sit and not really move that well and can clot. And that's thought to be one of the major mechanisms of stroke in AFib, a clot forms in the left atrial appendage, a piece of it breaks loose and ends up in the brain.
So in patients who can't safely take blood thinners, they're little devices that almost looked like tiny little cocktail umbrellas that we can insert into that pouch and then kind of inflate the umbrella, so the top of the umbrella covers over the opening of the appendage and blood can no longer get in or out of there. And that does substantially also lower the risk of stroke, not as effectively as blood thinners, but it's a good alternative in certain patients.
Alyne: And I'm assuming that in many of your patients, you see them doing very well after whatever procedures or medication they take.
Dr John Respass: The vast majority of our patients do very well. Any antiarrhythmic medications do have some risks. There are certain patients who can't take them because the use of anti-arrhythmic medication can be limited in patients with kidney disease or other types of heart disease.
Ablations are also safe procedures, but like any invasive procedure do have some risks. The primary risk to an atrial fibrillation ablation is a one in 400 chance of having a stroke during the procedure. So that's certainly a very scary possibility. Fortunately, it's rare. So the vast majority of our patients, yes, I would say, do very well.
Alyne: I guess the real point is go see a cardiologist when you have symptoms.
Dr John Respass: As a starting point, and you're probably going to end up finding your way to my subspecialty, which is cardiac electrophysiology, which is a subspecialty of cardiology that deals with arrhythmias.
Alyne: Well, thank you very much, Dr. Respass, for all this information.
Dr John Respass: Oh, you're very welcome.
Alyne: Cardiologist, Dr. John Respass is an attending physician at Montefiore St. Luke's Cornwall. I'm Alyne Ellis. Thank you for listening to this episode of our Health Track podcast, head on over to our website at montefioreslc.org to get connected to one of our providers. And if you found this podcast helpful, please share it on your social channels and be sure to check back in soon for the next podcast. Thank you for listening,
Atrial Fibrillation (AFib)
Alyne: Heart palpitations, shortness of breath, weakness, these are some of the signs that you need to see a cardiologist.
Our topic today is atrial fibrillation. Here to tell us more about this all too common issue and what can be done about it is cardiologist, Dr. John Respass, an attending physician at Montefiore St. Luke's Cornwall. I'm Alyne Ellis. Welcome to our Health Track podcast
Dr John Respass: Thank you very much. I'm happy to be here.
Alyne: So let's begin with what is atrial fibrillation? And it's commonly called, as we all know it probably, AFib.
Dr John Respass: Yeah, right. So atrial fibrillation is the most common arrhythmia that we deal with in the United States. It can affect up to one out of every 20 people over the age of 70. So we see it in the vast minority of the population. It is fundamentally a disorganized rhythm of the upper chambers of the heart, the atria.
So when you think about the anatomy of the heart, there are two atria at the top and two ventricles at the bottom. The ventricles are the main pumping chambers of the heart. The atria are sort of receiving chambers, but they're also where the heart's natural pacemaker resides. And so when someone goes into atrial fibrillation, instead of organized regular rhythm in the upper chambers of the heart, let's say 60, 70, 80 beats per minute, you end up with more or less continuous electrical activity. And if we were to measure the rate of that activity, it might be 300 times per minute.
So the upper chambers basically ripple and don't really move in a coordinated fashion and that results in the bottom chambers of the heart being bombarded with signals to beat. And those signals get through in an irregular and sometimes quite rapid fashion. So the hallmarks for atrial fibrillation are palpitations, a rhythm that is typically described as irregularly irregular, meaning there's no real rhythm or pattern to it. And that is unpleasant. It can lead to heart failure symptoms in extreme cases, and also is an important risk factor for stroke.
Alyne: And what causes this?
Dr John Respass: That's a tougher question. There's certainly a genetic component. People with high blood pressure are more likely to develop atrial fibrillation. It gets much more common with age. So with every decade, the likelihood that a patient might develop atrial fibrillation goes up. It is heavily correlated with obesity and also very heavily correlated with a type of sleep-disordered breathing called sleep apnea, which people may be familiar with as the condition where you have to wear the mask at night. And then there's a certain component of just bad luck.
Alyne: So when you have this, in addition to feeling uncomfortable, I know it can come and go, at least initially or maybe indefinitely, so that is very disconcerting, too.
Dr John Respass: Yes. So the earliest stages of the disease, we call the rhythm paroxysmal atrial fibrillation, meaning they're episodes that start and stop spontaneously, many times randomly without any clear understanding of why an individual had an episode at any given time. And then with time, those episodes become more frequent, they become longer. And then one day, a patient will have their first persistent episode, meaning they'll go into AFib and simply stay that way until some medical procedure or other intervention is performed to get them back to normal rhythm.
The paroxysmal stage tends to be more symptomatic because it comes out of the blue and tends to be very rapid. Oftentimes when patients are in AFib all the time, their body's sort of gets used to it and it becomes more tolerable. But it is the chronic stage or the persistent stage of atrial fibrillation where you can start to see heart failure.
Alyne: So I'm sure you recommend that at the very beginning, when you start to feel these symptoms, that you go in and see a cardiologist.
Dr John Respass: Certainly because the most important aspect of your care early in atrial fibrillation is to identify whether or not you are at increased risk for stroke. And that is done by scoring patients on a number of risk factors. And if you have a certain number of these risk factors, there is a substantial benefit to taking a blood thinner, an anticoagulant, to lower the risk by as much as 75% for stroke.
So that's the biggest thing we worry about early on. And then the secondary concern, which is often the primary concern for patients, is the amount of symptoms they're having from the AFib, and we would address that as well.
Alyne: So you said that you look for risk factors. What are the risk factors that you look forward to know that the person is at a higher risk for a stroke?
Dr John Respass: There's an acronym that's used to keep track of the risk factors. CHADS2VASC2, C-H-A-D-S two V-A-S-C two. The C is congestive heart failure; H is a history of hypertension; A is age, one point for being 65, two points for being 75; D is diabetes; S is prior stroke and you get two points for that, that's why there's the two in the name. And then VASC simply stands for vascular disease. So patients who have had a heart attack in the past, have had peripheral arterial disease, meaning blockages in the arteries, typically to their legs, that counts as a risk factor.
And then female gender counts as a risk factor. You get one point for that. Because for reasons we don't completely understand, women with AFib have somewhat more strokes than men do.
Alyne: So, how do you diagnosis this?
Dr John Respass: Well, during an episode, it's quite easy. You could diagnose it simply by listening to someone's heart. And certainly, an EKG is diagnostic during an episode. When patients are paroxysmal, oftentimes they'll be referred to us with a history of intermittent palpitations that come and go and last for anywhere from 30 minutes to four to five hours at a time. And that's enough for us to be suspicious, but we really need to capture an episode on some kind of rhythm monitor to make a diagnosis. And that could be a 24-hour heart monitor for frequent symptoms or, for less frequent symptoms, a 30-day monitor that can be worn as a patch on the skin. And there are even monitors that can last for up to three years that are injected under the skin.
Alyne: Now, what can we do about it once we have something like this?
Dr John Respass: Well, the most important thing, as we started to discuss before, is to assess stroke risk. And then when appropriate, take a blood thinner. The most common ones in use today, the generic names are apixaban, rivaroxaban and dabigatran. So those are very effective at lowering stroke risk, as I said before, by as much as 75%.
And then as far as symptoms are concerned, particularly for paroxysmal patients, we might place them on a medication that keeps their heart rate a little bit slower so that it doesn't go quite so rapid when they have an episode. There are several different anti-arrhythmic medications that are useful in certain populations of people that can prevent episodes entirely. And then there is ablation, which is an invasive procedure where someone like myself, an electrophysiologist, would go up into the heart with catheters and basically modify the heart's electrical system, so it's less able to go into atrial fibrillation.
Alyne: And if it were to become more serious, what are the procedures?
Dr John Respass: When you say more serious, you mean?
Alyne: All the time, as opposed to just on and off.
Dr John Respass: So when we're talking about paroxysmal atrial fibrillation, that's when it comes and goes, that's when our interventions are more effective. And so that is when we try to catch people and intervene when appropriate. Once someone becomes persistent, if their heart rates are consistently above a hundred beats per minute, that can lead to congestive heart failure where the heart enlarges and doesn't squeeze as well. That's a serious complication of atrial fibrillation when it occurs. And in that setting, we always try to get that patient back to normal rhythm, either through medications and typically then also the ablation procedure that I outlined.
When we find ourself in a situation where either patients are not safe candidates for procedures or we've tried it and it doesn't work, because ablation does only ultimately work in about 80 to 90% of people, there is a small subset in whom there's nothing we can do to keep them in normal rhythm. We will sometimes implant specialized types of pacemakers and perform a type of electrical disconnect between the upper and lower chambers of the heart, so the fibrillating atria at the top can no longer affect the ventricles, which are the pumping chambers we're worried about at the bottom.
Alyne: It sounds like, in many ways, there's a lot you can do.
Dr John Respass: Oh, there's a lot we can do. It's much better than it was, say, 15 to 20 years ago.
Alyne: Now, what about once this is controlled? What can the patient do? Is exercise safe? Do you recommend losing weight? Of course, I'm sure you do, but what kinds of activities can a person do?
Dr John Respass: Well, certainly the recommendation with weight depends on the point where you're starting. But the whole purpose of our modern atrial fibrillation management is to prevent the arrhythmia from interfering with a patient's life. So our goal is to keep people at completely normal activities without restrictions. That being said, general cardiovascular health recommendations include at least 30 minutes of exercise a day five to six days a week. That still stands for anyone with atrial fibrillation.
Certainly, I assess almost all of my patients with AFib for sleep apnea and treat it if it's present, because we know that untreated sleep apnea makes successful management of atrial fibrillation very difficult. And when patients are clinically obese with a body mass index over 30, we recommend they try to get that down below 30.
Alyne: Well, it sounds like good news in the long run in many cases. And thank you so very much for letting us know. Is there anything else you'd like to add?
Dr John Respass: The only other thing that I think we haven't covered is in patients who are not able to take blood thinners either because they've had serious episodes of bleeding or they have been falling frequently, and blood thinners are obviously risky in a patient who's falling frequently and possibly hitting their head because there's the risk of bleeding inside the skull, there are now alternatives to blood thinners. They're not as effective as blood thinners, but for patients who either can't or won't take blood thinners, they're now a reasonable alternative.
And these are called left atrial appendage occlusion devices, which is kind of a mouthful. But basically there is almost like a pouch off the upper left chamber of the heart and it's called the left atrial appendage. It's about the size of a half of a pinky finger. And when patients are in atrial fibrillation, that structure doesn't really move that well. And since it's a blind pouch, blood in there will sit and not really move that well and can clot. And that's thought to be one of the major mechanisms of stroke in AFib, a clot forms in the left atrial appendage, a piece of it breaks loose and ends up in the brain.
So in patients who can't safely take blood thinners, they're little devices that almost looked like tiny little cocktail umbrellas that we can insert into that pouch and then kind of inflate the umbrella, so the top of the umbrella covers over the opening of the appendage and blood can no longer get in or out of there. And that does substantially also lower the risk of stroke, not as effectively as blood thinners, but it's a good alternative in certain patients.
Alyne: And I'm assuming that in many of your patients, you see them doing very well after whatever procedures or medication they take.
Dr John Respass: The vast majority of our patients do very well. Any antiarrhythmic medications do have some risks. There are certain patients who can't take them because the use of anti-arrhythmic medication can be limited in patients with kidney disease or other types of heart disease.
Ablations are also safe procedures, but like any invasive procedure do have some risks. The primary risk to an atrial fibrillation ablation is a one in 400 chance of having a stroke during the procedure. So that's certainly a very scary possibility. Fortunately, it's rare. So the vast majority of our patients, yes, I would say, do very well.
Alyne: I guess the real point is go see a cardiologist when you have symptoms.
Dr John Respass: As a starting point, and you're probably going to end up finding your way to my subspecialty, which is cardiac electrophysiology, which is a subspecialty of cardiology that deals with arrhythmias.
Alyne: Well, thank you very much, Dr. Respass, for all this information.
Dr John Respass: Oh, you're very welcome.
Alyne: Cardiologist, Dr. John Respass is an attending physician at Montefiore St. Luke's Cornwall. I'm Alyne Ellis. Thank you for listening to this episode of our Health Track podcast, head on over to our website at montefioreslc.org to get connected to one of our providers. And if you found this podcast helpful, please share it on your social channels and be sure to check back in soon for the next podcast. Thank you for listening,