Transcription:
How to Recognize, Diagnose and Treat Atrial Fibrillation



PODCAST: Dr. Kenneth Ellenbogen, September 2020


Michael Carrese: [00:00:00] Most of us don't even notice our heartbeat. It just quietly pumps the ways we go about our day. But if you have something called atrial fibrillation, you can't help but notice. AFib is one type of irregular heartbeat and it's worth learning about because it can increase the risk of stroke by five times, and about one in four adults over 40 are at risk for having it. We're going to learn all about it today from Dr. Kenneth Ellenbogen, the chair of cardiology at VCU Health. This is Healthy with VCU Health, I'm Michael Carrese and Dr. Ellenbogen perhaps we can start with having to explain how the electrical activity in the heart is supposed to work normally. And then you can describe what's going wrong with AFib.

Dr. Kenneth Ellenbogen: [00:00:41] Sure. That sounds like a pretty good place to begin. You're right, normally, most people are completely unaware of their heartbeat and for those people, that's wonderful. That's the way it's supposed to work. That's really great. I think for patients who have atrial fibrillation, they have an abnormality of the electrical system of their heart, primarily located in the atrial chambers, which are the upper chambers of the heart. Now in normal people, there is a sequence of finely tuned electrical events. Pretty, absolutely amazing the way everything works, where they're electrical signals that emanate or begin in the sinus node, which is essentially the heart's normal pacemaker. These electrical signals fan out through both the right and left atrium there's areas where they're conduction and maybe a little bit more rapid.

And then they come to what's called the AV node, which acts sort of as a gatekeeper allows Signals to get to the ventricle. the ventricles, which are the bottom chambers of the heart and they are the electricity, the electrical signals that go to the bottom chambers of the heart go through sort of, I like to make an analogy it's like high-speed internet.

There are these cables called the His-Purkinje System, which allow rapid conduction to, and throughout the ventricles. Now atrial fibrillation, is what it sounds like, it's an abnormal heart rhythm, localized to the atria and a normal heartbeat is 60 to a hundred beats a minute. When it's below 60 beats a minute, we call it bradycardia.

And when it's above a hundred beats a minute, it's tachycardia. Now, if you're running on a treadmill, you want your heart rate to increase. So your heart can pump more blood to your muscles and you can run and not get tired or short of breath. But in atrial fibrillation, it's when the upper chamber beats pathologically rapid.

And if you actually put a catheter inside the atrium, when a patient, when someone is in atrial fibrillation, the heart rate is crazy fast. It can be anywhere from 350 to 800 electrical impulses per minute. And not only is that atrial rate amazingly fast, but it's completely disorganized. And by that, I mean in normal rhythm, there's a uniform sequence of activation of the heart and it goes the same way for every single beat. in AFib,

The electrical impulses come from different directions every second, coming from one part of the atrium that another part of the atrium. So that's what atrial fibrillation is. And its that chaotic Electrical rhythm that results in disordered muscle contraction. So the atria, instead of being a muscle that's acting as a booster pump it's really like a bowl of jello, it's just wobbling. And so it's not really the electrical instability leads to lack of mechanical contraction.

Michael Carrese: [00:03:51] You know, listening to all this, it seems amazing to me that the heart can withstand this for any period of time because some people live with this for years, right.

Dr. Kenneth Ellenbogen: [00:03:59] It is amazing to me that some people live in atrial fibrillation and do really, really well, have minimal symptoms.

But as a general rule, the patients who tolerate it aren't quite as many as we think. And often times they tolerate it because they're left in AFib or they may be older or relatively inactive. Most people do feel better in normal rhythm. That's the way the body was designed. That's the way everyone's born in sinus rhythm, AFib is really primarily a disease that happens as people get older, so there are very, very few people with AFib in their teens or twenties or thirties. It becomes more common as people get older. So it does in the vast majority of patients lead to sub-optimal function in one way or another.

Michael Carrese: [00:04:55] And do you know, you meaning science and medicine, what sets off the errant electrical activity.

Dr. Kenneth Ellenbogen: [00:05:04] That's a great question. We are working hard to try to understand why some patients have atrial fibrillation and others do not. We do know for example, that there are certain things that predispose patients to atrial fibrillation, sleep apnea, obesity, hypertension, for example, just a couple. But AFib is not necessarily related to coronary artery disease or heart attacks.

It is an electrical problem. And some people only have AFib had been no other cardiac problems. Some people have AFib and a variety of other cardiac problems.

Michael Carrese: [00:05:41] You know, I mentioned at the beginning that it increases a person's risk for stroke quite a bit. Why is that?

Dr. Kenneth Ellenbogen: [00:05:47] Because when the atriums in atrial fibrillation, it's not contracting, it's not moving normally.

And that leads to blood pooling and blood tends to pull in a structure called the atrial appendage, which has little ridges and furrows in it. And when the blood pools there, you can have a clot. a clot can be about the size of the tip of a ballpoint pen, and that clot can go shooting out the heart up the aorta, into the brain. in a clot Really the size of the tip of a ballpoint pen can result in paralysis. Somebody can be paralyzed

Michael Carrese: [00:06:24] My goodness. And again, so if this is happening all the time, there's more likelihood of clots and then more likelihood of stroke. I'm guessing?

Dr. Kenneth Ellenbogen: [00:06:31] Your guess is exactly what we're beginning to realize. And that is, there is a relationship between the amount of AFib a patient has and their risk of stroke.

So you're exactly right. Patients who are in a permanent AFib or in AFib for long periods of time. We absolutely worry about them developing strokes more than somebody who has AFib for 30 seconds.

Michael Carrese: [00:06:57] I also talked about the pervasiveness of this. It does seem like it affects a lot of people or at least a lot of people are at risk.

Has it been growing over the years or maybe because of what you said about age it's going to grow because our population is aging in the US?

Dr. Kenneth Ellenbogen: [00:07:10] We're not exactly sure what's going on. Some people believe that it's an epidemic of AFib and those people believe the epidemic is primarily a reflection and of the aging population. Others believe that this epidemic is related to the concomitant comorbid conditions. Let's face it, A lot more Americans are obese now than they were 50 years ago. So age is a contributing factor. Again, obesity, sleep apnea, hypertension we've seen more, and more of that, that's a factor. And finally, the third factor may be, we have so many Better ways to diagnose AFib. You still have to go to the doctor's office to get an EKG. Now, people buy these mobile apps, people buy watches, and they can figure out that they have AFib when, before we may not have caught it unless they happen to be in the doctor's office when they had it.

Michael Carrese: [00:08:06] I was actually going to ask you about that because you see people wearing those all the time.

So do you folks consider that to be medically accurate, What an Apple iWatch is reporting out?

Dr. Kenneth Ellenbogen: [00:08:17] For the most part, it often is accurate. So yes, it's changing the way we take care of these patients.

Michael Carrese: [00:08:23] So tell me more about that. What do you mean?

Dr. Kenneth Ellenbogen: [00:08:24] Well, I think gives patients the ability to say, Hey, I feel funny. My heart feels funny. And so now we're picking up more, AFib in younger people. We're picking up more episodes of AFib that are just brief in duration. Then, you know, if you have five or 10 minutes of AFib, you are unlikely to go to the doctor's office and get an EKG to catch it.

Michael Carrese: [00:08:44] Right. Is there a problem with people kind of over-reporting, can it make people more nervous than they need to be? Because it's really sensitive?

Dr. Kenneth Ellenbogen: [00:08:51] I don't know if it's a problem, certainly in some patients, it can be, but I think as a general rule, my belief has always been that it's better to have more information than less information, but if somebody is likely to just get very, very anxious with that information, then those devices are probably not for them.

Michael Carrese: [00:09:14] Yeah, that makes sense. So let's talk about treatment and what you folks do at VCU health to help these folks out, what's involved?

Dr. Kenneth Ellenbogen: [00:09:22] Well, we basically have a full repertoire of tools and techniques to treat AFib. About 22 years ago, we began a project with Johns Hopkins and the University of Alabama at Birmingham, probably the first three centers in the world to try to develop a catheter-based ablation approach to cure AFib. Ablation is the use of a catheter in energy delivered to the tip of a catheter to try to destroy those circuits or those areas of the atria that are either initiating or potentiating AFib. We've been interested in trying to treat AFib without drugs. There have always been drugs to treat AFib, but the area of drug development for the treatment of AFib has not really progressed much in the last 22 years. We've maybe have one or two new drugs compared to a couple of decades ago. And that has not been an area where people have put a lot of work and research. Although there are some interesting new drugs under development, and hopefully in the next five or 10 years, we'll have different classes of drugs, which work on different mechanisms that cause AFib. But we've been absolutely excited about trying to fix AFib, trying to.

I use the word cure, We're not there yet, but trying to find ways to make AFib go away, to make the progression of disease in the atrium Stop in those methods involve the use of either freezing or burning primarily in the atrium to get rid of the circuits or the areas that give rise to AFib. We've been on a 22-year journey.

We've been working with our colleagues all over the world, to develop new methods to treat AFib. We've done thousands and thousands of eighth of ablations over the last 22 years, many thousands. And there are many people who we've done who have not had AFib in 10 years or 15 years or 20 years. But it is an ongoing journey because AFib is not a stationary disease.

And if you see a patient in AFib today who maybe has 10 episodes of AFib a year, I asked a couple of hours. If you don't do anything at all, just say, Hey, why don't you come back in a couple years and a couple years, there's a pretty good chance that patient could be in AFib 24 hours a day, seven days a week.

So AFib tends to progress from short episodes or Peric SysML episodes to being stuck in it all the time. We call that persistent AFib or longstanding persistent AFib, where patients have to live the rest of their life in AFib. And so our goal is to find catheter methods, which we can use to treat that So they stop having AFib or the progression stops. That's one area we've been really working on both in the electrophysiology lab and in the operating room. The other part of AFib treatment that's relatively new is, Because of the increased risk of stroke, patients often take blood thinners and those blood thinners are associated with the risk of bleeding. You thin the blood out you prevent stroke, but you also get the patient at risk of bleeding. And in some people that risk of bleeding can be exorbitantly high, or they can end up bleeding and needing multiple blood transfusions. And in those people who can't take blood thinners, that have atrial fibrillation. They still have a risk of stroke.

We have what we call left atrial appendage, occlusion devices. A device that can be put in, in the catheterization laboratory, or a permanent device that closes off the left atrial appendage. So a patient does not Have a stroke and the patient does not need to be on blood thinner. So that's what we're working on as well.

And we're working on that with a group of international people. These devices have been developed, and we're trying to understand which patients are most likely to be improved by this.

Michael Carrese: [00:13:46] From a patient perspective, you know, they're listening to you talking about zapping inside of their heart. What's that procedure like for them and what's the recovery?

Dr. Kenneth Ellenbogen: [00:13:54] Oh, what a very good question. We also have that down after 22 years. I hope you'd be disappointed in me If we didn't tell you we had that down to a science. When I started out 22 years ago, if we did one of these procedures that took us eight hours, 15 years ago, if we did one of these procedures that took us six hours, I'd say, now we can do a procedure in two hours, sometimes two and a half to three hours, depending upon how complex it is. I often send patients home the same day. We tell them, Hey, you're going home. You know, we'd done at 11 o'clock they're home by four o'clock, and the next day they're getting their mail, they're cooking their lunch or dinner.

And five days later, they're running on a treadmill in the gym. So it's a very quick recovery. It's an invasive procedure, but the recovery is awfully quick.

Michael Carrese: [00:14:44] Yeah. So as we're wrapping up here, what's your message to folks who think they may be having this problem that, you know, there's hope and the treatments are readily available there at VCU health.

Dr. Kenneth Ellenbogen: [00:14:56] Yes. They're readily available. We have a total of six electrophysiologists including myself, but we have five-plus myself, all. Interested in helping patients who have atrial fibrillation and all interested in working with patients to find what works best for that patient.

Michael Carrese: [00:15:18] Well, on that good bit of news for listeners, I'm afraid to say we're out of time and I want to thank you very much.

Dr. Ellenbogen for being with us here today.

Dr. Kenneth Ellenbogen: [00:15:24] Thank you.

Michael Carrese: [00:15:25] You've been listening to Dr. Kenneth Ellenbogen of cardiology at VCU Health. To learn more. Call (804) 628-4327. Or go to our website vcuhealth.org/heart. Thanks for checking out this episode of Healthy with VCU Health. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library at www.vcuhealth.org/podcasts for topics of interest to you. Thanks for listening.

LINK: https://www.vcuhealth.org/pauley-heart-center/our-expertise/atrial-fibrillation-program