Scott Webb (Host): Atrial fibrillation, or AFib, is a common issue that if left untreated, can lead to strokes. I'm joined today by Dr. Suneet Mittal. He's the Associate Director of Cardiovascular Services at Valley Medical Group, Director of Electrophysiology, Medical Director of the Snyder Center for Comprehensive Atrial Fibrillation at the Valley Hospital, and the Director of Cardiac Research for Valley Health System, and he's here today to tell us more about AFib and dispel some of the myths about blood thinners.

 Welcome to Conversations like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Scott Webb.

Doctor, thanks so much for your time today. It seems like I see AFib or I hear AFib in commercials all the time. So I want to talk to you about that today. We want to dispel some of the myths about blood thinners. So good to have you on and let's start there. What is AFib?

Dr. Suneet Mittal: Yeah, thanks for having me on. So one of the reasons you're hearing a lot about atrial fibrillation is that it is very common. In fact, it is the most common sustained arrhythmia that we see in clinical practice. So atrial fibrillation is an arrhythmia that comes from one of the upper chambers in the heart, and it leads to an irregularly irregular heart rhythm, and this can often lead to no symptoms, but often leads to symptoms such as chest pain, shortness of breath, palpitations, lightheadedness, or dizziness. And one of the reasons why you hear so much about this today is not only because it's so common, but one of the real devastating consequences of atrial fibrillation is a stroke, which can often be the first manifestation.

So there's been a great interest in public awareness and identifying whether a patient may have atrial fibrillation and then initiating treatments for atrial fibrillation so that the patient's first presentation is never a stroke.

Host: Yeah, I see what you mean. Because it does seem like for many, they don't have symptoms and then the stroke is the first sign or symptom of AFib. How does that work? How is it possible for someone to have AFib, but really kind of not know it.

Dr. Suneet Mittal: Yeah, that's one of the incredible things about arrhythmias is that two patients can have the same arrhythmia and one feels it and the other does not and we don't have a good understanding of that. What we do know is that in atrial fibrillation, often for every symptomatic episode, there are many, many asymptomatic episodes.

And again, the reasons for that are not fully understood. And so it's really important to be able to identify patients if they're having atrial fibrillation to ensure that therapies are initiated that prevent some of these serious adverse events of which stroke is certainly the most feared.

Host: So, then let's talk about that then. You know, how do you diagnose AFib? If someone's not having symptoms, is it sort of diagnosed while you're kind of poking around looking for other things? But generally speaking, like how is AFib diagnosed?

Dr. Suneet Mittal: Yeah, that is a great question. So it turns out that AFib can only be diagnosed definitively by having some sort of an EKG done. That is the gold standard of making the diagnosis. So, you know, typically it was diagnosed when somebody was in the office and they had an EKG taken and that EKG showed that the patient was having atrial fibrillation.

Now patients often find it surprising because in many other conditions, diagnoses need confirmation with blood tests or other imaging studies. But in the case of AFib, that one EKG establishes the diagnosis, so you don't need a confirmatory blood test or imaging study like a chest x ray or ultrasound or CT scan, so that diagnosis is you know, somewhat easy.

Now what's really changed the paradigm for diagnosis is that today you don't need to be in a doctor's office to have an EKG done. Everyone walking around with a smartphone, you know, often has the technology to record an EKG, and importantly, smartwatches like the Apple iWatch has incorporated EKG recording technologies, and that is one of the reasons why more patients are becoming aware. Because in this era of having smart devices, rhythm and EKG analyses are increasingly being built right into those technologies, making it easier for a person to suddenly recognize that there may be something wrong with their rhythm.

Host: That's amazing. Yeah, we're not just using our smart watches to go through the drive thru and make it easy for us that they actually have these great medical benefits of science, medical technology benefits. It's really cool. I know blood thinners are often prescribed for patients with AFib. Maybe you can talk about that a little bit. Like what are the benefits or why are they prescribed and what are the benefits of blood thinners?

Dr. Suneet Mittal: Absolutely. So, one of the reasons why patients with atrial fibrillation have a stroke is that atrial fibrillation promotes stasis of blood, or pooling of blood, and that pooling of blood typically occurs in a particular area of the heart, which is called the left atrial appendage, and pooling of blood can basically cause clots to form, and if those clots then break off, they go into the brain and can cause pretty devastatingly large strokes.

 And so the way to prevent that from happening is to thin the blood, and there are two types of blood thinners. You know, often, people ask, can I take aspirin because aspirin is perceived as a blood thinner, but it turns out that drugs like aspirin are not strong enough, to prevent blood clots in atrial fibrillation.

And for that, you need stronger blood thinners. And, conventional one that many have heard of is a drug called warfarin or Coumadin, something that we had used for decades, to thin the blood. But today we have newer forms of oral anticoagulants that are commonly prescribed, which are a big advance in how we treat patients with atrial fibrillation. And by thinning the blood, now they can prevent these strokes from happening in the first place.

Host: So then when we think about blood thinners, right, is that for all patients with AFib or is it possible that younger patients I'm putting in quotes might not need the blood thinners?

Dr. Suneet Mittal: I would say that there are a small number of people who don't need a blood thinner, and one of the things that we use to determine somebody's need for a blood thinner is to risk stratify their risk of stroke. And there is a commonly used way to do that.

 And that is called using the CHADS VASc classification. And what CHADS VASc is, it's an acronym where each of the letters stands for something. A C stands for congestive heart failure. H stands for hypertension. A stands for age. And we look at age greater than 65 or greater than 75. D stands for diabetes, S stands for if you've had a prior stroke, and V stands for if you've had vascular disease in the past.

And each one of these is given a score of between 1 and 2, and ultimately the CHADS VASc score in any given patient can be anywhere from 0 to 9. And what we believe is that if you're a male patient with a CHA2DS2 VASc score of 2 or greater, or a female patient with a CHA2DS2 VASc score of 3 or greater, then you should be on a blood thinner.

And patients with a lower score than that can often be managed without a blood thinner. But in our experience, when you use these scoring systems, the vast majority of people, probably more than 80 percent, do qualify for needing a blood thinner.

Host: And do people have trouble with blood thinners? Are there side effects maybe with blood thinners? And if so, what do you do about that? If you know they need to be on blood thinners, but they're having some physical issues, right, with the blood thinners themselves, which is supposed to help with the AFib and prevent strokes, what do you do?

Dr. Suneet Mittal: So historically, when we only had warfarin or Coumadin as a blood thinner, one of the, challenges we had was that the drug often interacted with other drugs, and it also needed frequent blood tests for titration, so that the dose was correct and often even a patient's diet, if it varied, could materially impact how thin the blood got.

Now, these newer drugs that I've mentioned have taken some of those issues off the table. There are very rare drug interactions and almost never is any monitoring required. And almost never is there any dietary interaction. So we've taken most of those issues off the table. But what you can't ever take off the table is that anytime you prescribe a blood thinner, you do it with the known advantage of preventing a stroke by preventing the blood from clotting. But it always comes with the downside of a person's having an increased risk of bleeding. And there are some areas where patients bleed most commonly. Typically nosebleeds, bleeding in the urine, bleeding in the stool, and of course, most concerning, bleeding in the brain. And, you know, these are things that can affect two to 3 percent of patients a year when they take blood thinners.

And so the blood thinners cannot be used by everybody, but fortunately we have some other options in patients like that.

Host: Yeah, let's talk about some of those other options, because I, again, I mentioned as we prefaced here, got going, that I see and hear a lot of commercials about AFib, and it mentions the bleeding part of this, so obviously, you know, the benefit to preventing strokes is preventing the clots, but if you prevent blood from clotting, then folks who bleed otherwise, like a nosebleed, that could be a real big problem. So how do you help those folks?

Dr. Suneet Mittal: Thankfully we do have some non-pharmacologic strategies for stroke reduction. And one of them is implanting essentially what amounts to a filter in the heart. These are called left atrial appendage closure devices. There are two FDA approved for use in the United States.

One is called the Watchman device. Another is called the Amulet device. And in patients who cannot be on a blood thinner, we can often seal off the left atrial appendage, and therefore prevent these blood clots from breaking and going into the brain without a patient, you know, needing to worry about the long term use of a blood thinner.

Now today, we're using these types of devices in patients who are not able to tolerate blood thinners. But we've just recently completed two large studies of several thousand patients each, where patients were randomized to receive either a blood thinner or go directly to these devices. And in a few years, we'll have an idea of whether these devices can be used as simple alternatives in anybody who's at high risk of stroke due to atrial fibrillation.

Host: I see. We could probably do an entirely separate podcast just on those devices like Watchman. But good to know that there are alternatives for those who can't be on blood thinners. And you mentioned dietary earlier, and I hadn't thought about that connection. But I'm wondering, are there certain foods that we can't eat if we either have AFib and or are on blood thinners?

Dr. Suneet Mittal: No. Today, with the more modern blood thinners, there are really no dietary requirements. In general, we want patients to follow a heart healthy diet. We know that in general lowering weight can be helpful with the amount of atrial fibrillation you have. So there are other reasons, you know, to stay heart healthy and maybe modulate the amount of atrial fibrillation you have. But otherwise there's not a direct relationship in any way.

Host: Okay. Well, you are a wealth of information. Just give you a chance here as we wrap up, Doctor, final thoughts, takeaways about AFib. You know, it's one of those weird things that you could have it, but you don't know you have it. Seems like if you just go for a regular physical and they naturally or typically do an EKG, that would be a great way to diagnose that. As you say, also smartwatches, but just in general, final thoughts about AFib and blood thinners.

Dr. Suneet Mittal: Yeah, so I think that it's just important for people to recognize that, you know, we're starting to now explore whether patients should be screened for AFib. That's still very controversial, but if AFib is diagnosed, it's important that patients understand the need for risk stratification for stroke, get placed on blood thinners to prevent stroke when appropriate.

And if they're having challenges with blood thinners, then they should explore other proven alternatives. The one thing I'll say is we often see patients prescribed half dose blood thinners. The thought being, if you take half, you know, maybe you'll have less bleeding. That's something that shouldn't be done because that doesn't really help the patient.

So it's important that guideline based decision making be done at all times. And that importantly, if there's any questions that patients seek the advice of experts who manage lots of patients with atrial fibrillation.

Host: That's great advice from an expert. That's perfect. As you're saying there, you know, half doses of things, that doesn't sound like it meets the guidelines. And you sound like someone who meets the guidelines and you seem like the type of doctor we should be consulting with, but either way, it's been really educational, informational today. I'm sure listeners are nodding their heads too. So thank you so much. You stay well.

Dr. Suneet Mittal: Perfect. Thanks for having me.

Host: For more information about AFib at Valley, please visit valleyhealth.com/SnyderCenter or call 1-800-VAL-LEY1. That's 1-800-825-5391 to schedule an appointment. And if you found this podcast helpful, please share on your socials and check out our entire podcast library for topics of interest to you. And thanks for listening to Conversations Like No Other presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest please call 201-291-6090 or email Valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well