Evo Terra (Host): Welcome to DocTalk, presented by Montefiore Saint Luke's Cornwall. I'm Evo Terra. And with me again is Dr. Ahmad B. Hadid, an interventional cardiologist at Montefiore Saint Luke's Cornwall, as we talk about atrial fibrillation, what it is, why it matters, and what today's treatments can do to help. Great to have you back with me once again, Dr. Hadid.

Ahmad B. Hadid, MD: Thank you for having me.

Host: So, what exactly is atrial fibrillation? And how is that different from other sorts of heart rhythm things we might know of, like extra beats or heart murmurs or things like that?

Ahmad B. Hadid, MD: Again, thank you for having me. It's a great topic. We're going to talk about today is atrial fibrillation. It's the most common sustained heart rhythm disorder worldwide. So, every physician encounter this a few times a day. That's how important this topic is. AFib will affect millions of people, and the older we get and the older people lives, it becomes more common.

And a study showed that in patients above age of 80%, 20% of them, they will have atrial fibrillation. The concern about AFib, even though AFib is often able to be managed, the main concern is it will increase the risk of stroke. It can increase the risk of heart failure. It can increase the risk of other complications that have to be recognized and will be treated.

So, let's start with simple question. As you said, what's atrial fibrillation? Our heart normally when it beats, it beats in a very regular, coordinated rhythm. In atrial fibrillation, the upper chamber of the heart, that's called the atria, it beats rapidly and irregularly. As a result of that, the heart rhythm becomes irregular and sometimes goes fast. What patients will experience throughout this? Multiple symptoms can happen different in patients, fluttering in the chest, racing heart, some patients describe it as skipped beats or irregular pulse.

What's the concern about the atrial fibrillation? As you say, atrial fibrillation can lead to more complications with the heart if it's left untreated, especially if it's too fast, can drain the energy of the heart muscle, get the heart muscle to become weaker. If not treated appropriately, it will increase the risk of a stroke. And some people, it will affect their lifestyle. Somebody who's active, exercises every single day, and all of a sudden have some risk factor and end up in atrial fibrillation. The patient who used to exercises, walks two, three miles a day will not be able to walk half a mile because he will get symptom. So, the heart is irregular. And most of the time sustained all the time.

That's a little bit different from those extra heartbeats, we call it PVCs or premature ventricular contraction, where the heart is still within normal rhythm. But once in a while, you will feel that your heart is skipping a beat and then goes back to normal. So, that's the difference that we are talking about here.

Host: You mentioned some of these terrible things that might happen like stroke risk, heart failure, impacting overall life expectancy. What are some factors that make AFib more risky in certain patients?

Ahmad B. Hadid, MD: It all depends what caused the atrial fibrillation. It goes to the profile of the patient. So, why AFib happens, that's very important. What's the main thing that caused the AFib? So if you go, "Why atrial fibrillation happens in certain patient?" Again, atrial fibrillation, it can happen if the patient has a problem with the valve.

So if we have leaky valve, specifically certain valve called the mitral valve. It's a valve between the top of the heart, called the left atrium, and the bottom of the heart, called the left ventricle. If that valve starts leaking, you will get more blood flow inside the atrium than the top of the heart. So, the atria starts to get enlarged, and the electrical system starts to stretch little bit, and you go into atrial fibrillation. And important to manage this, important to manage the valve and deal with it because if we don't deal with it, the heart can become weaker. That's considered risky.

Other things that can lead to AFib is if somebody has some blockages, undetected blockage with the arteries, some blocked arteries, every time you walk, get short of breath, ultimately leads to a weaker heart muscle and can to atrial fibrillation. Atrial fibrillation sometimes happens in patients after they have heart surgery. It could be transient and then get back to normal.

The risk factors to have atrial fibrillation is multiple risk factors, as we said before. But one of the common things is uncontrolled hypertension. If somebody has hypertension not controlled well, that will lead us back to control the blood pressure. If somebody has bad sleep apnea, sleep apnea is the condition where the patient stops breathing at night, get less blood flow, to the lung and to the heart, and that ultimately can lead to atrial fibrillation. Diabetes can increase the risk of atrial fibrillation. Heart valve disease can increase the risk of heart disease. Excessive alcohol consumption, overweight, thyroid issues. So, all these have to be looked at, detected, treated to help to protect from AFib.

If AFib happens, we still have to control these factors and treat the AFib. And the way we treat AFib is we have to look into three issues. Number one, the atrial fibrillation tends to be a fast heartbeat. So, most patients come to the emergency room with very fast heartbeat. Our heart beats anything between 60 to 100 beats per minute. It's slow if we are resting, it's fast if we are active. However, with the AFib, most patients, when they come into the hospital, they feel flutter in their chest. Their heart rate's like 140, 150. We're putting too much pressure on the heart, has to work harder.

So, number one, for the management of AFib, we need to control the heart rate. We give them medication to slow the heart rate, so we don't put too much pressure into the heart. Number two, as we said, there is risk of a stroke. Why is that? Because as I said initially, the top of the heart called the atrium is really not squeezing completely, not contracting all the way. So, the blood can pool, can stay inside the top of the heart. If the blood does not move continuously, it can pool down there and form a clot. This clot commonly can come up to the brain, and that's how a patient can have a stroke. It's not only the brain, sometime it can find its way to the stomach or to the abdomen, and they have lack of blood coming to their bowel. Sometimes, a clot can travel to the arm, all of a sudden develop this lack of blood coming to the hand or down to the lower extremities. So, we need to prevent the clot in those patient. We need to prevent the clot.

And the way we treat this, we give them blood thinner. Initially, when we identify the AFib in the hospital, it's intravenous medication we start called heparin. And then, we make a decision what's the next step. We switch them to oral drugs. The common drug that we all now, older drug called warfarin or Coumadin, that used to be the blood thinner that we use all along. A few years back, we started using newer drugs available called NOAC, something like apixaban or Xarelto. Those drugs are easier to use, and they work faster.

The excitement about being on a blood thinner for atrial fibrillation is sometimes the older we get, certain patients who are higher risk of bleeding or fall or cannot be on a blood thinner, we have some other intervention that we can do for them to prevent a clot from forming, where we can go exactly to the spot where the clot forms into that atrium.It's called left atrial appendage, and we can put a occlusion device. So, we close that little hole. And this way, we can prevent the clot from forming there. This is an option for somebody, an elderly person who can fall, who can trip, or bleed every time he's on a blood thinner.

Who should be on a blood thinner for AFib? Anybody who has some risk factors. There are certain score to tell who is at risk of having a stroke. Somebody who has a blockage in the artery or coronary artery disease is higher risk of having a stroke. Somebody who has hypertension, somebody who has diabetes, somebody who had a previous stroke. So, there is certain score called the CHAD score, C-H-A-D score. If your score is elevated, you should be on a blood thinner. We balance this to see what your risk of bleeding is, and then we see what's the risk, what the benefit of being on those medication.

The third strategy for the treatment of atrial fibrillation is to maintain the normal rhythm. All the studies showed you do better if you maintain a normal rhythm. And the way we do that is by anti-arrhythmic medication. It's a pill or intravenous medication that you can take. It will help to keep the patient in normal sinus rhythm. Sometime if the medication does not work, we proceed with a procedure done under anesthesia called cardioversion, where we shock the heart to put the patient in normal rhythm, especially if you have a lot of symptoms.

And the exciting thing that, in the last ten years that became very common is called ablation, atrial fibrillation ablation, where we find the area in specific part of the heart that's producing this arrhythmia, and we can go up with a small catheter, find exactly what's going on, and we can do what's called ablation and stop this arrhythmia. Those are the strategies you do it for the treatment for this patient.

Host: This is all great. One thing I did want to ask you, we've talked a lot about the fluttering heart and the racing heart and the shortness of breath. Can AFib happen where a patient doesn't have any symptoms at all?

Ahmad B. Hadid, MD: It can. It can. Actually, it happened that this week I had an 88-year-old gentleman come in. He needed clearance to have a cataract surgery, ended up having an EKG, found to be in AFib. He feels okay. He does not feel bad. I mean, yes, it can happen, but more common is to have some symptoms. And the most common symptoms is flutter, palpitation, dizzy, lightheaded, short of breath more than usual. Sometimes certain patients could be asymptomatic.

Host: My last question to you is about those lifestyle factors you talked about, sleep apnea, stopping drinking, don't smoke anymore, losing weight. How much can patients actually reduce their AFib burden through behavioral changes like those?

Ahmad B. Hadid, MD: It's a great question. Because we know, especially when it comes to overweight and obesity, by reducing the weight, you can prevent AFib from happening. Lifestyle modification. It's important in two categories.

Number one, if we control this risk factor before AFib happens, we are preventing AFib from happening. That's better than doing it after AFib comes in. So if you lose weight, definitely you will decrease the chance of AFib happening by at least two, three folds. For excessive alcohol drinking, cutting down on alcohol to social drinking definitely will decrease the AFib at least by two, three folds.

Sleep apnea, it's very important risk factor that has to be treated before having AFib. And not only just because of the AFib, because untreated sleep apnea can lead to a lot of cardiovascular mortality. And if a patient has AFib and underwent a procedure, either treated by medication to prevent the AFib or treated by ablation, if sleep apnea not treated, it will have a risk of recurrent AFib. So, this is a great question. By treating this risk factor, lifestyle modification, losing weight, you treat sleep apnea, exercise regularly, cut down excessive alcohol drinking, it will decrease the recurrence of AFib anything between two to six folds.

Host: Wow. That's a significant number. that is very good. Dr. Hadid, we've talked several times, and I know you always like to summarize things. So, I will let you do that now.

Ahmad B. Hadid, MD: Thank you for having me again. we talked today about atrial fibrillation, which is a common public health problem because it's very significant, affecting a lot of patient, especially when we age. As I mentioned before, above age of 80, 20% of patients has atrial fibrillation. If it's detected early and treated appropriately, patient will do well and will avoid the complication. The most common complication concerning for AFib is stroke, and that should be treated with a blood thinner and there are some other options for patient who cannot tolerate a blood thinner. Lifestyle modification, it will help to prevent AFib from happening. And more important, if patient has AFib, treat it to prevent AFib from coming back.

Host: Dr. Hadid, always a pleasure chatting with you and getting great information. Thank you, sir.

Ahmad B. Hadid, MD: Thank you very much.

Host: Once again, that was Dr. Ahmad B. Hadid, an interventional cardiologist at Montefiore St. Luke's Cornwall. To learn more about our cardiac services, please visit montefioreslc.org. That is montefioreslc.org. And if you enjoyed this episode, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Evo Terra. This has been DocTalk, presented by Montefiore St. Luke's Cornwall. Thanks for listening.