MedStar Health DocTalk

Atrial Fibrillation

July 21, 2022 Sunjeet Sidhu, MD Season 2
MedStar Health DocTalk
Atrial Fibrillation
Show Notes Transcript


Comprehensive, relevant and insightful conversations about health and medicine happen here… on MedStar Health Doc Talk.

Atrial Fibrillation (AFib) is the most common type of arrhythmia. In the US, it affects between 2.7 million to 6.1 million Americans, and that number is projected to rise to 12.1 million in 2030.

Dr. Sunjeet Sidhu, cardiac electrophysiologist, discusses atrial fibrillation (AFib)—including risk factors, signs, and symptoms. We’ll also talk with him about when to seek care from a specialist and the treatment options available to patients at all stages along the AFib continuum.

Dr. Sidhu sees patients at MedStar Union Memorial Hospital, MedStar Franklin Square Medical Center, and MedStar Health Bel Air Medical Campus.

For interviews with Dr. Sidhu, or for more information about this podcast, contact Regional Media Relations Director, debra.schindler@medstar.net

(upbeat music) - Comprehensive, relevant, and insightful conversations about health and medicine happen here. When MedStar Health DocTalk. An irregular heartbeat, palpitations, lightheadedness, fatigue, or shortness of breath could all be symptoms of many things, but for millions of Americans, it's a sign of atrial fibrillation or AFib. We're talking today with cardiac electrophysiologist, Dr. Sunjeet Sidhu from MedStar Heart and Vascular Institute in Baltimore, to learn more about atrial fibrillation. I'm your host, Debra Schindler. Dr. Sidhu, welcome to DocTalk. - Thank you for inviting me, I'm glad to be here. - AFib can be somewhat complicated and I have so many questions. First help me understand why patients with AFib should see not just a cardiologist, but an electrophysiologist, or an EP such as yourself, what's the difference? - It's a great question. I think in general, there are a lot of patients with atrial fibrillation, and it's one of the most common arrhythmias in the world, in the United States as well. And for patients who have atrial fibrillation, they're usually picked up by their primary care doctor, either on a routine physical or they present to the emergency room with a very symptomatic AFib. And in general, my thought process has been, if a patient can at least see an electrophysiologist once, then I think that's worthwhile to have that discussion because there are lots of things that we can offer them that their primary care doctor or their cardiologist even cannot. And the field of AFib being that it is the most common arrhythmia is advancing light years all the time. And so the amount of things that we can offer in terms of new innovation, new therapies, new techniques is much more than what perhaps the primary care doctors can be kept abreast of just cause they have to do so much. - Do you used the word arrhythmia, - Help me understand what that is. - Arrhythmia simply put as an abnormal heart rhythm. And so that could be in this case, atrial fibrillation, there are other arrhythmias that people can have called SVT, which is common in our younger patient populations. And then there are other more deadly arrhythmias called ventricular tachycardia as well. And so as an electrophysiologist or colloquially, as I referred to a heart electrician, we deal with all these electrical problems with the heart. - So what made you go in that direction? I mean, I imagine you're a cardiologist first. - Yeah, so to become a cardiac electrophysiologist, you go through medical school, internal medicine, cardiology training. So I'm a board certified cardiologist. And then an additional two years to do an electrophysiology training. And in electrophysiology that additional training is focusing on heart arrhythmias and to do procedures in order to treat those arrhythmias as well. And so the things that interested me in heart electrophysiology or EP, is the fact that we have a lot of options to treat patients. And it's a problem that is previously, even if you go back 40 years was very difficult to treat 'cause we didn't have a lot of technology to do so. So the rapid pace of innovation was what excited me the most. - Was there something that motivated you in particular, a case maybe that had come in? - Oh, I could name several. I mean, from ranging from the young patients who have deadly arrhythmias, that you're able to change around their lives, to our older patients who end up coming in because they pass out because their electrical system has failed them, and you save their lives with a pacemaker. So there's lots of things, you know? And there's many cases in between sort of excited my passion about treating heart rhythm disorders. - I think when you bring up the term electrical, that is what makes it complicated for a lot of people to remember is that there is an electrical circuit that passes through the heart. How do you explain that to your patients? - I think about the heart as a big old engine, there's the pumping component of the engine. There's the actual pipes that brings the gas, or in this case, blood to the rest of the heart. And that's where you talk about your interventional cardiologist and stents. And then there's the electrical component that makes sure that the whole system is functioning in a coordinated fashion. And so those are the three ways that I separate the different components of the heart. And so you have your general cardiologist, your heart failure cardiologist, your interventional cardiologist, and your EPs. And they each focus on something a little bit different. - So in the intro I mentioned some symptoms that may indicate AFib, are there others? - Yeah, that's a great question. Patients come in with many different symptoms from atrial fibrillation. The most common are those that for patients who have sudden onset palpitations, they suddenly feel their heart fluttering or they feel their heart racing, but that's not it. Some patients can have associated chest pain, associated shortness of breath. There are patients who don't really feel their palpitations, but primarily feel that they just feel winded or they feel like they've aged excessively in the course of just a few weeks, they just feel like they can't do as much. Sometimes it's patients' spouses that are bringing up the fact that they're just not as vibrant as they used to be. Some patients will describe what's called a brain fog. I will even describe one patient, although I'm not saying that this is common, who knows that he has AFib because he gets a toothache every time. Now I don't want to be a general dentist and deal with toothaches, but there aren't patients can present very normally with atrial fibrillation. But in general palpitations, shortness of breath, chest pain, and difficulty exerting themselves. - So there's a lot of times though, that people might experience, my heart skipped a beat, maybe they're excited or they fearful. When is it the right time to go see a specialist? When is it dangerous? - Yeah, a lot of people can experience extra heartbeats, either PACs, extra heartbeats from the upper chamber, or PVCs, extra heartbeats from the bottom chamber. And a certain number of those even up to 500 of those a day is normal. Usually when I tell patients that they need to see someone is if they're having sustained palpitations. So if they're having it for several minutes or longer in a row, or if it's causing significant symptoms like lightheadedness feeling like they're about to pass out, chest pain, shortness of breath, those be reasons to seek care more urgently. - I'm sure that when they come in, they're very scared. - Yeah, a lot of of patients will come to us after they've gone through a lot of other workup for various other causes. And then finally someone's diagnosed them with atrial fibrillation. The unique thing about atrial fibrillation is that it often starts out as paroxysmal. Meaning patients will have episodes that come and go. And so you'll have a patient who will have an episode over last 20 or 30 minutes, by the time they get to their doctor, or the ER, or wherever their arrhythmia has ended. And so someone gets an EKG and tells 'em that their heart is normal. And that can also be pretty frustrating to patients as well, because they know something's wrong, but they keep being told that nothing's wrong with their heart. Sometimes it gets attributed to anxiety or some other issue, and it's really not the right answer. And so often it takes a little while to make that diagnosis or someone needs to be astute and do something called a rhythm monitor where they're doing a prolonged monitoring of someone's heart. But even then they might not be long enough 'cause patient symptoms with atrial fibrillation or episodes with atrial fibrillation can be so self limited, they can only have one a year or more. It just really depends patient to patient. - If they have an episode, do you think it's likely that they're going to have another one in a certain amount of time, and how long before it presents again? - Yeah, the trajectory for each patient's AFib can be quite different and it's hard to predict based on a first episode when their next episode will be, but more than likely they'll have another episode. And that's usually what I tell patients. It could be a week, it could be a month, it could be a year, it could be longer. And it's hard to know the answer to that question with their first episode of atrial fibrillation. In general, atrial fibrillation begets more atrial fibrillation. So what I mean by that is that atrial fibrillation can cause both chemical, biochemical, and structural changes to the heart that make it more likely for you to have more AFib. So once you have the diagnosis of atrial fibrillation, you are an AFib patient and some are better controlled than others, but it doesn't mean that you can't have more in the future. - What happens if you don't get it treated? How long can you go without getting it treated? - It it's a great question. So for patients who have paroxysmal AFib, they can go months or longer without an episode. And it really is patient dependent, but even AFib untreated, multiple episodes untreated, and continue to have more and more just means that you're gonna have more AFib. And the trouble with that is the further you are along the disease course. So I mentioned that patients often start with paroxysmal AFib, meaning that it comes and goes. At some point, it progresses to persistent AFib, which means they're stuck in AFib for days on end. And as you get to that stage, it becomes a little bit more difficult to treat. And there are even other patients who have been in AFib for over a year or longer. And so once you get to that stage, it just becomes more and more challenging. Our treatment strategies become less and less effective. So in general, we're trying to get to patients who have atrial fibrillation earlier and earlier. - Because there are risks. What happens if they get into severe AFib and it's not treated, what are the risks? - So AFib is associated with many things. The biggest thing that we worry about is the risk of stroke. The risk of stroke is based on certain stoke risk factors, which we can calculate based on a visit when we see a patient. And if their risk of stroke is high enough, we often recommend to them a blood thinner. The other things that patients are at risk for are things like heart failure. If they have significant symptoms of atrial fibrillation, it can affect their quality of life. There's even links between atrial fibrillation and things like dementia as they age. So there are a lot of things that are associated with atrial fibrillation that we definitely want to try to prevent. - Blood thinners seem like it would be such a, it seems like it would be an option that most people wouldn't prefer. - Well, it's a great question. You know, blood thinners are very effective at reducing your risk of having a stroke from atrial fibrillation. And in the past, when we were stuck with Warfarin or Coumadin, it was challenging because patients had to go frequently to their anticoagulation clinics. They had to have their blood checked at least once a month. They had to watch what they eat, a lot of medication interactions as well. And so that made it a little bit more challenging. With the newer agents over the last five, 10 plus years, it becomes a lot easier to take. The blood thinners are much more reliable in terms of the fact that you give a dose and you expect their blood to be thinned and it doesn't require as frequent checking of their blood counts. And so it has become easier, but some of the issues that come with blood thinners are still there, right? If you bleed, if you scratch yourself or cut yourself, you're gonna bleed more. Some patients will bruise more easily on blood thinners, whereas others won't have any trouble, but blood thinners have been the mainstay of treatment for preventing strokes. - That's what I mean about the blood thinners, because my husband, for example, is a fireman. And he would not be able to work as a fireman, if he were on blood thinners. - Yeah, so there are alternatives for patients who cannot be on blood thinners either because of their profession, because of, let's say they have problems with balance and they're falling a lot and there's risk for internal bleeding, or because they've actually suffered a large internal bleed. We have alternatives, there's two devices on the market. But the essential idea behind that is there's an area in the heart called the left atrial appendage where approximately 95% of all clots form in patients who have atrial fibrillation. And the way a stroke happens in AFib is that there's a clot that forms it breaks off and goes to the brain and causes a stroke. And so for many years, one option was to surgically remove this left atrial appendage. Obviously that's a big open surgery. And so not something that we recommend for any patient coming in to see us, unless they're going to surgery for some other reason. But instead, what we recommend is closure of that left atrial appendage. And there's a few ways to do that, but essentially through the vein in the leg, we can go up into the heart and deploy this device, which essentially seals off the left atrial appendage and makes their stroke risk similar to someone who is going to be on a blood thinner, who is on a blood thinner. So there are alternatives for patients where it's high stroke risk. - Is that the only medical option or there are others? - Well, so that's a great question because blood thinners do not treat the AFib. They treat the risk of stroke related to atrial fibrillation. - I see. - And I like to separate those two things out because there's the component of stroke risk, you treat with blood thinners, or left atrial appendage occlusion, or we talk about how to treat their AFib rhythm. And so for that, there are medical options and there are also procedural options. In terms of medical options, there's a whole slew of different drugs that we can use. Some of which have less side effects, some of which have more side effects, but there's a good armamentarium that we have of different medications, depending on the patient's scenario that we can use to treat atrial fibrillation. And then there's even procedures to treat atrial fibrillation such as catheter ablation. - When do you know what is the right approach for your patients medically, versus going to the next step of having a procedure done? - Yeah, so up until recently, usually you have to have a patient that would fail a medicine first, meaning that we would try medication, they would do well for a while, for example. And then they start to have breakthrough episodes of atrial fibrillation. And then we would consider either an alternative medication or a procedure, the ablation. More recently, however, we found that ablation as a first line therapy for AFib. Meaning that instead of medications, is more effective. So it comes to a patient physician conversation, meaning what are the patient's values? What do they feel? How do they feel about medications? What's their been reaction? Have they had any reactions to medications in the past? Are there certain factors to their medical history, which make certain medications less or more useful or less or more dangerous? And that's what helps us decide what's the better option for the patient. It's still on relatively equal footing in terms of which would work for a single patient. And that's when specific characteristics come into play as to what the right strategy is for one patient. And sometimes there isn't one right strategy and that's when it comes to a patient physician conversation. - So the next step then would be an ablation procedure, explain how that plays out. - So, for most patients who have atrial fibrillation, the ablation that we recommend for them is something called pulmonary vein isolation. And it's a complicated term, but the concept behind it is that the majority of triggers for patients who have atrial fibrillation that is paroxysmal that's early in the disease course, are coming from these veins, these veins that drain blood from the lungs back into the heart. And what we do to treat that is we electrically isolate those veins from the rest of the heart. Back when this was first described by a few surgeons, they used to do that surgically. Thankfully we don't have to subject patients to open heart surgery for the same thing. And so instead what we do is we go in, again, through the vein in the leg, we go into the left side of the heart and we can either freeze or cauterize the tissue around the veins to essentially create this electrical fence around the veins to prevent these triggers from AFib, from the veins causing atrial fibrillation in the heart. And that's proven to be very effective for patients, particularly those patients early in their disease course of atrial fibrillation in terms of reducing the burden of AFib, reducing their need for being on antilithic drug therapy, medications for atrial fibrillation. It doesn't necessarily change dramatically their stroke risk. And so that's where those other strategies in terms of blood thinners and the Watchman or Amulet device come into play, but dramatically can help improve the symptoms from atrial fibrillation. - Is it immediately effective? And how long does the procedure take? It's done in a cath lab, let's make that clear. It's not done in an operating room. - Correct. - But in the cath lab. And then how long is the patient generally in there? - Yeah, it's a great question. So, when this was first described, it would be an all day thing. But thankfully, the technology's improved significantly. Our skills have improved and so it's actually gotten a lot faster. So in general, what I tell my patients is that the actual procedural time is gonna be about an hour to 90 minutes. - Wow. - It is done under general anesthesia- - That sounds quick. - Yeah, I even have cardiologists that will tell me, "Oh, when I was training, AFibs used to take eight to nine hours." That's not true anymore. So I would say between an hour to 90 minutes, patients are fully asleep for the whole procedure. Can't say many good things came outta COVID. But one of the things that came out of the COVID pandemic is we were forced to figure out how to get patients out of the hospital. And so what we realize is that most of our AFib ablation patients can go home that day. And so now, just over the last two years, we started putting in these little collagen plugs to prevent bleeding, which is the main reason patients stayed overnight. And now I would say that 90 plus percent of my patients are going home after an AFib ablation that evening. - When you go in to do a procedure like that is the person in AFib? So that you're able to see where that circuit is traveling around the heart, or do you have to create. - Most of the time, we are not looking at patients in atrial fibrillation because the ablation procedure that has the most data for it is really just targeting triggers from AFib, which are these structures. So it's more of an anatomic ablation targeting a structure rather than arrhythmia. Sometimes patients who come in for an AFib ablation will have another arrhythmia mechanism. So they'll have, like I alluded to earlier, something called SVT or they'll have something called atrial flutter. And so what we'll do is we'll target those as well during that ablation procedure. And that is, it's more critical to have the patients in arrhythmia when we do the procedure. - Is it immediately effective? - Great question, so, in general, yes, we do see a good response for patients right away. The only challenge is, and I warn patients about this, is you can see some atrial fibrillation during the healing phase of ablation. What I mean by that is, we're going into the atrium, we're creating a little irritation by doing our procedure and that irritation can trigger AFib. And so some patients can have AFib in the first one to three months after an ablation related to healing and not necessarily meaning that their AFib ablation hasn't worked. It's just a little early to say. So although many patients will see a result right away, for some patients, they might have some early AFib during the healing phase that will then go away later. - Would you say that it's a cure? - There is no cure for AFib, unfortunately. And so both medicines and ablation work to help reduce the burden of AFib. They borrow terminologies from other areas of medicine. I almost think of it like putting AFib in remission rather than a cure. - It can come back. - Yes. And the thing is, atrial fibrillation is more common as we age is common with a lot of medical conditions like obesity, hypertension, diabetes. And so a lot of things that may cause atrial fibrillation in the first place may still be there. Or alternatively patients as we get older are likely to have more AFib. So I do tell patients that at some point the AFib might come back because our risk factors for AFib might still be there, or God willing, we all keep getting older. So, that's also possible as well. - Is it hereditary. - In general, no. Although there are groups of genes that make patients more likely to have AFib. I usually don't think about that unless someone tells me that they're having AFib before the age of 50. At that point, I start worrying a little bit more that they're AFib may be related to some hereditary mechanism. There are also other very, or I should say more rare cardiac conditions that are inherited, that are linked with AFib as well. But in general, no. - What's the most unusual case that you've had would you say? Someone very young? - Yeah, I will tell you that, one of the most interesting cases I've had in the last two years is actually a young patient with AFib. So usually, like I said, most of my patients tend to be in their fifties or older with atrial fibrillation, because atrial fibrillation becomes more common as we age. But just in the last two years, we've been seeing a fair number of patients with atrial fibrillation after COVID, and fair number of young patients after COVID with atrial fibrillation. And so I can think of one patient off the top of my head who was in his mid twenties and completely healthy, otherwise, very active, fit, and developed COVID. And while in the hospital with COVID went into persistent atrial fibrillation was in atrial fibrillation for months. We tried multiple different medications to try to keep him out of AFib, none of which were effective. And we finally took him for an ablation about six months later, after going through multiple different medication iterations first. And with the ablation, he's not had any AFib since. And so, there are some unique cases out there and there are more that we can think of. - That sounds like a journal pub case. Yeah, that's very fascinating. Have there been other ones from COVID? - Yeah, we've seen a fair bit of arrhythmias related to COVID. There has been an increased risk of atrial arrhythmias and ventricular arrhythmias. So arrhythmias in the upper and lower chambers of the heart with patients who've had COVID. So either because they've had AFib already and we've seen more exacerbation of their AFib with COVID pneumonia or COVID infection, or that they have nuance at AFib in the setting of coming in with COVID. - Is there anything that someone can do to prevent it, say they're having it or they feel the onset of it. Can they drink water or change positions? - For most patients, there's not a clear trigger for atrial fibrillation. Some patients do, and for some patients it might be a glass of wine or certain exercises, but most patients are not aware of a specific trigger for atrial fibrillation. Now, in general, in someone who has atrial fibrillation, there are things that we can do to help reduce their risk of having more AFib outside of medicines, outside of procedures. And the AHA coined this term, the simple seven. And so, there are a lot of lifestyle things that are easy to say, but hard to implement. So if someone's smoking, making sure they quit smoking, making sure their blood glucose is well controlled if they have diabetes, making sure their blood pressure is controlled, making sure they're eating a healthy diet, making sure they're maintaining a healthy body weight, and making sure they're getting about 30 minutes of exercise a day, can actually dramatically reduce the amount of AFib you have. - Okay. - And the last one I forgot to mention was if they are drinking alcohol more than one standard equivalent of a drink per day, then they should cut back on their alcohol intake as well. And those are all things that they can do to help reduce the risk for AFib. - What's a common scenario that your patients come in and say, I mean, what happens in their lives that trigger a visit to your office? - Usually the scenario I get, like one that I saw earlier today is someone who experience fluttering in their chest. They'll feel like going up the flight of steps is a massive chore for them, and it'll last for a few hours or maybe even a full day. And then the next day they'll feel back to normal. And that's usually their description of that episode of atrial fibrillation. And then they'll go in and they'll get some rhythm monitoring done by their primary care doctor or their general cardiologist to make the diagnosis of AFib. And that's generally the patients that I will see. There are clearly some patients that are much more severe and those come straight to the emergency room, but often it's a fluttering in the chest and some exertional shortness of breath. - And when you say the monitor, is that the Holter? - Yeah so, people used to see those Holter monitors where they'd hook it onto their belt and they'd have all these wires connected to them. You know, we've got a little bit more sophisticated than that. Now we can do these little things that look like bandages that you apply to your chest with a little computer chip on it, and that will record their heart rhythm for up to two weeks. And so using that is, one it's a little bit easier to deal with, but it gives us great data to say, "Well, are they having AFib, how much AFib they're having or not." And so that's also helpful as well. - You brought up this phrase longstanding persistent AFib. Can you talk about treatments for that condition? - Yeah, as I mentioned earlier, there's these stages of atrial fibrillation. And currently the way we describe it is paroxysmal, which is the early stage. Persistent, meaning you're stuck in AFib for days on end, and then longstanding persistent, where you've been in atrial fibrillation for a full year. And those are patients who we have a lot of difficulty managing. And in the past we would try ablations, but ablation and a cardio ablation. Meaning what I described with pulmonary vein isolation, we know is probably not enough for them. That their AFib has gone so far, that there's been enough structural changes in the heart that make it so that the standard ablation we do for most patients is not greatly effective for them. And so instead, what we're sending patients for now is a newly FDA approved procedure called hybrid ablation. And so with a hybrid ablation, what we do is we collaborate with our surgeons and we do an ablation from both the outside and the inside of the heart. And so we tackle the heart from both sides. And so the first part of the procedure, is the surgeons will make a small incision, maybe about a centimeter or two, about two finger breaths underneath the breast bone. And they'll go in behind the heart with a little catheter and they'll do an ablation on the back wall of the heart from the outside a tissue that we really can't get to effectively from the inside of the heart. Then after they're finished, we then go in from the inside of the heart, through the vein the same way I described before. And we're able to see what the surgeons have done from the outside and touch up the areas that they were not able to get to from the outside. And so it's a great sort of partnership between us and cardiac surgery in trying to manage these very difficult patients, because they can do certain things from the outside of the heart. We can do certain things from the inside of the heart. And in the past, although this might have been done as a big open heart procedure, cracking the chest open. - And now you're not even cutting bone, not even cutting through the chest. - Don't have to cut through the chest. Don't have to stop the heart. You know, the surgical part of the procedure is under 40 minutes. My part of the procedure still under 90 minutes. And so it's been a big improvement in the management of patients who have long standing persistent atrial fibrillation. And has been shown to be superior to just the regular old ablation alone. - And what are the results like for the patient? What's their recovery process like? - Yeah, great question. So usually it's a little bit longer in the hospital. And so instead of them going home the same day, they're either going home the next day or two days later. Postoperatively, they may have a little bit more in the ways of chest discomfort. So people feel like they've been beat up in the chest for a few days and we do follow 'em very closely to make sure they're not having any fluid build up around the heart or anything like that. But in general, they've done very well. And I've had a lot of patients with great experiences who have had AFib for years and have undergone this hybrid ablation procedure and have done really well since. - There's been so many changes in treating AFib through the years. - So AFib, is a very complex problem. And although it fits under one name in terms of a diagnosis, there's a lot of pathophysiology that goes into atrial fibrillation and how to manage that is very different. And so there's a lot of work going into all these different avenues behind how we better care for our AFib patients. - Let me switch gears real quickly here, because I'm thinking of all of the ways now that people are able to self diagnose using equipment that they buy at CVS or Walmart, or even the apple watches. Is that a blessing for you as a physician, or is that dangerous for people to self diagnose? - It's a great tool and we're still figuring out how to use those tools. So they range the gamut. So there's the people who will buy the little pulse ox device that will say if their heart rate is fast and what their oxygen level is. That hit a lot of fever pitch, especially during COVID cause people are really worried about their oxygen level. They're the blood pressure cuffs. So some of the sort of higher end blood pressure cuffs, not only will they check your blood pressure, but they can actually sense in a regular heart rhythm. So they act as a screening method for AFib. So what'll happen is the blood pressure cuff will go off, it'll have a little symbol on there to say that you have an irregular heart rhythm, doesn't mean you have AFib. It just means your heart rhythm's a little irregular, but that might prompt that patient to tell their primary care doctor and their primary care doctor might then get a monitor to look for atrial fibrillation. And if they have atrial fibrillation, maybe that they weren't aware of, maybe they're the group of patients that have no symptoms from AFib. You know, finding that AFib becomes important because if they do have atrial fibrillation and we find that out before they've had a stroke, we could potentially prevent a stroke. So there is some value behind those tools. And then going even more advanced, you have the things like the new Fitbits, the apple watches, the galaxy watches. There are devices that can do passive detection for atrial circulation via similar mechanism. Basically they have a little pulse sensor on the back that faces your wrist, and they can look for it in a irregular heartbeat. Again, doesn't say that you have AFib, but it is a way to at least screen some patients who have irregular heart rhythm that may actually turn out to be AFib, but it would require more testing. And there's even a way that the apple watch, galaxy watch, even a device called the Cardio Mobile. You can actually get an EKG. And so for some patients who have a lot of symptoms of palpitations and they fail to be captured on a monitor, because when they're wearing a monitor, of course they have no symptoms. You know, some patients will invest in an apple watch, or a galaxy watch, or a cardio mobile, and will get this device to do a one lead EKG. Basically capture a rhythm strip that they can look at, or they can even bring in to show their doctor to say, "Look, I had some symptoms, this is what I saw. Is this anything, or is this nothing?" And so that's another valuable tool. And then going on the more extreme spectrum, there is even an implantable device that for patients who are really having trouble finding arrhythmia or finding the cause of perhaps them passing out, we can put an implantable device underneath the skin that does the same thing. This is the size of like a Trident stick of gum that goes in underneath the skin. And instead of monitoring, let's say an apple watch has a battery life of two days. This thing could monitor for up to four years. - What is the first thing that you do then if someone brings that kind of information into you? What what's the next step for you? - The problem with a lot of these devices, is that they over diagnose, or they're unsure, or they can't really figure out what the rhythm is. And so they say undetermined or possible AFib is usually what they'll call it. And so it then requires one, someone to verify. So often they'll bring it into clinic. Will look to see, do I agree, do I disagree? And, if I agree, then I'll usually do some more testing to see, are they having more AFib? What's their burden of atrial fibrillation. Get some more data on that before we proceed. - What's the testing like an EKG. - Either an there an EKG? Sometimes patients will need an echo, So when I think about an EKG echo, stress, all these kinds of things, it has different parts of the heart mechanism. So an echocardiogram mostly only checks for the function of the heart muscle, as well as the function of the valves. But in EKG, where a rhythm monitor, like those patch monitor, I described earlier you can wear for quite a while and figure out burden of arrhythmias and things. - Interesting stuff. Any final thoughts on AFib? - Yeah, AFib is a big problem. I think it is somewhat underrecognized and can even go on undertreated because classic teaching behind atrial fibrillation from the nineties and early two thousands, was get patients on a blood thinner, prevent a stroke, maybe control their heart rate, but you don't need to worry about AFib so much. And that's really not the right way to be treating AFib anymore. So for patients who have symptomatic atrial fibrillation, we have great strategies in which to treat them both medically lifestyle wise and ablation in terms of surgical or invasive interventions. And so we have a lot of options. So patients don't need to live in misery with their AFib. I think we have ways to help them. - Excellent. The heart is such an interesting muscle and I've really enjoyed talking and learning about AFib with you today. Thank you so much for taking the time. We've been talking with Dr. Sunjeet Sidhu with the MedStar Heart and Vascular Institute in Baltimore. Thank you, Dr. Sidhu for sharing your expertise here with MedStar Health DocTalk. For more information on atrial fibrillation, go to MedStarhealth.org and put AFib in the search box or for an appointment with Dr. Sidhu call 4-1-0-5-5-4-6-7-2-7.