A common heart rhythm disorder, atrial fibrillation also increases patients’ risk of stroke.
Learn more about the options available for atrial fibrillation patients to reduce their stroke risk from a UVA specialist in heart rhythm disorders.
Reducing Stroke Risk in Patients with Atrial Fibrillation
Featured Speaker:
Dr. Rohit Malhotra
Dr. Rohit Malhotra is board-certified in internal medicine and cardiovascular diseases; his specialties include caring for patients with heart rhythm disorders. Transcription:
Reducing Stroke Risk in Patients with Atrial Fibrillation
Melanie Cole (Host): A common heart rhythm disorder, atrial fibrillation, also increases patients’ risk of stroke. My guest today is Dr. Rohit Malhotra. He’s board certified in internal medicine and cardiovascular diseases. His specialties include caring for patients with heart rhythm disorders at UVA Heart and Vascular Center. Welcome to the show, Dr. Malhotra. Tell the listeners, what is atrial fibrillation?
Dr. Rohit Malhotra (Guest): Thanks for having me. Atrial fibrillation is an abnormal rhythm in the heart. Essentially, the heart beats because of electrical signals that arise from the top chamber of the heart and travel down to the bottom chamber. In some people, abnormal signals can arise so that the heart, instead of beating regularly and changing in rate depending upon need, such as exercise, will beat fast and irregular at times when it shouldn't be—sometimes during sleep, sometimes during activity. These can lead to symptoms of shortness of breath, chest pain. In essence, what ends up happening is that many people end up feeling very fatigued and are unable to do their normal daily activities. This can be detected quite easily by checking your pulse, or often the blood pressure cuff, for example, will demonstrate that the heart rate is fast and irregular. Unfortunately, this abnormal rhythm can lead to an increased risk for stroke. The reason that happens is because most chambers in the heart actually have an inlet and an outlet where blood will come in and blood will go out. But there is a chamber on the left side of the heart called the appendage. It’s sort of like the appendix of the heart, where blood can only come in and out through one doorway, for example. The problem is, when the heart starts beating fast and irregularly, the blood doesn't pump out of that chamber appropriately, and that can actually lead to clot formation, and those clots can then break off and cause stroke or blood clots in the arm or the leg.
Melanie: So that is really why patients with atrial fibrillation are at higher risk for stroke. So how is stroke risk for a-fib typically managed in patients?
Dr. Malhotra: Well, the two big risk factors that we think about with atrial fibrillation are stroke, as you mentioned, as well as potentially heart failure, where the heart starts going really fast for long periods of time. So in general, what we want to do is prevent clot formation in the atrial appendage in that top chamber of the heart. Predominantly, the way that this has been done historically over years has been using medication. Predominantly, one medication has been available up until the last two or three years, and that’s been Warfarin, or Coumadin. This is a medication that will thin the blood and help prevent clots from forming. Unfortunately, Warfarin can be quite cumbersome for patients to take. It involves alterations in the diet and monitoring of blood levels in order to make sure that the blood is not too thin but also that an effective dose has been consumed by the patient. Now, in the recent past, in the last three years or so, there have been newer medications that have come to market that allow for either once-daily or twice-daily dosing. The blood is thin, clots don't form, and the risk of stroke is reduced. These medications don't involve changes to diet. They don't involve checking blood levels. Now, one of the issues that has arisen is that we’ve had many years’ worth of experience of using Warfarin, so we know how, in general, to make people’s blood clot, should they have a problem. If somebody needs emergency surgery or falls and bumps their head and starts bleeding, we need to manage that. With some of the newer medications, we don't have quite as much experience and so don't have great agents to reverse the effect. With time, the medications will filter out of the system, but sometimes we need to accelerate time, if you will.
Melanie: Dr. Malhotra, what are some innovative treatment options and research that UVA is offering? Tell us a little bit about the procedures that people can have to treat their atrial fibrillation and decrease their stroke risk.
Dr. Malhotra: There are two different approaches to that. In the recent past, we were involved in a trial. I talked about the appendage and its contribution to stroke risk in atrial fibrillation. One question that arose several years ago was what happens if we actually close off the appendage in one way or another and thus prevent blood from going into this chamber, and thus hopefully limiting the risk of clot formation? It appears to be quite effective, and there are a number of different approaches for actually closing off the atrial appendage. One is to place a device either inside the heart, in the appendage, and close that off. We’ve recently been conducting part of a national trial of one of the devices available for this, and the FDA’s currently reviewing that. And so, we’re not continuing. Their nationwide study has been closed for now and may re-open in the future, or the device itself may be approved. There is another procedure that involves actually placing a suture in a relatively non-invasive way where we put catheters around the heart as well as within the heart and close off the appendage from the outside. And that involves no use of blood thinners after the procedure, and that’s been thus far in our experience very effective. There are a number of institutions in the country participating in that type of work. There is a newer study that’s opened that involves a surgical procedure. It actually involves using two or three keyhole incisions, thereabout, a centimeter to two centimeters long in the chest, and we’re actually able to place what almost looks like a hairclip over the appendage from the outside, and that closes off the appendage and makes sure that no blood can get in or out. During this procedure, while it is a surgical procedure, the heart remains beating, and in general, patients have been doing very well with that. That hairclip style device has been used in surgery, cardiac surgery, for a long time, but we’re part of a trial looking at doing this procedure by itself without doing any cardiac surgery other than just putting this clip on. Beyond that, there really is a lot of debate as to whether reducing the total amount of atrial fibrillation actually has an impact on stroke risk. So, one approach that people take to managing atrial fibrillation and stroke risk is to potentially try to reduce the amount of atrial fibrillation, and for that we do a variety of different rhythm-related procedures to try and help people stay in rhythm. In general, we do that predominantly for symptoms but there may be some benefit in terms of stroke risk reduction. With that, we have catheter-based techniques where we place catheters into the heart and modify the electrical system, either by heating up the tissue or in fact using a newer technique using a balloon that will freeze some of the tissue and leaves normal tissue function but changes the electrical properties of the heart and may limit the risk of atrial fibrillation. There also are some surgical techniques that are used as well.
Melanie: Dr. Malhotra, in just the last minute that we have, why should patients come to UVA for treatment of their heart rhythm disorders?
Dr. Malhotra: I think we have a wide number of people that are actually intimately involved in doing these procedures, we have about 10 years’ worth of experience, and the advantage ends up being that we offer people a wide variety of different techniques. There are multiple approaches to doing these types of procedures in order to close off the appendage or limit the amount of atrial fibrillation, and we have a wealth of experience with all of those techniques, I think more so than most hospitals in the country, in fact. So, I think we offer perspectives that are really unique, and we tailor all of our therapies specifically to the patients that we treat on a daily basis.
Melanie: Thank you so much. You’re listening to UVA Health System Radio. For more information about UVA Heart and Vascular Center, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Reducing Stroke Risk in Patients with Atrial Fibrillation
Melanie Cole (Host): A common heart rhythm disorder, atrial fibrillation, also increases patients’ risk of stroke. My guest today is Dr. Rohit Malhotra. He’s board certified in internal medicine and cardiovascular diseases. His specialties include caring for patients with heart rhythm disorders at UVA Heart and Vascular Center. Welcome to the show, Dr. Malhotra. Tell the listeners, what is atrial fibrillation?
Dr. Rohit Malhotra (Guest): Thanks for having me. Atrial fibrillation is an abnormal rhythm in the heart. Essentially, the heart beats because of electrical signals that arise from the top chamber of the heart and travel down to the bottom chamber. In some people, abnormal signals can arise so that the heart, instead of beating regularly and changing in rate depending upon need, such as exercise, will beat fast and irregular at times when it shouldn't be—sometimes during sleep, sometimes during activity. These can lead to symptoms of shortness of breath, chest pain. In essence, what ends up happening is that many people end up feeling very fatigued and are unable to do their normal daily activities. This can be detected quite easily by checking your pulse, or often the blood pressure cuff, for example, will demonstrate that the heart rate is fast and irregular. Unfortunately, this abnormal rhythm can lead to an increased risk for stroke. The reason that happens is because most chambers in the heart actually have an inlet and an outlet where blood will come in and blood will go out. But there is a chamber on the left side of the heart called the appendage. It’s sort of like the appendix of the heart, where blood can only come in and out through one doorway, for example. The problem is, when the heart starts beating fast and irregularly, the blood doesn't pump out of that chamber appropriately, and that can actually lead to clot formation, and those clots can then break off and cause stroke or blood clots in the arm or the leg.
Melanie: So that is really why patients with atrial fibrillation are at higher risk for stroke. So how is stroke risk for a-fib typically managed in patients?
Dr. Malhotra: Well, the two big risk factors that we think about with atrial fibrillation are stroke, as you mentioned, as well as potentially heart failure, where the heart starts going really fast for long periods of time. So in general, what we want to do is prevent clot formation in the atrial appendage in that top chamber of the heart. Predominantly, the way that this has been done historically over years has been using medication. Predominantly, one medication has been available up until the last two or three years, and that’s been Warfarin, or Coumadin. This is a medication that will thin the blood and help prevent clots from forming. Unfortunately, Warfarin can be quite cumbersome for patients to take. It involves alterations in the diet and monitoring of blood levels in order to make sure that the blood is not too thin but also that an effective dose has been consumed by the patient. Now, in the recent past, in the last three years or so, there have been newer medications that have come to market that allow for either once-daily or twice-daily dosing. The blood is thin, clots don't form, and the risk of stroke is reduced. These medications don't involve changes to diet. They don't involve checking blood levels. Now, one of the issues that has arisen is that we’ve had many years’ worth of experience of using Warfarin, so we know how, in general, to make people’s blood clot, should they have a problem. If somebody needs emergency surgery or falls and bumps their head and starts bleeding, we need to manage that. With some of the newer medications, we don't have quite as much experience and so don't have great agents to reverse the effect. With time, the medications will filter out of the system, but sometimes we need to accelerate time, if you will.
Melanie: Dr. Malhotra, what are some innovative treatment options and research that UVA is offering? Tell us a little bit about the procedures that people can have to treat their atrial fibrillation and decrease their stroke risk.
Dr. Malhotra: There are two different approaches to that. In the recent past, we were involved in a trial. I talked about the appendage and its contribution to stroke risk in atrial fibrillation. One question that arose several years ago was what happens if we actually close off the appendage in one way or another and thus prevent blood from going into this chamber, and thus hopefully limiting the risk of clot formation? It appears to be quite effective, and there are a number of different approaches for actually closing off the atrial appendage. One is to place a device either inside the heart, in the appendage, and close that off. We’ve recently been conducting part of a national trial of one of the devices available for this, and the FDA’s currently reviewing that. And so, we’re not continuing. Their nationwide study has been closed for now and may re-open in the future, or the device itself may be approved. There is another procedure that involves actually placing a suture in a relatively non-invasive way where we put catheters around the heart as well as within the heart and close off the appendage from the outside. And that involves no use of blood thinners after the procedure, and that’s been thus far in our experience very effective. There are a number of institutions in the country participating in that type of work. There is a newer study that’s opened that involves a surgical procedure. It actually involves using two or three keyhole incisions, thereabout, a centimeter to two centimeters long in the chest, and we’re actually able to place what almost looks like a hairclip over the appendage from the outside, and that closes off the appendage and makes sure that no blood can get in or out. During this procedure, while it is a surgical procedure, the heart remains beating, and in general, patients have been doing very well with that. That hairclip style device has been used in surgery, cardiac surgery, for a long time, but we’re part of a trial looking at doing this procedure by itself without doing any cardiac surgery other than just putting this clip on. Beyond that, there really is a lot of debate as to whether reducing the total amount of atrial fibrillation actually has an impact on stroke risk. So, one approach that people take to managing atrial fibrillation and stroke risk is to potentially try to reduce the amount of atrial fibrillation, and for that we do a variety of different rhythm-related procedures to try and help people stay in rhythm. In general, we do that predominantly for symptoms but there may be some benefit in terms of stroke risk reduction. With that, we have catheter-based techniques where we place catheters into the heart and modify the electrical system, either by heating up the tissue or in fact using a newer technique using a balloon that will freeze some of the tissue and leaves normal tissue function but changes the electrical properties of the heart and may limit the risk of atrial fibrillation. There also are some surgical techniques that are used as well.
Melanie: Dr. Malhotra, in just the last minute that we have, why should patients come to UVA for treatment of their heart rhythm disorders?
Dr. Malhotra: I think we have a wide number of people that are actually intimately involved in doing these procedures, we have about 10 years’ worth of experience, and the advantage ends up being that we offer people a wide variety of different techniques. There are multiple approaches to doing these types of procedures in order to close off the appendage or limit the amount of atrial fibrillation, and we have a wealth of experience with all of those techniques, I think more so than most hospitals in the country, in fact. So, I think we offer perspectives that are really unique, and we tailor all of our therapies specifically to the patients that we treat on a daily basis.
Melanie: Thank you so much. You’re listening to UVA Health System Radio. For more information about UVA Heart and Vascular Center, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening.