According to the CDC, up to 6 million people in the US have Atrial Fibrillation. Atrial fibrillation, often called AFib, is the most common type of heart arrhythmia. With the aging of the U.S. population, this number is expected to increase.
An arrhythmia is when the heart beats too slowly, too fast, or in an irregular way.
Tune into SMG Radio to hear SMG cardiologist Dr. Robert Altman discuss the latest effective treatment options to help patients with A-fib.
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Life Off Beat - - Living with AFibrillation
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Learn more about Dr. Altman
Robert Altman, MD
Dr. Robert Altman specializes in Clinical Cardiac Electrophysiology. He is a cardiologist who diagnoses and treats patients with abnormal heart rhythms. He comes to Summit Medical Group from Mount Sinai St. Luke’s and Mount Sinai Roosevelt where he was and attending physician, the Co-Course Director of the Cardiac Pathophysiology Course, and Assistant Professor at the Icahn School of Medicine at Mount Sinai.Learn more about Dr. Altman
Transcription:
Life Off Beat - - Living with AFibrillation
Melanie Cole (Host): According to the CDC, up to six million people in the United States have atrial fibrillation. Atrial fibrillation often called “AFib” is the most common type of heart arrhythmia. With the aging of the US population, this number is expected to increase. My guest today is Dr. Robert Altman. He’s the Director in Clinical Cardiac Electrophysiology at Summit Medical Group. Welcome to the show, Dr. Altman. What is atrial fibrillation or AFib?
Dr. Robert Altman (Guest): Thank you very, very much for having me here. I’m really happy to talk about the subject which, as you said, affects many people in the United States and throughout the world and is an increasing problem. So, atrial fibrillation is a heart arrhythmia and then arrhythmia is simply an abnormal heart rhythm. Atrial fibrillation itself is an abnormal heart rhythm that primarily affects the upper chamber of the heart in which there’s nearly continuous and chaotic electrical activity in the upper chambers. That leads to a very fast and irregular pulse in the lower chambers. A number of problems can result from that.
Melanie: Who would be at risk for AFib?
Dr. Altman: The biggest risk factor for atrial fibrillation is actually age. As we get older, more and more of us develop atrial fibrillation. And, in fact, once you hit eighty or ninety years old, it’s almost ten to twenty percent of people will develop atrial fibrillation. However, it is not only a disease of older people. Other medical problems like sleep apnea, being overweight, other cardiac problems like valve disease or coronary artery disease can predispose you to having atrial fibrillation. There is also a subset of otherwise completely healthy people who have completely normal hearts who will also go on to develop atrial fibrillation.
Melanie: Would someone feel it, Dr. Altman? What are some of the symptoms?
Dr. Altman: That’s a very good question and it’s one of the things that I find very interesting about this problem. Some people, when they go into atrial fibrillation from a normal rhythm, feel just plain awful. That results, usually, in them seeking medical care either in an emergency room or primary care doctor or cardiologist for instance. Some people feel so ill that they might call 911. On the other hand, there are patients who have atrial fibrillation who have virtually no symptom from the arrhythmia. It’s actually not uncommon that we diagnose this problem incidentally either at a primary care doctor’s office or, say, when somebody’s coming in for another medical procedure like a colonoscopy. Most people present somewhere in between with mild to moderate symptoms. Those symptoms primarily are fatigue, shortness of breath with exertion, or the sensation that your heart is beating irregularly or quickly.
Melanie: Are there some complications if it’s not found and treated?
Dr. Altman: Yes. So, finding atrial fibrillation is really the primary concern because once we make a diagnosis, we can really prevent the major complications that are associated with the arrhythmia. Specifically, the most important complication associated with AFib is the risk of stroke. In general, when you have atrial fibrillation, whether it’s an arrhythmia that stays with you all the time or comes and goes as it does in some people, your risk of having stroke is about five times that of the general population. We need to know that you have it in order to reduce that risk.
Melanie: If you do diagnose someone with AFib, what’s the first line of defense? What are some treatments you use?
Dr. Altman: So, really, as I mentioned, the most pressing issue is trying to, first of all, stabilize the patient who’s unstable. Those are the patients who, as I mentioned before, might present to an emergency room or call 911 feeling awful. However, for the vast majority of patients, it’s a stable rhythm and there’s nothing that needs to be done immediately to correct the problem. However, an assessment of the risk of stroke is absolutely necessary because initiation treatment of blood thinners is what’s effective at preventing that. We use a risk score that has an acronym called CHA2DS2-VASc in order to assess an individual’s risk of stroke. What that does is take into consideration other problems that a patient has in addition to atrial fibrillation and allows us to make an accurate assessment of what the risk of stroke is and then determine the need for a blood thinner based on that.
Melanie: Once they’re on a blood thinner, is this something that they’re on for the rest of their life?
Dr. Altman: So for the most part, the CHA2DS2-VASc score and I can tell you what that acronym stands for is really what’s used to determine whether a blood thinner is initiated or not. Depending on how high that score is really determines the length of treatment with the blood thinner. For the most part, if you have other risk factors, once you’ve been diagnosed with atrial fibrillation, use of a blood thinner is usually continued for the lifelong treatment. There are newer therapies which are interventional therapies which have been developed which may, at some stage, obviate the need for a blood thinner in some patients who are at risk for bleeding.
Melanie: So, tell us about some of those.
Dr. Altman: Sure. So, in general, I just want to elaborate a little bit more about the CHA2DS2-VASc score. The “C” stands for “congestive heart failure”. The “H” stands for “hypertension”. The “A” stands for “age greater than 65”, you get one point; or greater than 75, you get two points. The “D” stands for “diabetes”. The “S” stands for “stroke” for which you get 2 points. And the “VASc” is “vascular disease” such as coronary artery disease. There’s also a risk factor for female gender. It gets you one point as well. Once you hit two points, it’s usually clear that the risk of a blood thinner is lower than the risk of not being on a blood thinner and we tend to prescribe a blood thinner. In patients for whom a blood thinner is indicated but who have an otherwise high risk of bleeding, say, somebody who’s had bleeding from their gastrointestinal tract in the past, there are new procedures which are called “left atrial appendage occlusion devices”. What they do is they block off the most common place that a clot forms in the heart during atrial fibrillation such that if a clot forms there, it can’t leave the heart and cause a stroke.
Melanie: So, these other types of treatments, are they permanent? And, let’s speak about them separately whether you’re using electrical cardioversion or catheter ablation. Explain to the listeners a little bit about what those are and whether they’re a permanent solution.
Dr. Altman: Sure. So, let me talk about the treatment of the rhythm itself. So, once you have made this determination of the risk of stroke, then we need to decide how we’d like to treat the rhythm itself. For many people, just starting medications to slow the pulse down while not necessarily treating the rhythm itself can make people feel much better. And, if we can make the patient feel normal again by slowing down their pulse, that’s called the “rate-control strategy”. And, rate control and anticoagulation can be an end in and of itself and is an appropriate management strategy for atrial fibrillation. For those patients who continue to feel symptoms despite the pulse being controlled with medication, then we need to talk about other ways to manage the rhythm itself. That may involve what’s called first an “electrical cardioversion” in which patients come into the hospital, receive anesthesia, and then receive an electrical shock. That shock can almost always restore a normal rhythm. However, it’s very unclear how long it lasts for an individual patient. Some people revert immediately back into atrial fibrillation following the shock and others may not revert back to atrial fibrillation for years. If the cardioversion is unsuccessful in that the atrial fibrillation returns, then there are really two options for treatment. The first are medications called “antiarrhythmic medications” which have about a 60% success rate in maintaining sinus rhythm. Each of those comes with their own set of side effects and needs to be tailored individually for a patient. The second option is an invasive procedure, a minimally invasive procedure, using catheters called an “ablation procedure”. During that procedure, the catheter’s inserted into the heart and small burns are made inside the heart tissue to try to eliminate atrial fibrillation. In certain subsets of patients, that can be very, very successful. For the general population of patients with atrial fibrillation, the success rate is between sixty and eighty five percent for eliminating the arrhythmia. To determine where you might fall in that success rate, the conversation with an electrophysiologist is very important.
Melanie: Dr. Altman, can someone live a long, good quality of life with atrial fibrillation?
Dr. Altman: Absolutely. In fact, once the stroke risk is reduced by starting blood thinners when appropriate, it is the goal of the treatment of atrial fibrillation to restore normal quality of life and normal length of life. That’s why we do the procedures that we do in order to restore the quality of life that a patient had before the diagnosis.
Melanie: And, give us some of your best advice on lifestyle modifications that can help as a side along with the treatment or possibly prevent AFib altogether.
Dr. Altman: So, what we’ve learned is that all of the recommendations that we’ve been giving to remain heart healthy, in general, also seem to prevent atrial fibrillation and they also seem to improve the success rate of the procedures that we do to eliminate atrial fibrillation. So, to be specific, one emerging and very important risk factor for atrial fibrillation that also can improve the outcome of a procedure to eliminate atrial fibrillation by up to 50% is the diagnosis and treatment of sleep apnea. Sleep apnea is a major cause of atrial fibrillation and is something that should be taken seriously, evaluated, and treated appropriately by a sleep specialist. Other risk factors like diabetes and hypertension, when they’re controlled with medication, also reduce the risk of atrial fibrillation and improve the success of any procedure that may be done. Weight loss is very important along with moderating alcohol and continuing to do exercise.
Melanie: And, tell us about your team at Summit Medical Group.
Dr. Altman: We have a fantastic team of cardiac electrophysiologists and general cardiologists here. Myself and Dr. Jonathan Steinberg work together as cardiac electrophysiologists within the group and we work with the many very skilled cardiologists here to come up with a comprehensive approach for each patient who presents with atrial fibrillation. And, as I said before, that sometimes involves medications or procedures. What we’re really lucky to have here at Summit Medical Group is the multispecialty practice in which it’s very easy for me to refer to, say, a sleep medicine specialist in a patient who has been recently diagnosed with atrial fibrillation and needs treatment for sleep apnea. So, we really take a holistic approach to the management of this arrhythmia. We don’t segment it so that you’re only be seeing an electrophysiologist or only be seeing a cardiologist. We really think that management of the entire patient is important to the management of this specific arrhythmia. We are also able to provide, when necessary, really the cutting edge of treatment with regard to interventional procedures for atrial fibrillation. With mine and Dr. Steinberg’s experience, we’ve had a vast experience with the multiple technologies that are available for cardiac ablation of atrial fibrillation.
Melanie: Thank you so much for being with us today. It’s great information. You’re listening to SMG Radio. For more information, you can go to www.summitmedicalgroup.com. That’s www.summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.
Life Off Beat - - Living with AFibrillation
Melanie Cole (Host): According to the CDC, up to six million people in the United States have atrial fibrillation. Atrial fibrillation often called “AFib” is the most common type of heart arrhythmia. With the aging of the US population, this number is expected to increase. My guest today is Dr. Robert Altman. He’s the Director in Clinical Cardiac Electrophysiology at Summit Medical Group. Welcome to the show, Dr. Altman. What is atrial fibrillation or AFib?
Dr. Robert Altman (Guest): Thank you very, very much for having me here. I’m really happy to talk about the subject which, as you said, affects many people in the United States and throughout the world and is an increasing problem. So, atrial fibrillation is a heart arrhythmia and then arrhythmia is simply an abnormal heart rhythm. Atrial fibrillation itself is an abnormal heart rhythm that primarily affects the upper chamber of the heart in which there’s nearly continuous and chaotic electrical activity in the upper chambers. That leads to a very fast and irregular pulse in the lower chambers. A number of problems can result from that.
Melanie: Who would be at risk for AFib?
Dr. Altman: The biggest risk factor for atrial fibrillation is actually age. As we get older, more and more of us develop atrial fibrillation. And, in fact, once you hit eighty or ninety years old, it’s almost ten to twenty percent of people will develop atrial fibrillation. However, it is not only a disease of older people. Other medical problems like sleep apnea, being overweight, other cardiac problems like valve disease or coronary artery disease can predispose you to having atrial fibrillation. There is also a subset of otherwise completely healthy people who have completely normal hearts who will also go on to develop atrial fibrillation.
Melanie: Would someone feel it, Dr. Altman? What are some of the symptoms?
Dr. Altman: That’s a very good question and it’s one of the things that I find very interesting about this problem. Some people, when they go into atrial fibrillation from a normal rhythm, feel just plain awful. That results, usually, in them seeking medical care either in an emergency room or primary care doctor or cardiologist for instance. Some people feel so ill that they might call 911. On the other hand, there are patients who have atrial fibrillation who have virtually no symptom from the arrhythmia. It’s actually not uncommon that we diagnose this problem incidentally either at a primary care doctor’s office or, say, when somebody’s coming in for another medical procedure like a colonoscopy. Most people present somewhere in between with mild to moderate symptoms. Those symptoms primarily are fatigue, shortness of breath with exertion, or the sensation that your heart is beating irregularly or quickly.
Melanie: Are there some complications if it’s not found and treated?
Dr. Altman: Yes. So, finding atrial fibrillation is really the primary concern because once we make a diagnosis, we can really prevent the major complications that are associated with the arrhythmia. Specifically, the most important complication associated with AFib is the risk of stroke. In general, when you have atrial fibrillation, whether it’s an arrhythmia that stays with you all the time or comes and goes as it does in some people, your risk of having stroke is about five times that of the general population. We need to know that you have it in order to reduce that risk.
Melanie: If you do diagnose someone with AFib, what’s the first line of defense? What are some treatments you use?
Dr. Altman: So, really, as I mentioned, the most pressing issue is trying to, first of all, stabilize the patient who’s unstable. Those are the patients who, as I mentioned before, might present to an emergency room or call 911 feeling awful. However, for the vast majority of patients, it’s a stable rhythm and there’s nothing that needs to be done immediately to correct the problem. However, an assessment of the risk of stroke is absolutely necessary because initiation treatment of blood thinners is what’s effective at preventing that. We use a risk score that has an acronym called CHA2DS2-VASc in order to assess an individual’s risk of stroke. What that does is take into consideration other problems that a patient has in addition to atrial fibrillation and allows us to make an accurate assessment of what the risk of stroke is and then determine the need for a blood thinner based on that.
Melanie: Once they’re on a blood thinner, is this something that they’re on for the rest of their life?
Dr. Altman: So for the most part, the CHA2DS2-VASc score and I can tell you what that acronym stands for is really what’s used to determine whether a blood thinner is initiated or not. Depending on how high that score is really determines the length of treatment with the blood thinner. For the most part, if you have other risk factors, once you’ve been diagnosed with atrial fibrillation, use of a blood thinner is usually continued for the lifelong treatment. There are newer therapies which are interventional therapies which have been developed which may, at some stage, obviate the need for a blood thinner in some patients who are at risk for bleeding.
Melanie: So, tell us about some of those.
Dr. Altman: Sure. So, in general, I just want to elaborate a little bit more about the CHA2DS2-VASc score. The “C” stands for “congestive heart failure”. The “H” stands for “hypertension”. The “A” stands for “age greater than 65”, you get one point; or greater than 75, you get two points. The “D” stands for “diabetes”. The “S” stands for “stroke” for which you get 2 points. And the “VASc” is “vascular disease” such as coronary artery disease. There’s also a risk factor for female gender. It gets you one point as well. Once you hit two points, it’s usually clear that the risk of a blood thinner is lower than the risk of not being on a blood thinner and we tend to prescribe a blood thinner. In patients for whom a blood thinner is indicated but who have an otherwise high risk of bleeding, say, somebody who’s had bleeding from their gastrointestinal tract in the past, there are new procedures which are called “left atrial appendage occlusion devices”. What they do is they block off the most common place that a clot forms in the heart during atrial fibrillation such that if a clot forms there, it can’t leave the heart and cause a stroke.
Melanie: So, these other types of treatments, are they permanent? And, let’s speak about them separately whether you’re using electrical cardioversion or catheter ablation. Explain to the listeners a little bit about what those are and whether they’re a permanent solution.
Dr. Altman: Sure. So, let me talk about the treatment of the rhythm itself. So, once you have made this determination of the risk of stroke, then we need to decide how we’d like to treat the rhythm itself. For many people, just starting medications to slow the pulse down while not necessarily treating the rhythm itself can make people feel much better. And, if we can make the patient feel normal again by slowing down their pulse, that’s called the “rate-control strategy”. And, rate control and anticoagulation can be an end in and of itself and is an appropriate management strategy for atrial fibrillation. For those patients who continue to feel symptoms despite the pulse being controlled with medication, then we need to talk about other ways to manage the rhythm itself. That may involve what’s called first an “electrical cardioversion” in which patients come into the hospital, receive anesthesia, and then receive an electrical shock. That shock can almost always restore a normal rhythm. However, it’s very unclear how long it lasts for an individual patient. Some people revert immediately back into atrial fibrillation following the shock and others may not revert back to atrial fibrillation for years. If the cardioversion is unsuccessful in that the atrial fibrillation returns, then there are really two options for treatment. The first are medications called “antiarrhythmic medications” which have about a 60% success rate in maintaining sinus rhythm. Each of those comes with their own set of side effects and needs to be tailored individually for a patient. The second option is an invasive procedure, a minimally invasive procedure, using catheters called an “ablation procedure”. During that procedure, the catheter’s inserted into the heart and small burns are made inside the heart tissue to try to eliminate atrial fibrillation. In certain subsets of patients, that can be very, very successful. For the general population of patients with atrial fibrillation, the success rate is between sixty and eighty five percent for eliminating the arrhythmia. To determine where you might fall in that success rate, the conversation with an electrophysiologist is very important.
Melanie: Dr. Altman, can someone live a long, good quality of life with atrial fibrillation?
Dr. Altman: Absolutely. In fact, once the stroke risk is reduced by starting blood thinners when appropriate, it is the goal of the treatment of atrial fibrillation to restore normal quality of life and normal length of life. That’s why we do the procedures that we do in order to restore the quality of life that a patient had before the diagnosis.
Melanie: And, give us some of your best advice on lifestyle modifications that can help as a side along with the treatment or possibly prevent AFib altogether.
Dr. Altman: So, what we’ve learned is that all of the recommendations that we’ve been giving to remain heart healthy, in general, also seem to prevent atrial fibrillation and they also seem to improve the success rate of the procedures that we do to eliminate atrial fibrillation. So, to be specific, one emerging and very important risk factor for atrial fibrillation that also can improve the outcome of a procedure to eliminate atrial fibrillation by up to 50% is the diagnosis and treatment of sleep apnea. Sleep apnea is a major cause of atrial fibrillation and is something that should be taken seriously, evaluated, and treated appropriately by a sleep specialist. Other risk factors like diabetes and hypertension, when they’re controlled with medication, also reduce the risk of atrial fibrillation and improve the success of any procedure that may be done. Weight loss is very important along with moderating alcohol and continuing to do exercise.
Melanie: And, tell us about your team at Summit Medical Group.
Dr. Altman: We have a fantastic team of cardiac electrophysiologists and general cardiologists here. Myself and Dr. Jonathan Steinberg work together as cardiac electrophysiologists within the group and we work with the many very skilled cardiologists here to come up with a comprehensive approach for each patient who presents with atrial fibrillation. And, as I said before, that sometimes involves medications or procedures. What we’re really lucky to have here at Summit Medical Group is the multispecialty practice in which it’s very easy for me to refer to, say, a sleep medicine specialist in a patient who has been recently diagnosed with atrial fibrillation and needs treatment for sleep apnea. So, we really take a holistic approach to the management of this arrhythmia. We don’t segment it so that you’re only be seeing an electrophysiologist or only be seeing a cardiologist. We really think that management of the entire patient is important to the management of this specific arrhythmia. We are also able to provide, when necessary, really the cutting edge of treatment with regard to interventional procedures for atrial fibrillation. With mine and Dr. Steinberg’s experience, we’ve had a vast experience with the multiple technologies that are available for cardiac ablation of atrial fibrillation.
Melanie: Thank you so much for being with us today. It’s great information. You’re listening to SMG Radio. For more information, you can go to www.summitmedicalgroup.com. That’s www.summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.