Atrial fibrillation (AF) is the most frequently diagnosed cardiac rhythm disorder. Affecting 2.5 million people in the United States, AF can be associated with an increased risk for death, congestive heart failure, and stroke.
Tune into SMG Radio to hear cardiac electrophysiologist Jonathan Steinberg discuss the latest effective treatment options to help patients with AF.
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The Latest Treatments for Atrial Fibrillation
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Learm more about Jonathan S. Steinberg, MD
Jonathan Steinberg, MD
Dr. Jonathan Steinberg specializes in the diagnosis and treatment of heart rhythm disorders, and has an international reputation for expertise in catheter ablation of cardiac arrhythmias.Learm more about Jonathan S. Steinberg, MD
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The Latest Treatments for Atrial Fibrillation
Melanie Cole (Host): Atrial fibrillation is the most frequently diagnosed cardiac rhythm disorder affecting up to 2.5 million people in the United States. My guest today is Dr. Jonathan Steinberg. He is a cardiologist and electrical physiologist with Summit Medical Group. Welcome to the show, Dr. Steinberg. Tell the listeners: what is atrial fibrillation.
Dr. Steinberg: Atrial fibrillation or also commonly known as A-fib is an irregular ,rapid heartbeat that originates in the upper or atrial chambers of the heart, so that the upper chambers are actually quivering at around 500 times a minute. That's the basic electrical mechanism of A-fib.
Melanie: So, the heart really is an electrical conductor, as an organ, isn't it? Would you feel this quivering? Would you feel something? What are some symptoms?
Dr. Steinberg: So, those many, many impulses in the upper part of the heart are channeled down or transmitted to the lower part of the heart, which are the pumping chambers. Most patients can feel the activity of their pumping chambers when they deviate from normal rhythm. Some of the symptoms that people experience are a rapid irregular heartbeat or the consequences of the loss of coordination and efficiency of the heart. Those many electrical impulses that are channeled to the pumping chambers, partially get filled to that by natural mechanisms. So, the bottom part of the heart is not beating at 500 times a minute, but maybe beating at anywhere between a 100-180 beats per minute, for example. That rapid irregular rhythm can be sensed but because the heart's output diminishes during the A-Fib, there is often a sense of tiredness, fatigue, weakness, shortness of breath and a variety of other similar symptoms. But, some of the symptoms are not so obviously those of a rhythm disorder, so can be very difficult to recognize and can overlap with many other cardiac and non-cardiac conditions.
Melanie: Are there some complications if it's not diagnosed?
Dr. Steinberg: Yes, there can be. One other point to mention about symptoms is that roughly around a quarter of patients with atrial fibrillation actually have no symptoms whatsoever. That makes it very difficult to come up with a diagnosis and is one of the important reasons that all patients should be seen regularly by their physicians, so they can be examined and, if appropriate, have an EKG done. Now, in some patients with A-fib, there are important conditions that can result directly from the A-fib. The most concerning and the most serious would be the risk of stroke. Not every patient with A-fib has a risk of stroke. Younger, healthier patients who have no cardiovascular conditions, other than an electrical abnormality like A-fib, actually don't have an elevated risk of stroke. But, older patients, patients with heart disease, prior heart attack, heart failure, valvular conditions or high blood pressure, diabetes and, particularly, if they have had a prior stroke, can have an increased risk of stroke and sometimes a very dramatically increased risk of stroke. That is the most serious complication that can result from A-fib. There's also a risk of heart failure and possibly an increased risk of death overtime as well.
Melanie: So, then, if you do diagnose somebody, how do you diagnose them with A-fib? If it doesn't happen all the time, how can you kind of catch it when it's happening?
Dr. Steinberg: So A-fib comes in two flavors. Most people start up by having intermittent A-fib, medically we call it “paroxysmal A-fib”. In general, the A-fib gets to be more common, more frequent, more prolonged over time and, in a substantial minority of patients converts, into a constant form of A-fib, called “persistent A-fib”. If it's not present all the time, as you imply, it can be difficult to diagnose. Then, we use EKG recording systems. If you come into the office when you're having symptoms, or to the emergency room, an EKG will right away diagnose A-fib. There are also monitors that you can wear or have implanted and even nowadays smartphone ECG systems that can be used to record EKGs at any time and that means we can record intermittent arrhythmias much more readily than we could otherwise.
Melanie: What's the first line of defense, then? Do you look towards medicational interventions, or do you look to some others? When does it require intervention? So, let's start with you first line of defense.
Dr. Steinberg: The first thing that is done is one makes an assessment of the risk of stroke. There are scoring systems that allow us to estimate a patient's long-term risk of stroke and when that risk is elevated, we generally will prescribe a form of blood thinner or anticoagulant. There are a variety of new anticoagulants that have hit the markets and there's the old main stay that has been around for more than 50 years called “Coumadin” or “Warfarin”. All of these anticoagulants can substantially reduce the risk of stroke. That would be the first line of defense against the most serious complication of A-fib. The second item that comes up for discussion is how often is the A-fib happening, how debilitating are the symptoms, how disruptive are they, are there any clinical complications including deterioration of heart function that results from the A-fib? If there are major clinical or symptomatic problems from A-fib, there are medications that can help. They come in two different classes. The first class we call “rate control” and those are medicines that are used to just slow the heart rate during A-fib. It doesn't prevent the A-fib from coming back or convert it back into a normal rhythm, but if your heartbeat is slower when you're in A-fib, it usually is not as symptomatic. The second class of medicines are called anti-arrhythmic medicines. They are designed to suppress the fibrillation and prevent it from returning. There are a variety of medications available but, unfortunately, there are no superstars around or on the horizon. For some patients who don't respond to initial medication treatment, there are interventional procedures called “catheter ablation”.
Melanie: So, let's speak about catheter ablations for a minute. This is a minimally invasive procedure or non-surgical procedure, correct? What happens there?
Dr. Steinberg: Yes, very much so. This is a non-surgical procedure performed intravenously which means we place catheters or small tubes through the veins, usually through the veins in the groin and those veins give us access to right side of the heart. From the right upper chamber, we cross the membrane into the left upper chamber. The left upper chamber has the origin or trigger side of most episodes of atrial fibrillation. There are veins that enter the left upper chamber that are carrying oxygen-rich blood back from the lungs. These veins are called “pulmonary veins”. Most people have four different veins and in and around the opening of the veins there are little stringy muscle fibers that under normal circumstances are not electrically active or independent and have no known normal function. But, when people are vulnerable to A-fib, these muscle fibers become electrically active and are, by far, the most common trigger or initiating side of atrial fibrillation. When we do a catheter abolition procedure, we freeze the opening of the veins to prevent the electrical activity from emerging from these veins and setting off fibrillation in the rest of the heart. So, the main purpose of a standard ablation procedure is to electrically isolate all of the pulmonary veins.
Melanie: Would you ever have to do ablation a second time? Does it work for the long haul or do you have to do it again? And then, when does it go to a pacemaker or some sort of surgical procedure?
Dr. Steinberg: In a majority of patients, there is a very nice and often complete response to the ablation procedure the first time around, particularly if the A-fib has been intermittent. Some patients require a second procedure generally to touch up the first procedure. When there is a sustained response over months and years, there can be a return of atrial fibrillation, even many, many years after the successful procedure. In these instances, we can do repeat ablation as well. Other types of interventions--more extensive ablation, surgical ablation--are reserved for very special circumstances when patients have very severe A-fib and its consequences. A pacemaker is generally not used unless the patient has a very slow heart with an independent of the A-fib, but sometimes as a result of medical treatment but, in and of itself, a pacemaker is not specific treatment for A-fib.
Melanie: So, if you would wrap it up for us in the last few minutes here, Dr. Steinberg, and it’s such great information about A-fib. If there's a way to prevent it, what you really want the listeners about heart health and why they should come to Summit Medical Group for their care.
Dr. Steinberg: So, the most important thing is to have regular medical care, so your doctor can be vigilant for the development of A-fib or its symptoms and, very importantly, to treat the cardiovascular conditions that make you at greater risk of having A-fib. Most importantly, that would be high blood pressure but also obesity, diabetes and other forms of heart disease. Once the A-fib has occurred, your physician at Summit Medical will work with cardiology and electrophysiology to determine what is the best therapeutic approach for you.
Melanie: Thank you so much, Dr. Steinberg for being with us today. 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!
The Latest Treatments for Atrial Fibrillation
Melanie Cole (Host): Atrial fibrillation is the most frequently diagnosed cardiac rhythm disorder affecting up to 2.5 million people in the United States. My guest today is Dr. Jonathan Steinberg. He is a cardiologist and electrical physiologist with Summit Medical Group. Welcome to the show, Dr. Steinberg. Tell the listeners: what is atrial fibrillation.
Dr. Steinberg: Atrial fibrillation or also commonly known as A-fib is an irregular ,rapid heartbeat that originates in the upper or atrial chambers of the heart, so that the upper chambers are actually quivering at around 500 times a minute. That's the basic electrical mechanism of A-fib.
Melanie: So, the heart really is an electrical conductor, as an organ, isn't it? Would you feel this quivering? Would you feel something? What are some symptoms?
Dr. Steinberg: So, those many, many impulses in the upper part of the heart are channeled down or transmitted to the lower part of the heart, which are the pumping chambers. Most patients can feel the activity of their pumping chambers when they deviate from normal rhythm. Some of the symptoms that people experience are a rapid irregular heartbeat or the consequences of the loss of coordination and efficiency of the heart. Those many electrical impulses that are channeled to the pumping chambers, partially get filled to that by natural mechanisms. So, the bottom part of the heart is not beating at 500 times a minute, but maybe beating at anywhere between a 100-180 beats per minute, for example. That rapid irregular rhythm can be sensed but because the heart's output diminishes during the A-Fib, there is often a sense of tiredness, fatigue, weakness, shortness of breath and a variety of other similar symptoms. But, some of the symptoms are not so obviously those of a rhythm disorder, so can be very difficult to recognize and can overlap with many other cardiac and non-cardiac conditions.
Melanie: Are there some complications if it's not diagnosed?
Dr. Steinberg: Yes, there can be. One other point to mention about symptoms is that roughly around a quarter of patients with atrial fibrillation actually have no symptoms whatsoever. That makes it very difficult to come up with a diagnosis and is one of the important reasons that all patients should be seen regularly by their physicians, so they can be examined and, if appropriate, have an EKG done. Now, in some patients with A-fib, there are important conditions that can result directly from the A-fib. The most concerning and the most serious would be the risk of stroke. Not every patient with A-fib has a risk of stroke. Younger, healthier patients who have no cardiovascular conditions, other than an electrical abnormality like A-fib, actually don't have an elevated risk of stroke. But, older patients, patients with heart disease, prior heart attack, heart failure, valvular conditions or high blood pressure, diabetes and, particularly, if they have had a prior stroke, can have an increased risk of stroke and sometimes a very dramatically increased risk of stroke. That is the most serious complication that can result from A-fib. There's also a risk of heart failure and possibly an increased risk of death overtime as well.
Melanie: So, then, if you do diagnose somebody, how do you diagnose them with A-fib? If it doesn't happen all the time, how can you kind of catch it when it's happening?
Dr. Steinberg: So A-fib comes in two flavors. Most people start up by having intermittent A-fib, medically we call it “paroxysmal A-fib”. In general, the A-fib gets to be more common, more frequent, more prolonged over time and, in a substantial minority of patients converts, into a constant form of A-fib, called “persistent A-fib”. If it's not present all the time, as you imply, it can be difficult to diagnose. Then, we use EKG recording systems. If you come into the office when you're having symptoms, or to the emergency room, an EKG will right away diagnose A-fib. There are also monitors that you can wear or have implanted and even nowadays smartphone ECG systems that can be used to record EKGs at any time and that means we can record intermittent arrhythmias much more readily than we could otherwise.
Melanie: What's the first line of defense, then? Do you look towards medicational interventions, or do you look to some others? When does it require intervention? So, let's start with you first line of defense.
Dr. Steinberg: The first thing that is done is one makes an assessment of the risk of stroke. There are scoring systems that allow us to estimate a patient's long-term risk of stroke and when that risk is elevated, we generally will prescribe a form of blood thinner or anticoagulant. There are a variety of new anticoagulants that have hit the markets and there's the old main stay that has been around for more than 50 years called “Coumadin” or “Warfarin”. All of these anticoagulants can substantially reduce the risk of stroke. That would be the first line of defense against the most serious complication of A-fib. The second item that comes up for discussion is how often is the A-fib happening, how debilitating are the symptoms, how disruptive are they, are there any clinical complications including deterioration of heart function that results from the A-fib? If there are major clinical or symptomatic problems from A-fib, there are medications that can help. They come in two different classes. The first class we call “rate control” and those are medicines that are used to just slow the heart rate during A-fib. It doesn't prevent the A-fib from coming back or convert it back into a normal rhythm, but if your heartbeat is slower when you're in A-fib, it usually is not as symptomatic. The second class of medicines are called anti-arrhythmic medicines. They are designed to suppress the fibrillation and prevent it from returning. There are a variety of medications available but, unfortunately, there are no superstars around or on the horizon. For some patients who don't respond to initial medication treatment, there are interventional procedures called “catheter ablation”.
Melanie: So, let's speak about catheter ablations for a minute. This is a minimally invasive procedure or non-surgical procedure, correct? What happens there?
Dr. Steinberg: Yes, very much so. This is a non-surgical procedure performed intravenously which means we place catheters or small tubes through the veins, usually through the veins in the groin and those veins give us access to right side of the heart. From the right upper chamber, we cross the membrane into the left upper chamber. The left upper chamber has the origin or trigger side of most episodes of atrial fibrillation. There are veins that enter the left upper chamber that are carrying oxygen-rich blood back from the lungs. These veins are called “pulmonary veins”. Most people have four different veins and in and around the opening of the veins there are little stringy muscle fibers that under normal circumstances are not electrically active or independent and have no known normal function. But, when people are vulnerable to A-fib, these muscle fibers become electrically active and are, by far, the most common trigger or initiating side of atrial fibrillation. When we do a catheter abolition procedure, we freeze the opening of the veins to prevent the electrical activity from emerging from these veins and setting off fibrillation in the rest of the heart. So, the main purpose of a standard ablation procedure is to electrically isolate all of the pulmonary veins.
Melanie: Would you ever have to do ablation a second time? Does it work for the long haul or do you have to do it again? And then, when does it go to a pacemaker or some sort of surgical procedure?
Dr. Steinberg: In a majority of patients, there is a very nice and often complete response to the ablation procedure the first time around, particularly if the A-fib has been intermittent. Some patients require a second procedure generally to touch up the first procedure. When there is a sustained response over months and years, there can be a return of atrial fibrillation, even many, many years after the successful procedure. In these instances, we can do repeat ablation as well. Other types of interventions--more extensive ablation, surgical ablation--are reserved for very special circumstances when patients have very severe A-fib and its consequences. A pacemaker is generally not used unless the patient has a very slow heart with an independent of the A-fib, but sometimes as a result of medical treatment but, in and of itself, a pacemaker is not specific treatment for A-fib.
Melanie: So, if you would wrap it up for us in the last few minutes here, Dr. Steinberg, and it’s such great information about A-fib. If there's a way to prevent it, what you really want the listeners about heart health and why they should come to Summit Medical Group for their care.
Dr. Steinberg: So, the most important thing is to have regular medical care, so your doctor can be vigilant for the development of A-fib or its symptoms and, very importantly, to treat the cardiovascular conditions that make you at greater risk of having A-fib. Most importantly, that would be high blood pressure but also obesity, diabetes and other forms of heart disease. Once the A-fib has occurred, your physician at Summit Medical will work with cardiology and electrophysiology to determine what is the best therapeutic approach for you.
Melanie: Thank you so much, Dr. Steinberg for being with us today. 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!