Scott Webb (Host): Atrial fibrillation, or AFib, is common and there are many myths and frequently asked questions about AFib that my guests are here to address. I'm joined today by Dr. Neel Patel;. He's an electrophysiologist with WakeMed Heart & Vascular - Complex Arrhythmia. And I'm also joined by Michelle Deans. She's a provider for the WakeMed Heart Vascular Atrial Fibrillation Center.

This is WakeMed Voices, a podcast from WakeMed Health and Hospitals in Raleigh, North Carolina. I'm Scott Webb. It's great to have you both here today. We're going to talk about AFib. Of course, that's the abbreviated version, easier to say, but atrial fibrillation. And essentially, we're going to talk about some of the common myths and frequently asked questions and sort of dispel those myths and all that good stuff.

So Dr. Patel, I'm going to start with you. You know, I've heard this before. I have known someone who has AFib, but basically AFib will kill me. True or not?

Dr. Neel Patel: Thank you, Scott, for having this and for arranging this. Yeah, absolutely. AFib is a very common chronic illness, if we can think of it in that fashion, much like hypertension and diabetes. As we get older, it seems to be one of those conditions that people develop over time. And if you ask a neighbor or a friend or a family member, I'm sure they'll say, "Yes, I know someone with AFib."

But the common misconception, will AFib kill me? It's something that I actually hear about a lot in clinic. And what it ultimately comes down to, it's just like what we had talked about, it's a chronic disease that all of us are managing to some degree or burden over, you know, a lifespan of a patient. And what we found is that the better we can control this, the longer people live a normal life. Most of the symptoms that are related to AFib, people experience when their AFib isn't controlled, when their rates are fast. And certainly, if the rates are faster, the AFib can cause the heart muscle to weaken, which, if It isn't controlled, can shorten a life. But ultimately, it's a diagnosis that doesn't really kill somebody or shorten someone's lifespan. It's more one of those things where the better we control it, the normal life patients do live. And as long as we're reducing the burden, patients do just fine.

Michelle Deans: In the long run, AFib itself, the electrical issue won't kill you. It won't stop your heart, but the things that it causes down the road increases overall mortality. It has a five-fold increased risk of developing heart failure, which Dr. Patel just mentioned, just the extra stress on the heart while you're in AFib, especially at a higher heart rate. There's also a 2.4-fold increased risk in stroke. And so, heart failure and stroke are our main focuses when we think about treating AFib or reducing the burden of AFib. There is also a 1.5-fold increased risk of dementia and heart attack.

Host: So then, Michelle, I have my list of, you know, things that I want to go through today, the myths and frequently asked questions. So, does that mean that in some patients, AFib may cause a heart attack, but in others, it may not, right? So in other words, it's not going to cause a heart attack in everyone who has AFib. It's maybe more personalized or unique to the person. Is that right?

Michelle Deans: Definitely. So, AFib can cause a heart attack in one of two ways. One is if somebody already has coronary artery disease, which is plaque buildup in the coronary arteries that supplies blood, oxygen to our heart muscle. If you already have plaque in those coronaries, and you're in AFib, that can put more strain on the heart muscle, which then can lead to a heart attack. So, that's one way AFib can lead to a heart attack.

The other one is if you form a blood clot because of AFib, that blood clot can then travel down one of the coronaries, blocking the blood flow, which leads to a heart attack as well. But those risks overall are low. Like I said, it's a 1.5-fold increased risk of having a heart attack.

Host: Right. And as Dr. Patel was saying, it's really like people live with AFib quite successfully and quite well. There may be other complications, there may be other risk factors. So, there's a lot spinning around in my head right now. Dr. Patel, are there different types of AFib?

Dr. Neel Patel: Yes. You know, we give AFib a designation. And a lot of the time when we're seeing patients, we kind of label them as one of three categories, either paroxysmal, persistent, or permanent. And we can kind of think of AFib on that spectrum. You know, paroxysmal patient is someone who's had episodes of AFib frequently. They last very short in duration. They're infrequent in terms of their episodic occurrences. They don't last long at all. Again, patients come out of them on their own.

And then some patients, over time, if that paroxysmal state is left untreated or changes within the left atrial dimension of the heart, it can progress to a persistent AFib. And that's commonly what we see where patients come in, you know, days in AFib or up to a week and I've started, I kind of know when I went into it, but they don't really come out of it on their own unless we do something about it, whether it's a cardioversion or giving them a medication. And then, these episodes can also become more frequent in duration. They can happen instead of a couple times a year, a couple times a month. And then, permanent is a designation that patients and physicians kind of come to as in an agreement together. And that is that any attempt to try to get them out of AFib has been unsuccessful in the past and continues to be unsuccessful going forward. And so at that point, patients and physicians kind of come to that consensus that it's very unlikely that we can get them out of AFib. And the goal is then directed to keeping the heart rate controlled and, as always, to minimize the stroke risk by keeping them on blood thinners.

Host: Right. Yeah, it's hard for me to get my mind around, Doctor, that someone could be in AFib for days on end or even a week. I mean, that just sounds, I don't know, terrifying, you know. And it makes me wonder, Michelle, you know, thinking about ways that folks might try to stop AFib or stop a stroke from AFib. Is aspirin one of them? Is that something that folks might turn to?

Michelle Deans: It used to be that aspirin was given to low or intermediate risk patients, but not anymore. Our newest guidelines for AFib, it's based on literature and many studies that help guide us in making the best evidence-based decisions when we're treating AFib. So, those guidelines now tell us that aspirin is not recommended. It's not enough to protect people against a stroke from AFib.

The way we determine if people need stronger blood thinners is using a risk score calculator, essentially called a CHADS-VASc score. You add up points for different risk factors, such as high blood pressure, previous heart attack, and you get points for those things. The more points you have, the higher stroke risk you are. And if you're considered high risk, then you should be on a strong blood thinner ongoing. If you're low risk, then you don't need to be. And if you fall in this intermediate risk, then it becomes a conversation. Dr. Patel, would you like to talk more about that?

Dr. Neel Patel: So, you know, we talk about, in my discussion with patients in the clinic, I start off by saying, if we can take away one thing from this conversation, it's that AFib increases the risk for stroke. And when I say this, I think patients really perk up and kind of get that understanding that a stroke could be truly devastating at any age, whether it's the 30-year-old with their first episode of AFib or the 90-year-old that's fully functional and carrying on their day to day life as if they're 50.

So, anticoagulation or a blood thinner is extremely important. And it's something that the CHADS-VASc score does kind of give us an overall risk assessment based on risk factors that are incorporated into this score. But what I always tell patients, and it's always a discussion between a patient and their provider, and that discussion is the young and healthy patients that have virtually none of these risk factors, a stroke can be truly devastating. You know, those patients, if they're on a blood thinner, their overall bleeding risk is very low. So, it's not uncommon that after having this discussion with certain patients, that they opt to be on the blood thinner anyways. And certainly, for older patients with many risk factors, the risk of stroke is much, much higher. And in those patients, unless there's an overwhelming risk of bleeding, we almost always recommend a blood thinner.

Now, everything is kind of individualized to a patient. And certainly if they've had risk-threatening bleeding in the past, there's a discussion. And even then, there's newer therapies that are out there, such as left atrial appendage occlusion with a Watchman device or an amulet, which we can use in these certain patient populations to eventually get them off of a blood thinner.

Host: Yeah, which does seem the goal, obviously. You know, we're going to talk more about ablation in a bit, doctor, but maybe you can address this one that I put on my list here, you know, can I stop my meds after an ablation?

Dr. Neel Patel: You know, ablation by far is better than any medications, and those medications being antiarrhythmic medications, carries the best success. And we kind of talked about the different types of AFib, that paroxysmal, persistent, and permanent. Ablation, medications all work best in that paroxysmal stage.

So, this is something that I think the cardiology society is recognizing more and more, the early referral to places that have an AFib center like WakeMed or to an electrophysiologist when patients are in that paroxysmal stage where these medications work much better, ablation works much better. And we can also slow or even prevent the progression from that paroxysmal to persistent or even worse to that permanent stage.

So, a lot of patients come to us on medications already because they are in that persistent stage. And at that point, you know, an ablation is an enticing option if those medications have not really been beneficial to them. So, it's not uncommon after an ablation, that I'll talk to patients and show them what findings we found during the case. When we do an ablation procedure, we get a lot of useful information that otherwise we can't get from a non-invasive imaging study. And I show these patients what their atrium essentially looks like. And for a lot of patients that have extensive scar or various triggers for AFib in different areas of the heart, we like to keep them on these medications for at least a short period of time, anywhere from six weeks to six months, just to slow and quiet that electrical activity that can happen initially after an ablation. What I mean by that is there's a lot of inflammation and edema that occurs with ablation, especially if we do a significant amount of ablation. And sometimes being on those medications can help suppress what we call AFib episodes during the blanking period. And that blanking period is essentially the timeframe for the heart muscle to heal after an ablation. And then, usually, if patients have done well during that period, the first thing we talk about on their subsequent followup visit is can we discontinue that antiarrhythmic medication? The question often comes up about the blood thinner, that is the absolute last thing that we consider discontinuing. But again, you know, stroke is one of those things where that can be a truly catastrophic scenario. So, it's often a very involved discussion, and we're very hesitant to stop the blood thinner.

Host: Yeah. And really see the benefits of early diagnosis, early referral, as you're saying, because you don't want it to get to that permanent stage if it can be helped. You know, doctor, maybe it's because I'm a hypochondriac, but I feel like if I had AFib, that I would have a hard time exercising because of your fear of triggering AFib, right? I'm just wondering, how do you talk with patients about that? What are your thoughts about that? If they tell you, "I can't exercise, I have AFib," what do you say?

Dr. Neel Patel: AFib will certainly cause someone's extra tolerance to decrease. So, it's very common that patients come to us and say, you know, "Going up the stairs now, I have more shortness of breath, more fatigue." And those are common complaints where they fit. And I think that the best way to think about this is when we think about atrial fibrillation, the atria are the top chambers of the heart that actively pump blood into the ventricle and the ventricle then pumps blood to the rest of the body. So, that's a very synchronized contraction where the atrium pushes blood into ventricle pushes blood out to the rest of the body.

In atrial fibrillation, that top chamber is "quivering" to a certain extent. And so, that amount of blood flow isn't circulating as perfectly or as synchronized as it should. So, it's not, you know, surprising in that scenario that patients often say, "Hey, I just don't have the exercise ability. I was previously able to walk three blocks without any shortness of breath. And now that I'm in AFib, I can't." And so, you know, my recommendation is always they certainly should continue to exercise. Exercise in that regard will not hurt them. They may have some limitations and we say, "Exercise to the extent that you feel comfortable." If at any point you feel you're going to get lightheaded or dizzy or you feel like you're going to pass out, by all means, you should stop, rest, kind of compose yourself, and then start up a little slowly again. But exercise in and of itself is not something that we tell patients you should limit yourselves from doing. And we all come and hear this thing where I've only gone to AFib when I've exercised and these triggers that we talk about that certain people say, you know, exercise is my trigger for AFib, almost always there will be another trigger. So, exercise is always a good thing for all aspects of cardiac care and it's something that we don't often tell patients to stop doing.

Now, that being said, Michelle talked about that coronary artery disease with AFib. So if you develop any symptoms of chest pain, shortness of breath, lightheadedness, dizziness, or feeling like you're going to pass out, you should certainly stop activity. Always speak with your physician and see if that's something that you can kind of work around.

Host: Yeah. Michelle, maybe you can take us through how one monitors AFib, like how do they do their due diligence and make sure that they're monitoring themselves as best as possible?

Michelle Deans: Yeah. So, there's a few different options for people to monitor themselves at home for more AFib and then there's ways for us to get the same information as well. So if somebody wants to know if they have AFib or have a diagnosis of AFib, they can use a couple different options. They can get a Kardia mobile device, which is a small device you put your fingers on and it connects to an app on the phone that says if you're an AFib or not. Those are very accurate and you can send that information to your physician as well through myChart.

The other way you can monitor is with a smartwatch. There's a lot of them that monitor in the background and can give you a burden measurement of how much you're in AFib. You can also send those to your physician as well. You can do something as simple as pulse checks at home using a pulse ox monitor to see if your heart rate is irregular because that's the hallmark of AFib, an irregular heart rhythm. So, those are the ways that people can monitor themselves at home.

The options that we have as providers, one of them is called an event monitor, which is essentially a big sticker that goes on the chest wall that you wear for anywhere from two to four weeks and it captures 24/7 data on your heart rhythm. It gives us a lot of information about how much you're in AFibs or what the burden is, how fast or slow it is, and are there any other irregular heart rhythms that we should be made aware of before we do anything.

The last option for monitoring is a very long term option. It's an implantable loop recorder that goes right up under the skin on your chest. It's the size of a paperclip. And it's a very fast procedure, five minutes. We just inject it under the skin and the battery life can be up to six years. And that gives us a ton of information for people who need long-term monitoring.

Again, the monitoring of AFib is important to know if your AFib is progressing at all. Are you having more frequent episodes of AFib? Are they lasting longer? That's the data that we want to know when we're monitoring for AFib, because that then tells us we need to be more aggressive in treating and reducing your AFib burden

Host: Sure. And as you say, not only does the tech sound like something out of a James Bond film or something, Star Wars, whatever, but also all that information can be shared with your provider through myChart really easily, right?

Michelle Deans: Very easily. And sometimes that can save you an appointment too.

Host: Right. Yeah. So, let's talk about, Michelle, again, I was mentioning earlier that I'm a bit of a hypochondriac, and if I had AFib, I feel like I would want to go to the ED every single time, just stop what I'm doing and run to the ED because I was in AFib. But I'm guessing actual folks with AFib probably don't do that, but maybe sort of take us through this a little bit. You know, when should someone go to the ED? Should they go every time they're in AFib? That sort of thing.

Michelle Deans: Yeah, it's a great question because everybody or most people who have AFib tend to have anxiety related to it as well. You're having an irregular, sometimes fast heart rhythm. I mean, it's a heart problem. A lot of people feel very anxious about it, end up going to the ER because of it. But not everyone needs to go to the ER.

The two reasons to go to the ER is if your heart rate maintains greater than 130s and won't come down. or if you're having any severe symptoms. Those are the two reasons that you can go to the ER. If you don't meet those two criteria, you can wait to contact one of your providers the following day or at the end of the weekend and kind of review the situation and go from there. Dr. Patel, do you want to add anything?

Dr. Neel Patel: Yeah, you know, I think that the big focus there, like you talked about, is are those symptoms? And it's not uncommon for patients to check their pulse and find out that they're going fast. And as long as their blood pressure is acceptable and they're feeling okay, you can always take these extra medications to lower the heart rate. And that is something that you should always speak to your physician about in terms of, you know, how exactly to take those medications and when you should take them. But if at any point you feel that you're lightheaded or dizzy, or you're about to pass out, those are symptoms that warrant further attention and should be evaluated by someone in the ER.

Host: Yeah. All right. So then,, I'll start with you, Michelle, let's go through basically like an overview of the therapies that are available, have you start with rate versus rhythm control.

Michelle Deans: Yeah. So when we think about therapies for AFib, it really depends on the amount of AFib you're having. As Dr. Patel mentioned, is it paroxysmal, persistent? So, how much AFib you're having, how strong or weak your heart muscle has become because of AFib. And really, at the end of the day, it comes down to patient preference. This has to work for you. You have to be comfortable with the plan for it to work. But when we're looking at therapies, we're focused on rate control, meaning slowing down your AFib because most people go too fast when they're in AFib. So, we want to slow it down. The way we do that is with medications like beta blockers or calcium channel blockers such as metoprolol and cardizem.

Rhythm control is really when we're focusing on reducing the amount of AFib someone's having. We can reduce the amount of AFib one of two ways, either with strong medications, you consider them anti-AFib medicines, we call them antiarrhythmics, so with antiarrhythmic medications or with a procedure called a catheter ablation.

The other way we can control rhythm to get somebody out of AFib quickly is with a cardioversion. That's essentially an electrical reboot of the heart. We send it an electrical signal through the heart muscle. It resets the heart and gets somebody out of AFib. It depends how advanced the AFib is that then determines how quickly the AFib returns because rebooting the heart doesn't change the AFib disease itself. It just resets it so it can come back at some point.

Host: Sure. And Dr. Patel, what about DCCV? What is that? What does that entail? It's a reset, but not the fix.

Dr. Neel Patel: That's right. Yeah. Michelle kind of touched on it a little bit. That's the cardioversion that we talk about. It's a procedure that we often have patients come into the hospital, it can be done as an outpatient or as an inpatient. And as long as they're taking their blood thinner medications consistently without missing any doses, it's a procedure that can be done as a standalone procedure.

So, we usually sedate patients so they're not uncomfortable, and it's delivering electrical energy through pads on the chest to restore normal rhythm. Now, the caveat to this is, and one of the main reasons that we stress the importance of being consistent and not missing the blood thinners, is that if there's any question of, missing doses of blood thinners, we have to first confirm that there isn't a blood clot already formed within the heart. And that's where an additional procedure such as an esophageal echo, or an echo done through the esophagus or food pipe, needs to be done to rule out a blood clot. And if there isn't, then we can proceed with the cardioversion. And the cardioversion, like Michelle mentioned, is a reset, I mean, there's no way of predicting when AFib can return. And that's where these medications or ablation can come into play.

Host: Yeah. We've all rebooted our computers, Doctor. We have some issues connecting today. We've all rebooted our computers and sometimes it works great and sometimes it doesn't. So, I see what you're saying. It's a reset, but it may not be a fix for most. Let's finish up then the therapies at least and have you kind of compare and contrast the drugs versus ablation.

Dr. Neel Patel: Yeah, absolutely. So, this is again what Michelle had kind of touched on with antiarrhythmic medications, those anti-AFib medications versus catheter ablation. And like I briefly spoke about before, we really want to capture this patient population in that paroxysmal stage. That's where both the medications and ablation just work a lot better.

When it comes to AFib, there's no cure. But these medications and ablation can drastically reduce the burden, which over time, the less time spent in AFib, we think, will cause less issues throughout a patient's life. So, these medications, some of which kind of depend on multiple factors, are options that patients have in the event that they want to try something more conservative. So, it can be medications that are taken daily, medications that are taken as a what we call "a pill in pocket" strategy. where they take it when they have these episodes of AFib to come out of AFib. and there's multiple different classes of these medications that, you know, it's kind of one of those things where we try and see how they do. And if it's ineffective, we can always consider other options as well.

Catheter ablation, and there's multiple different energy types that we now use from the cryotherapy, which is the freezing type of ablation to radiofrequency ablation, which is heat energy, thermal energy, to our newest form of energy, which is pulse field ablation. And what these are designed to do, they're strategies that are, in a way, an invasive procedure, but they've gotten better over time and the risks have gotten better over time. And so, these are a great option for patients at any stage that is more successful in reducing the burden than any other medication that we have. So, it's an enticing option for patients that have either failed antiarrhythmic drug therapy or for patients that want a more definitive treatment for their AFib.

Now, catheter ablation is always something that we always have patients come in for and we kind of go over in detail. It's a procedure that's done under general anesthesia with an anesthesiologist present. And we're basically targeting areas that can trigger AFib. For most patients, that's the pulmonary veins that insert into the left atrium. And then, we also use an individualized approach where we give patients adrenaline to see if there's specific triggers to that patient, that if it does induce AFib, we can target those at the time of the procedure as well.

Host: Well, I have to tell you both, I've been on my end, fortunately, no one could see me, but I've been on my end of this conversation, just sort of shaking my head a lot today. Just how far the treatment, the understanding and the treatment of AFib has come in the years that I've been hosting these podcasts. It's really amazing. A lot of head shaking on my part. I'm sure listeners as well. Michelle, just want to give you first last word, if you will, finish up here. Give us an overview of the Atrial Fibrillation Center as a trusted resource.

Michelle Deans: Thanks, Scott, for asking. I'm the physician assistant that runs WakeMed Heart & Vascular's Atrial Fibrillation Center. We're located in the Heart Center at the main campus of WakeMed and we have an hour for appointments and we discuss a wide spectrum of AFib topics. It's for patients with new onset AFib or AFib that seems to be progressing and worsening over time. And we talk about what AFib is, why that patient has developed it, like what their specific risk factors are and how we can modify those risk factors from things like blood pressure control, diabetes, obesity, sleep apnea.

And I have the great ability to use a multidisciplinary referral approach to treating AFib. So, I send people to the specialists that they need to see to help modify those risk factors, such as sleep medicine, bariatrics, nutrition. If they don't already have a cardiologist, I get them a general cardiologist, as well as an electrophysiologist like Dr. Patel and we go over all the treatment options and then I typically send them to electrophysiology.

Dr. Neel Patel: Yeah. And Scott and Michelle, thank you. Michelle has done a fantastic job at WakeMed with the AFib clinic. And it's one of those things where I think it's going to be a model for many hospitals in the country to try to do something similar. It's the perfect avenue for patients that have been newly diagnosed with a condition and they're just trying to get more information, trying to understand how this could have developed and how they can prevent further episodes. Michelle has the ability to refer these patients whoever needs to see them on the sooner side.

And I think patients, at least in talking to them, sometimes even during their visit, it's not uncommon that Michelle will come and grab one of us and say, "Hey, do you want to just talk a little bit further about the ablation or the medication piece?" And there's many of us that would go right on over next door to the clinic and talk to these patients. And, you know, the amount of comments in terms of patients saying, "Wow, this is awesome." This is not something that I otherwise would have expected to speak with a physician and appointment where they thought they were just going to kind of get more general information.

So, I think that this clinic overall has been an awesome, awesome-- it's something that I walked into, but Michelle's been working on for years. And I think patients definitely will benefit, and it's also kind of good for them to get the general information before seeing cardiologists or electrophysiologists where they have very little time to spend on all of this other stuff.

Host: Right. Well, I really appreciate your time today. I appreciate the time, your expertise, the education. A lot churning through my head. I'm going to keep thinking about this conversation long after we've disconnected. But you all are doing great work. Really appreciate it. Thanks so much.

Dr. Neel Patel: You're welcome.

Michelle Deans: Thank you.

Host: And to learn more about WakeMed's Atrial Fibrillation Center, please visit wakemed.org. And if you found this podcast helpful, please share it on your social channels and take out the full podcast library for additional topics of interest. This is WakeMed Voices, a podcast brought to you by Wakeman health and hospitals in Raleigh, North Carolina. Thanks for listening.