Let's talk AFib, or atrial fibrillation

Electrophysiologist Dr. Richard Jones, of the MedStar Heart and Vascular Institute, talks about symptoms and treatment for the full spectrum of the most common form of cardiac arrythmia: atrial fibrillation. 

 

Are you feeling a flutter in your chest, or maybe your smartwatch is signaling an irregular heartbeat? It's time to tune in to your heart's health because atrial fibrillation (AFib) is not just a condition for the textbooks—it's a growing concern for millions.

 In the latest episode of 'MedStarHealth Doc Talk,' we sit down with Dr. Richard Jones, an electrophysiologist from the MedStar Heart and Vascular Institute, to delve into the intricacies of AFib. With a projected 30% increase in cases every two decades, understanding AFib has never been more critical.

 AFib is the most common type of serious heart rhythm abnormality in adults. When the heart's upper chambers quiver chaotically, they fail to pump blood effectively, leading to symptoms like palpitations, fatigue, and potentially life-threatening strokes. But what's more alarming is that some individuals with AFib might not feel any symptoms at all, making them ticking time bombs for stroke risks.

 Dr. Jones explains how new guidelines by the American College of Cardiology and the American Heart Association are categorizing AFib and recommending best practices for treatment. These guidelines emphasize the importance of early intervention and the role of lifestyle changes in managing AFib.

 The episode also highlights the latest advancements in treatment, such as catheter ablation—a procedure that targets the heart's electrical misfires to prevent AFib episodes. Dr. Jones shares that while this isn't a cure, it's a significant step forward in managing the condition and improving quality of life.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

>> Speaker A: 0:05

Comprehensive, relevant, and insightful conversations about health and medicine happen here. Whenmedstarhealth dot talk in 2020, data collected from around the world made clear that the most common form of an irregular heartbeat, called atrial fibrillation, or AFib, is on the rise. The number of AFib cases is trending upwards by at least 30% every 20 years. According to the CDC, 12.1 million people will have Afib in 2030. Who among us will be one of them? We know that atrial fibrillation can lead to stroke. The stakes are high. So last November, the American College of Cardiology and the American Heart association released guidelines to help categorize AFib and recommend best practices for treatment. Electrophysiologist Dr. Richard Jones from the Medster Heart and Vascular Institute joins me today to tell us more about those guidelines and everything listeners need to know about afib. I'm your host, Debra Schindler. Thank you for being here, Dr. Jones.

>> Speaker B: 1:18

Glad to be here, Debra Thank you for inviting me.

>> Speaker A: 1:21

Atrial fibrillation is so common that most of us, at least most of us over the age of 45, know someone who's experienced it or who's been treated for it. And it can be pretty scary when you're having symptoms. What is actually happening when a person experiences atrial fibrillation?

>> Speaker B: 1:38

Fantastic. Thank you for the question. Yeah, so, as you mentioned, atrial fibrillation is the most common, heart rhythm issue out there. Here in the United States and worldwide. It's characterized by, typically an irregular heartbeat, or an irregular heart rhythm is how it's commonly referred to. And what's happening in Afib is the top chambers of the heart that normally squeeze to fill the bottom chambers. And, the bottom chambers squeeze to the pump blood to the body. These top chambers are quivering. They're fibrillating, they're going 300 and 5450 beats a minute. And kind of just chaos in these top chambers. And that gets, transmitted to the bottom chambers as this very irregular rhythm that people tend to feel as fast. Palpitations, they can sometimes see on their apple Watch or fitbit these days that the heart rate just jumps up and kind of stays high, and it's erratic and all over the place. And that's often a sign of atrial fibrillation. as you mentioned, one of the most worrisome, features of atrial fibrillation, it's its ability to increase one's risk of stroke. And that tends to come from those fibrillating top chambers where blood doesn't move well, and when blood isn't moving, well, it can form a clot. A clot that forms in the heart can be pumped to the brain, and that's a stroke. but that clot can really go anywhere in the body and cause damage to any body part or organ due to lack of blood flow wherever that clot happens to go. And so that's why one of the first things we look at when someone is diagnosed with atrial fibrillation is, what is their risk of having a stroke and afib? And that's where blood thinning medicines and things like this can be helpful to reduce that risk.

>> Speaker A: 3:14

Well, it seems that the impact of having atrial fibrillation could really span a full spectrum, because some people don't even realize they were in Afib.

>> Speaker B: 3:23

Absolutely. I think that's a great point, and it always stands out to me. This patient I saw in the hospital where I was looking at the patient, and telemetry was up above their head, and their heart rate was going 160 beats a minute in Afib, and I could see it on telemetry, but they had no clue because they were looking, facing away from the monitor. And I asked them, do you feel anything at all? And they said, absolutely not, doc. I feel absolutely fine. And so that's certainly one end of the spectrum where people have no clue that they're in Afib, and they can be going very fast, even, and have no clue.

>> Speaker A: 3:54

Is it still dangerous if they don't feel it?

>> Speaker B: 3:56

Sometimes, it can be even a little bit more dangerous, to be quite honest. Because if the heart is allowed to go unchecked for weeks and months at a time in a very fast rhythm, at some point the heart, like any muscle, will kind of tire out, and the heart function can actually reduce from going so fast for so long. And so we often see that, we refer to that as a tachycardia induced cardiomyopathy, or simply a weakening of the heart due to a prolonged episode of a fast heart rate in this atrial fibrillation. And so it can absolutely be an issue, but they can span from the spectrum of feeling nothing at all. To some people, knowing the moment they go into Afib like that, they absolutely feel it. I've had one patient describe it as a fish flopping in their chest. Another patient, it felt like a squirrel was running around in their chest. That's how symptomatic they are when they're in atrial fibrillation. Other people experience shortness of breath, shortness of breath when they walk around a reduction in exercise kind of capacity. Right, doc? I used to be able to walk up this hill. I had no problems. I took my dog for a walk every day. Now, all of a sudden, in this Afib, I'm huffing and puffing to get up the hill. And so that's another kind of symptom of atrial fibrillation. Fatigue often comes, with Afib, some people can feel the fatigue in the rhythm. Other people describe it kind of as they break out of afib, they can feel that fatigue. and so that can be another common symptom of atrial fibrillation.

>> Speaker A: 5:22

Feeling that a squirrel is running around on a wheel in your heart is not something that you're likely to not notice.

>> Speaker B: 5:28

Exactly.

>> Speaker A: 5:29

What should somebody do if they have that sensation? Should they lay down? Should they not be walking the dog?

>> Speaker B: 5:35

That's a great question. I mean, there are lots of ways to approach that. I think anytime your heart rate is going fast and sustained and you have symptoms, the safest thing is probably to call, EMS to get immediate help.

>> Speaker A: 5:46

It's a 911.

>> Speaker B: 5:47

It can be. I mean, some people's heart rates get very elevated, and depending on what other medical conditions you have, it can be somewhat serious. I think. If there's any time where something is sustained for long periods of time and you're feeling short of breath or you're having chest discomfort, anything like that, I think it's always right to just call ems, get immediate help, get to a hospital, and we can sort things out. Afib is not one of these rhythms. Some people who may be listening to this may have heard of SVT or superventricular tachycardia, fast rhythms that come from the top chambers of the heart that are kind of a separate, category from atrial fibrillation. Atrial fibrillation is also a top chamber rhythm, if you will. but it kind of gets its own special, category with atrial fibrillation and its cleas and atrial flutter kind of being grouped together because they have this, increased risk of stroke and different ways of approaching its management. But SVT tends to be that rhythm. M where people have heard, if you bear down, you can sometimes break out of it and things like that. With Afib, those maneuvers don't necessarily work so well. Oftentimes we have to use medicines if someone stays in sustained, fast rhythms or even procedures, like ablation procedures, to try and kind of, control that atrial fibrillation, if you will.

>> Speaker A: 6:58

You mentioned the flutter. I want to distinguish between the flutter and the fibrillation, what's the difference? And is the flutter not so dangerous? It's not so risky, or is it still just as risky?

>> Speaker B: 7:09

Oh, perfect question. So, atrial flutter is. We often refer to it as a cousin to atrial fibrillation. They're two kind of separate rhythms, if you will, but they tend to co occur oftentimes. People who have atrial flutter, we will go on 30, 50% of the time. they will go on to develop atrial fibrillation. And in atrial flutter, instead of that chaos that we see in the top chambers, where the top chambers are just quivering and going 300 and 5450 beats a minute in chaos. In flutter, the top chamber gets stuck in a loop, and so the top chamber tends to be going still quite fast. 200 and 5350 beats a minute, somewhere like that. And that loop is the difference between the two, if you will. It's kind of a structured loop that sometimes we have to treat. With cardioversion, we shock people out of, which is also used for Afib or an ablation procedure. One of the bigger differences between atrial fibrillation and atrial flutter is it can sometimes be difficult to control atrial flutter with medications, meaning to slow down the rhythm or to have people pop out of the rhythm. With what we call anti rhythmic medicines, atrial flutter tends to be a little bit more difficult to control as medicines, whereas atrial fibrillation can be a little bit easier. Both rhythms, though, is important to notice. We use this scoring system called the chad's vas score, to look for one's risk of stroke. That's how we risk stratify, is use the scoring system called Chad's vasc, and that simply stands for congestive heart failure, hypertension, or high blood pressure. We look at age, diabetes, history of a previous stroke, history of a prior heart attack or other vascular disease, and then, actually being a female gets another point as well in the scoring system. And that's how we determine one's need for blood thinning medicines or other strategies to reduce one's risk of stroke. So, both AfiB and aflutter increase the risk of stroke, and slightly different in terms of, how we kind of manage them with medicines and ablation and things like that. Usually someone with a chad score of zero. We don't recommend blood thinning medicines because oftentimes in that situation, blood thinning medicines may have a higher risk, whereas their stroke risk is higher than the general population, but not so high as to warrant maybe being on a blood thinning medicine. if you have a chad's vascore of one, that's where we really start having conversations with the patient about whether or not a blood thinner makes sense with what they do and how they want to approach things and how they approach their overall risk for stroke. Some people are very worried about stroke, and they want to do everything they can to reduce that risk. And so starting a blood thinner for a chad's vascular 1 may make sense there, or we look at other risk factors. Right. Is the top chamber of the heart very dilated? Is there other medical comorbidities, like chronic kidney disease or severe obesity or things like that, that may elevate one's risk? That's outside of that scoring system? And then generally, a chad's vascore of two or higher is where our guidelines recommend blood thinning medicines, for sure. The newer guidelines have made a move to a 2% risk of annualized, risk of stroke or more, which allows us to take into account other risk factors outside of that chad's vascular that may elevate one's risk for stroke in these rhythms.

>> Speaker A: 10:15

So you mentioned the svts. Is that an arrhythmia?

>> Speaker B: 10:18

It is. It's a different form of arrhythmia. it tends to come in kind of three main buckets, if you will. There's, ah, an atrial tachycardia, or a little focus that starts firing fast, an isolated little focus. There's, avnrt, or this little loop that the heart gets stuck in right at the central junction box between the top and bottom chambers, electrically. And then there's AvRT, which is kind of a bigger loop that the heart can get stuck in, which is an abnormal connection between the top and bottom chambers, electrically. This is different from Afib and atrial flutter in that SVT doesn't increase one's risk for stroke. and then when we start talking about, medical management or even ablation procedures, ablation tends to be much more successful for SVT procedures, whereas for atrial fibrillation, there's no true kind of cure for atrial fibrillation. We use medicines, we use ablation procedures to try and knock down the amount of AFib. One is having, to decrease that burden, in particular, if they're very symptomatic with Afib, or if they've had a prior reduction in their heart squeeze, like we talked about, if they go fast and don't know it for a while, and the heart function really reduces, those are really reasons to really be aggressive and try to control the amount of Afib.

>> Speaker A: 11:29

You're having an irregular heartbeat, palpitations, lightheadedness, fatigue, shortness of breath. All could be symptoms of, Afib. Are there others? What's the craziest one that you've heard of?

>> Speaker B: 11:42

I mean, the one that we often find, even when patients say, I don't feel anything in Afib, is oftentimes fatigue. Another is this exercise intolerance. Right. I used to be able to do this and that and not have any issues, and all of a sudden, I'm huffing and puffing when I do it. I think those really stand out. And I think a lot of times, if it's unclear if someone is having symptoms from atrial fibrillation, well, oftentimes, that's where we may reach for a cardioversion procedure, a procedure where we sedate someone and make them sleepy so they don't feel anything, and then we can shock the heart back in a normal rhythm. Now, in normal rhythm, we can say, well, you know, you were in Afib then. Now you're in normal rhythm. Do you feel any different? Oftentimes, that's where you find that the fatigue has gone away, the shortness of breath has gone away that they didn't realize was there, especially with exertion. Right. That shortness of breath. And younger folks, it tends to be with exercise. Right. I used to be able to, run 5 miles. All of a sudden. Now I run a mile, and I'm out of breath. That's where it really becomes evident. If it wasn't clear before, is that juxtaposition that you're in normal rhythm now after the cardioversion and then the weeks before you were in Afib, how different do you feel? And that's how we kind of try to tease out sometimes if someone truly has symptoms, because if you have symptoms from atrial fibrillation, then that is a class one indication to think about performing an, ablation procedure. And in some cases, even without trying medications, some people don't want to try medications. In other cases, people have failed medications. And if that's the case, then we can proceed to this catheter ablation procedure, where we target the most common triggers for atrial fibrillation, which tend to come from these veins, what we call the pulmonary veins that plug into the top chamber of the top left part of the heart. And those pulmonary veins can have abnormal electrical firing, and that electrical firing can set the heart off into atrial fibrillation. And that's the most common trigger for Afib. It's not the only trigger for atrial fibrillation, but it's the most common trigger for atrial fibrillation. And that's why, when we perform a catheter ablation procedure, the idea is to either freeze, we're using heating energy. are the two common modalities these days. we kind of, create purposeful scar at the entrance of those veins with an ablation procedure, and scar does not conduct electricity. So now the vein can be firing away, but the heart will never see it because it gets blocked by this purposeful scar we've created. And that's the idea behind a catheter ablation procedure for atrial fibrillation.

>> Speaker A: 14:11

M now, when those scars are created, does that mean. I mean, they're not going to form immediately when you do the procedure, right. So the patient comes out, can they still be an Afib after a procedure like that?

>> Speaker B: 14:24

That's a wonderful question. We actually refer to the kind of three months after an Afib ablation procedure as the healing phase. That's when this freezing, which we most commonly do these days, the freezing and creating that cell death, creates inflammation in the heart tissue itself and can actually be pro arrhythmic, can actually sometimes cause Afib to be a little bit more common in that healing phase. And so, oftentimes, we'll reach for cardioversion to shock back out if needed, or even sometimes a medication to just help smooth over that first three months of that healing phase. And so, oftentimes, we have folks who are already coming into the procedure on medicines, and we'll continue those medicines for three months, or if there is recurrence of Afib in that healing phase, if it comes back after an ablation, we may use an anti arrhythmic medication to get through that healing phase, with the idea being that hopefully, after three months, we can wean off that medicine. Now that the heart is healed, the inflammation has settled down, and that's when we really, truly get a good sense of how well that procedure is going to work for that patient. It's not truly a cure. I certainly wish that an ablation procedure meant that Afib would never, ever happen again, which isn't quite how these procedures work. In part, it's because there can be other triggers for atrial fibrillation. We're going after the most common trigger, which is these pulmonary veins. But sometimes the back wall can be very scarred of that top chamber, and that can be a source of trigger, sometimes other rhythm issues, like we talked about with svts, can actually trigger atrial fibrillation, or there can be triggers on the right side or this type of thing. And so, while we do the best we can, and while ablation has come a long way, I think it's important to think about Afib as not truly being a cure, but that we're managing it. Many people do remarkably well after an Afib ablation procedure and may not have Afib for years. But as we follow people long term over not only one or two years, but decades, oftentimes the Afib comes back. So an ablation procedure isn't perfect, but I think it's a big tool that we have in terms of trying to manage atrial fibrillation, to really knock down the, amount of afib that someone is having. And newer data and the newer guidelines that you had mentioned, make reference to that in the sense that earlier rhythm control, trying to keep people out of Afib earlier, tends to prevent that progression of Afib down the road.

>> Speaker A: 16:45

What kind of afib is there? And I guess that's hand in hand with the question, how long does Afib last? How long are episodes? Right?

>> Speaker B: 16:54

Yes, absolutely. And so we tend to classify Afib classically in terms of exactly that. The duration. How long does it stay? Afib that comes and goes. We tend to refer to that as paroxysmal atrial fibrillation, or sometimes referred to as paf. paroxysmal afib doesn't typically require cardioversion because it comes and goes on its own. People pop in and out of it. It can last for seconds, minutes, hours, even days at a time, but people often come out of it on their own. That's the definition of peroxysmal atrial fibrillation. If you're in Afib for longer than seven days at a time, then we refer to that as persistent atrial fibrillation, and then for over a year, long standing persistent atrial fibrillation. And then if after a variety of conversations and perhaps oftentimes attempts to manage afib in some way and we can't keep it away, there's a category called permanent atrial fibrillation, which is just a kind of, way of stating that we're no longer going to try and keep the afib away. And sometimes we do that for a variety of reasons. Maybe a couple of ablations have tried, and it doesn't work. or maybe someone really isn't well enough for an ablation procedure. or sometimes people, especially in the past, really had no symptoms in Afib, and no one worked very hard to get them out of that. it's less likely for that type of thing to occur these days because I think we understand that the earlier we kind of manage afib, the less likely it is to be an ongoing issue down the road. but that's one area where permanent atrial fibrillation could also occur.

>> Speaker A: 18:26

Clarify for me the difference between persistent and long standing.

>> Speaker B: 18:30

Persistent afib persistence just means it's been present for seven days or more, but less than a year. Long standing persistent is someone who's been in a year, oftentimes even longer, of atrial fibrillation. And the longer you're in Afib, the more difficult it is for us to get you out of Afib. And so I think there's been a recognition of that, especially, since my training has started. And we try to aggressively kind of manage folks with, their atrial fibrillation to try to prevent the long stream kind of, or the downstream consequences. That is, of the fact that the more Afib stays, the harder it is to get you out in this type of thing.

>> Speaker A: 19:09

I can't imagine being in Afib for that length of time, years. What's the longest case that you've ever had? And was that patient in some kind of treatment or just letting it go and then coming to you years into it?

>> Speaker B: 19:25

Yeah, often it's that I think, certainly 1020 years ago, maybe there wasn't, the ablation procedures were just kind of really becoming a thing in the early two thousand s. And we had medicines, and there's the treatment strategy of where we can always put in a pacemaker and ablate the central junction box between the top and bottom chamber. So the top chamber is left in Afib. The bottom chamber is now controlled by the pacemaker, which is one way that we still use to manage atrial fibrillation, but that may have been more commonly used, I suppose, back in the day, but certainly people have been in Afib for many years. I've seen people in Afib for a decade or more. like I said, there is this category of permanent atrial fibrillation where it was been decided that we're just going to leave someone in Afib because they're not having any symptoms in Afib at the time. And oftentimes we counsel our patients, while that's okay now, if five or ten years from now you do have issues with atrial fibrillation, it becomes very difficult to get you out at that time. And so nowadays, there's less permanent atrial fibrillation, typically without some sort of attempt to get someone out of Afib, usually, or otherwise, ah, an in depth conversation to make sure that it's understood what permanent atrial fibrillation means.

>> Speaker A: 20:35

Okay. we wanted to talk about the guidelines today. So what was the standard of care before the guidelines, and what are the new guidelines now? Is that helpful?

>> Speaker B: 20:44

Yeah, I mean, it was an update on the guidelines from, I think, 2014. So it's not that we didn't have anything in place up until now. It's just now they've kind of been updated and revamped a little bit. I think now there is an appreciation that earlier management of atrial fibrillation, meaning rhythm control, keeping people out of Afib, prevents some of these downstream consequences of Afib, which can include all the symptoms we talked about that people may have. Sometimes people in heart failure in particular, can have fluid buildup that comes along with heart failure in Afib, can sometimes make that much worse. so I think there's now, with some studies that have come out over the last, I guess, five years or so, have shown that trying to keep folks out of Afib who have heart failure is a worthwhile cause because the Afib often makes the heart failure worse. and so I think there's been a recognition that earlier rhythm control, meaning trying to keep someone out of Afib, is a, ah, strategy that probably makes a lot of sense for the vast majority of folks, especially when they're initially, diagnosed with Afib. I think there's an appreciation that in a younger patient, managing Afib with a rhythm control strategy, whether it's medicines or catheter ablation, can help prevent some of that downstream, effects of Afib, which also means that the Afib is easier to treat if you treat it earlier rather than let it go and kind of run amok, and then it becomes very difficult to treat years later.

>> Speaker A: 22:09

So the new proposed classifications using stages recognize as Afib as a disease continuum, which is what you're describing. Why should patients care about that?

>> Speaker B: 22:20

Yeah, I think the staging system is interesting. Right. I think they look at Afib as kind of this, situation where someone is at risk for Afib. Someone then develops Afib, and we have the paroxysmol and persistent and long standing persistent and things like that that we talked about. And then I think they, in these most recent guidelines, at another stage, for someone who's had a catheter ablation procedure and doesn't seem to have much Afib at this time. And so that's kind of, received its own category as a population of patients that's different from everyone else. I think the other thing that the guidelines really focus on is that patient who's at risk for AfiB, or even someone with Afib, that there are a lot of lifestyle modifications that can be beneficial independent of medicines, independent of catheter ablation procedures. And certainly, the combination of everything is helpful, and those are things like weight loss, for example. We know that people who lose 10% of their body weight tend to have less Afib burden. We know people who have sleep apnea and have that treated tend to have less atrial fibrillation burden. We know people who improve their exercise tolerance can have less Afib. And so all of that, I think, certainly was better represented in these guidelines than it had been in the past. And understanding that atrial fibrillation is not just give medicines and perform catheter ablation procedure, which, of course, is where I tend to, meet patients, is when we're to that point. But even with that, we all stress in clinic that it's important to aim for weight loss, it's important to, increase physical fitness, it's important to stop smoking. It's important to control diabetes, it's important to control high blood pressure, not only for Afib, which is often how we're meeting patients, of course, but I think all of that helps health in general. So I really like that aspect of these guidelines.

>> Speaker A: 24:10

Is there a standard of care for each stage of the AFIB? Is being, reinforced by the guidelines?

>> Speaker B: 24:17

Not so much a standard of care per se. I think what the guidelines allow us to do is to, treat each patient individually. Right. Every patient is going to have a, different response to medications, every patient, in terms of how well they respond to it, but also how much they want to take medicine. Some patients don't want to take medications, and others are okay with it. Some patients would rather have a procedure than take medicines, and other patients would rather take medicines than have a procedure. And so I think what the guidelines do is just kind of give us a general set of rules by which we can then go in and see a patient and talk about kind of all of the possibilities, and then with the information that we bring to the table, and then the information they bring to the table through shared decision making as we refer to it, we come up with kind of the best treatment strategy, which can differ for differing patients. Everybody wants to approach things differently, and everyone can.

>> Speaker A: 25:11

Who typically is an AfIB patient? Who do you have come into your office, and how do they come to you? Do they have to go to a cardiologist first to come to you?

>> Speaker B: 25:20

Oftentimes they do, I think, because, oftentimes they present to their primary care or to an urgent care with a little bit of palpitation or some shortness of breath. And the EKG shows atrial fibrillation. And usually the first stop from there is to a cardiologist. So many patients do, come to us via cardiology, a little less likely directly from primary care, but that can happen as well. And really, it's a whole gamut of patients who have atrial fibrillation. Right. I think we heard of, oh, I'm blinking on the football player's name. I think it was JJ Watt who had, a bout of atrial fibrillation within this last year, and he was cardioverted. And this type of. So, you know, it can happen in athletes, it can happen in, know, distance runners and things like that, but it tends to come hand in hand with a lot of those things we talked about, the chad's vasque. Right? So a lot of medical comorbidities tend to increase one's chance of having atrial fibrillation. It also is more common as we age, just simply as a result of getting older. But certainly things like having a weak heart or congestive heart failure, high blood pressure, diabetes, having heart valve issues, that kind of can sometimes increase the pressures in those top chambers of the heart, can increase one's risk of atrial fibrillation. We often see it in patients who have kidney disease and are on hemodialysis. I think the patient population can vary quite a bit, actually.

>> Speaker A: 26:40

You mentioned before about the smartwatches, and I'm wondering if there is an association with this increase, the increase where they think every 20 years, there's a 30% increase of people who are experiencing Afib. Does that have anything to do with us detecting more Afib because of these smartwatches and Fitbit?

>> Speaker B: 27:01

Yeah, I think there's a lot more wearable devices out there. Right. And to some extent, I think that's a great thing. It allows us to sometimes catch things that we would not have caught before. Maybe we catch it earlier, maybe we never have caught it before, and now we're catching it on these wearable devices like that. And I think that's part of it. I think there's also been an increased recognition of the need to look for and treat AFib. I think in particular in patients who've had a prior stroke, and there's no real smoking gun as to what caused that stroke. Atrial fibrillation has been found to be common in that population. And oftentimes we go really hunting for Afib, up to and including putting in little implantable devices to see if we can catch AFib. Not in a day or a week in terms of monitoring, but years of monitoring.

>> Speaker A: 27:44

According to Pew Research center, at least 20 smartwatches on the market now have the ability to detect irregular heart rhythms. And both Apple and Fitbit are currently supporting studies of their products on the effectiveness of using devices for monitoring. But that's ongoing. It's not something that you would want to use alone as a monitoring tool. Right?

>> Speaker B: 28:07

I mean, sometimes we use it, sometimes that's how it first comes to recognition. There are these wearable devices that allow us to catch things, like I said, that we may not have caught before. Additionally, there are little, quite literally, mobile ekgs that you can take, right, the cardia mobile device, where you put your fingers on two little electrodes, and you can get your own rhythm strip, or you put fingers on two electrodes and then on your leg, and you can get a six lead EKG. We use these in clinic. I have people send me these strips quite often and wonder if they're in atrial fibrillation or some other arrhythmia. These wearable devices are fantastic, and that can raise awareness and allow us to find stuff that we may not have otherwise easily found. Oftentimes, though, there are lots of false positives. Right. The devices and the algorithms they use are designed to be overly sensitive, to say that something may be irregular or an abnormal rhythm, even though it may just turn out to be a lot of noise or the irregularity in the rhythm that the device wants to think is Afib may just be an extra beat from, the top chamber of the heart, called a Pac, or from the bottom chamber called a PVC. And these things aren't really atrial fibrillation by any means, but the device senses that irregularity and maybe wants to call it Afib. So there are certainly some false positives and a little downside. There can be a lot of extra data that comes from that, that clinicians have to sort through. But at the same time, I think it's an important part of our know. You know, I certainly use it a lot when patients come in with, Apple Watch or Fitbit data or whatever data they have. We look at it, know, scrutinize it together and talk about what it looks like, what it means, and this type of thing. So I think it's certainly here to stay, and I think it can be a valuable part of the overall management.

>> Speaker A: 29:46

Where do you go from there? Once you have that data, do you then put the patient on some other kind of regime? What other diagnostics are there for determining Afib?

>> Speaker B: 29:55

Yeah. No, that's fantastic. So just because the device says it's Afib doesn't always mean it's Afib. I think that's important to put out there. Just because a device says Afib doesn't mean you have Afib. I think at that point, we may reach out for, what we call a Zeo patch is often the patch we use, although there are other ways of doing this. But it's a little sticker that patients, wear that can monitor their heart rate and rhythm for, oftentimes, two weeks at a time. It can be anywhere from three days to two weeks. But often, when we're first kind of trying to figure out what's going on, we may reach for one of those two week monitors.

>> Speaker A: 30:28

It monitors through a sticker. Is it saving the information on a chip?

>> Speaker B: 30:33

Yeah, exactly. It's got its own little electrode there, and it basically following, has a little ekg that it's recording, and it stores all the data. Oftentimes, we have patients, mail that back. Sometimes those can actually be followed in quasi real time where people are actually monitoring what's coming in from those, devices.

>> Speaker A: 30:51

Remote monitoring?

>> Speaker B: 30:52

Well, yeah. it's called, ah, mcot m. Or kind of a mobile telemetry kind of device where, the company who makes the device is monitoring it from afar and would alert a physician if something kind of came up. But, yeah, we, you know, it's not always that an apple Watch showing a heart rate that jumped up to 180 is diagnostic. So we have to go looking more to see what that jump up was and what that was all about. And so we have to go in search of kind of what that is. And usually the first step is one of these patch. These patches.

>> Speaker A: 31:21

What about that loop that you were telling me about? Tell me about the loop.

>> Speaker B: 31:25

Yeah, sometimes we reach for a loop recorder, right. If someone has infrequent issues that we can't seem to catch on a patch, or someone has passing out episodes where they're occurring infrequently, and we never were able to catch it on a patch. They didn't pass out while they were wearing the patch, or like I alluded to before, in the situation where someone's had a stroke and we're looking for Afib, and the patch didn't show Afib, but that's only two weeks of monitoring. Well, then we can put a small, little, implantable device under the skin. It's about the size of a jumbo paperclip. In terms of length, the width is probably a couple of those paperclips stacked on top of each other. And we put that. It's a simple procedure. We make a small little incision just to the left of the breastbone, use a lot of numbing medicine, but don't even have to use sedation, typically, for this type of procedure. and we're able to put this little device under the skin, and now we can monitor the heart rate and rhythm for the next four to five years instead of just a matter of a couple of days or a couple of weeks.

>> Speaker A: 32:22

This is an office visit. And then you stitch it closed?

>> Speaker B: 32:28

Yeah, usually. Oftentimes, we see them in clinic, and that may become part of the treatment strategy. So we'll see them, we'll talk about it. We'll talk about the procedure and kind of walk them through what it will look like. And then it's usually, at least here, performed at, Franklin Square Union Memorial. a small little procedure, but one where you typically go home 15 or 30 minutes afterwards, it probably takes about 10 minutes or so to put in. Oftentimes, you may stitch the skin together. Other times, we use a little bit of glue or stereo strips or things of that sort. The incision itself is quite small. It does leave a small little scar, but quite small in terms of the grand scheme of things. And it gives us that ability, again, to monitor things for years at a time. And so if someone passes out every seven months or something, now we have something in place that will allow us to see what the heart is doing. Right. Does the heart rate go super slow and that's why they passed out? Does it go super fast and that's why they passed out? it gives us that ability to monitor long term. And then in terms of atrial fibrillation, oftentimes we use it to monitor for Afib burden. Right. How is someone doing after an ablation procedure? Well, now we can look at the data and see how much Afib they've had on this loop to see how well that ablation procedure has worked.

>> Speaker A: 33:37

What causes Afib?

>> Speaker B: 33:38

Afib is kind of brought about by all those medical conditions we've talked about earlier that can certainly increase one's chance, but it's this abnormal firing that we were talking about in those pulmonary veins that seems to be the most common trigger for atrial fibrillation. And so that electrical firing, is what sets the heart off into afib. If I put a pacing wire up into anyone's, heart and pace that top chamber fast enough, I can probably put just about anyone into atrial fibrillation. This is the heart doing it to itself. That firing within those veins kind of sets the heart off into Afib. And so that's kind of the cornerstone when we perform an ablation, is to really isolate those veins with either that heating or freezing energy, that we talked about, in terms of kind of blocking off that trigger.

>> Speaker A: 34:22

What about genetics? Is there a genetic component?

>> Speaker B: 34:26

Yeah, I think there's undoubtedly a genetic component to Afib, and you certainly see that when you take a family history and someone's grandma had afib and someone's mom had afib, and here they are with Afib. So there is a bit of a genetic component to. It's not something we tend to test for, like other heart issues. In particular, weak hearts. oftentimes, as we're trying to work up why one might have a weak heart, that tends to be an area where we use a lot of genetic testing, a lot, because then we can look, for other family members who may have a similar genetic mutation, if you will. And Afib, it's not really used that much, but there is probably undoubtedly a genetic, kind of link there. But there's so many other things that increases one's chance of having afib. Increased weight, high blood pressure, diabetes, sleep apnea. Probably certainly plays a role in all of this. Other, weakening of the heart can play a role in one, developing Afib. Valveular issues. These type of things certainly play a role as well, but genetics is part of it.

>> Speaker A: 35:22

As we talked about, the kinds of afib there are and the different treatments for each kind, each category. Paroxysmal.

>> Speaker B: 35:30

Paroxysmal. Paf. Paf, paf.

>> Speaker A: 35:35

would be treatment with medication. Just medication.

>> Speaker B: 35:38

It depends. You could proceed to catheter ablation for paroxysmal atrial fibrillation. Absolutely. No one category prevents you from performing an ablation. Certainly permanent means you've kind of given up on it. So you're not planning to perform any ablation procedures. You're just going to let the Afib be long standing, persistent, at least when I first got here was my understanding where the hybrid procedure was playing a role. although they may have loosened that a little bit, but I'm not.

>> Speaker A: 36:01

Give us a quick, brief description of what that hybrid procedure is for anybody who's interested.

>> Speaker B: 36:07

So, a hybrid procedure is where we have a surgeon who will perform what we call epicardial, or on top of the heart ablation for Afib by getting access, to the heart, under the breastbone. And then they're able to put a special tool back there. And when they tunnel that tool back there, they ablate the tissue of the outside of the heart. And then typically what happens is we come in as cardiac electrophysiologists and then ablate from inside the heart and touch up any areas where maybe they weren't able to reach with a, surgical tool. And so that's a procedure that, is used for long standing persistent atrial fibrillation. And folks who have been in Afib for a long time and has had some success here, I must say. And so I think it's a very reasonable procedure to discuss, and it's a.

>> Speaker A: 36:57

Rather advanced treatment option. what is next? What's on the horizon for patients with Afib?

>> Speaker B: 37:02

Yeah, I think next in our world is what's called, electroporation, or many kind of little. We've talked about freezing and we've talked about burning kind of these thermal energies that we use to create scar. Now, kind of an old technology is revived in electroporation, where we use a special catheter that delivers these tiny little shocks. And this form of ablation leads to, holes forming in the cells of heart muscle. And that's how it creates scar. And the potential benefits of Electroparation is that it may be a little bit more selective for heart tissue. it doesn't damage surrounding structures. Maybe there's, some suggestion that it can be done faster than other ablation procedures, and so it saves some time. Most of these ablation procedures we're performing these days are done under general anesthesia. and so anything that saves time, I think we're all for that.

>> Speaker A: 37:49

And they're not done through the open chest, correct. They're done.

>> Speaker B: 37:52

Thank you for mentioning that. You're exactly right. All of these ablation procedures that we perform are performed through the veins, so we get access. What I tell patients, we put big ivs, some of them are very large ivs, kind of the size of a jumbo straw in diameter. But the idea, is big ivs through the vein at the top part of the leg. and we get several of those access points and big vein there, and that allows us to bring equipment up to the heart through the blood vessels. So everything is done through blood vessels, and we get up to the heart that way.

>> Speaker A: 38:21

And then what's the recovery like? Patients go home the next day.

>> Speaker B: 38:25

Oftentimes actually go home the same day, believe it or not. oftentimes go home the same day. We'll want to monitor for several hours afterwards. So if it's late in the day, we often keep a patient overnight, and that's not a problem. But many times can go home the same day. Oftentimes we tell them no kind of heavy lifting or exercise, usually for a week or two, at least seven to ten days for sure. and that's in large part to let those big iv sites heal up. Nowadays, we tend to use a little bit of a collagen plug to help prevent any sort of bleeding issues. But nevertheless, we ask patients no heavy lifting, no kind of, structured exercise for a week or two after the procedure. And then really they can kind of get back to doing what they want to do at that point.

>> Speaker A: 39:02

It's amazing stuff. Even just going into the EP lab is really very, scientific in there. Very high tech.

>> Speaker B: 39:10

Yeah. Imaging, it's a really cool place to be. Yeah. We've got a huge, large screen. We've got multiple picture and pictures. We've got fluoroscopy. We create 3d maps of people's heart from within their heart with these special mapping catheters that we have.

>> Speaker A: 39:24

And how does that help? What does the 3d mapping do?

>> Speaker B: 39:27

Well, for Afib, what we're largely doing is to just find where these veins are in any one patient's body. And so we create a quick little 3d map. We oftentimes get a ct scan beforehand just so we understand what their anatomy looks like, what their heart looks like, where their veins plug in, and this type of thing. But in order to know where to, for example, put that freezing balloon or where to use that heating catheter, we create a 3d map inside the heart using special mapping catheters prior to starting the procedure. And so that just allows us to understand the lay of the land, know where all the structures are, we identify structures we want to avoid and this type of thing.

>> Speaker A: 40:03

So you could actually see the electrical circuit on your imaging, on your screen.

>> Speaker B: 40:09

For Afib, we oftentimes look at scar. So we create, what's called a voltage map, where we look at, how healthy the tissue is. It's judged by the amount of voltage it creates, as we're kind of mapping along that area. And areas of scar tend to have very low voltage. Areas of normal tissue have high voltage, and so we can use that to sometimes help guide our ablation procedures in Afib. for example, not only do we go after those veins, which is the cornerstone of any atrial fibrillation ablation, but sometimes we go after other areas of scarred, tissue or in the management of atrial flutters, sometimes we have to go after other areas of the heart as well. So it's not only kind of a pulmonary vein kind of, ablation procedure, sometimes we have to target other sites as well.

>> Speaker A: 40:52

Is there hope, then, once a person has a treatment done in the lab, that they won't have to be on blood thinners for the rest of their life?

>> Speaker B: 40:59

That's a great question and one that we always chat about before proceeding with an ablation procedure. As it stands now, there's no randomized, controlled data that shows that performing an ablation procedure and getting your Afib episodes down to as close to zero as possible decreases one's risk of stroke. So whether a patient is having an ablation procedure or not, the use of blood thinning medicines is always kind of guided by that Chad's VAS score. So, in some patients where the chad's vas score is zero or one, we'll often start a little bit of blood thinner beforehand, a couple of days of blood thinner beforehand, just to make sure they may tolerate it, or 1 may choose to start it right after the ablation. No matter what. No matter one's chad's vascore, there's always, three month period where we tend to use a blood thinner after the procedure. Anticoagulation, the typical things we see on tv, Zarelto and eloques and amperdaxin, cumin, all of these things are the typical blood thinners we use. And so anyone who has an Afib ablation procedure will be on, typically right around two to three months of blood thinner. Afterwards, no matter what their Chad's vascore is after that time period, then the continued use of anticoagulation is guided by that Chad's VAS score. So if someone's chad's vascore was high enough to warrant blood thinners before an ablation, then even the ablation is wonderfully successful, as oftentimes it is. And people don't have much less Afib and much less symptoms than Afib. They still would warrant long term, indefinite anticoagulation based off the chad's fast score, if it was above two or more. And so the ablation procedures, is not a way to get rid of the blood thinning medicine. That's a great point.

>> Speaker A: 42:39

What's the final takeaway, do you think, for listeners? What's the most important thing you hope they understand about Afib?

>> Speaker B: 42:45

Afib is truly a journey. It tends to be this progressive kind of disease and can come more frequently and more often and for longer durations. And I think while there are treatments there and can be a bit intimidating to kind of navigate through that, I think what I want patients to know is that we're here to kind of shepherd them through that process, through their particular journey of atrial fibrillation.

>> Speaker A: 43:06

If an ablation doesn't work or Afib comes back after a treatment, can a patient get another procedure?

>> Speaker B: 43:12

Yes. the cornerstone of that, ah, first ablation procedure is often going after those pulmonary vein triggers that we talked about. But if Afib comes back, we can go after other triggers. And so, certainly, more ablations can be helpful in that situation as we target more tissue, more areas that could be triggering AfiB. And so it's somewhat common to have more than one procedure. Certainly, we hope the first procedure is the one that is durable and provides long lasting, suppression of AFIB. But sometimes we do have to go back, and it's certainly possible to do more than one ablation.

>> Speaker A: 43:43

And you've seen success in the second try or maybe the third try. Third try is a charm.

>> Speaker B: 43:49

Yeah. Especially in that second go, we make sure that those veins that we tried to isolate remain isolated. Sometimes there's a little area that maybe the balloon didn't touch as well, or our, heating catheter didn't create great scar. And so now that area is reconnected. So now that vein that has that abnormal firing going on is connected back up to the heart. And so in particular, in that second one, and certainly any procedure that we do afterwards, we make sure those veins are isolated, and then we start looking for other areas.

>> Speaker A: 44:17

Can you walk me through an ablation procedure?

>> Speaker B: 44:20

Absolutely. So they'll arrive to our hospital, which right now, where we're performing all this complex heart stuff and catheter ablation procedures is at Union memorial. And so you usually arrive an hour and a half, 2 hours before the procedure. That allows us to get ivs and any labs that we may need before the procedure and for people to talk to, the patient about the procedure, any questions to be answered, this type of thing. And then the procedure is done in one of our sophisticated electrophysiology labs, where we have very high, tech equipment that allows us to perform these procedures for an Afib ablation procedure. These days, someone is, intubated, general, anesthesia is used, and so they're asleep for all of this. and then while they're asleep, we get access into the veins at the top part of the leg, and that allows us, to put big ivs in that big vein, and we get numerous ivs that allows us to bring equipment up to the heart to safely perform the procedure. And the procedure itself takes about an hour, hour and a half or so. the total procedure time, if you include kind of set up and time to take down, is probably closer to two or two and a half hours. And then they'll leave our lab and go to the recovery area. Usually there we have them lie flat as we just took those big ivs out. So we'll have them, lie flat for two or 3 hours or so, and after that, we'll have them get up and start walking around with the help of the staff in our recovery area. And then usually somewhere around five, 6 hours of total time after they came out of the lab is when they can usually go home. And so the day is a little bit long, right, a couple of hours beforehand, several hours for the procedure, and several more hours afterwards to recover. but most people are able to go home the same day before you.

>> Speaker A: 45:57

Take them out of the lab into recovery, is there a way to test what you've done?

>> Speaker B: 46:02

That's a great question. We look to make sure that, what we were setting out to do, which is oftentimes in a first time procedure to isolate those veins, we look to make sure that that's the case, and we do so by sophisticated mapping to show that there's no signal getting into the vein because that area that we've just created the scar in doesn't allow for any information, no electrical activity to get across. sometimes we use pacing maneuvers and things like this to show that, the work that we did, which is to isolate those veins was done. And so we do do that kind of testing. For every patient who gets an AFIB ablation.

>> Speaker A: 46:36

You are truly an electrician of the heart. Yes. We've been talking with Dr. Richard Jones, of the Medstar Heart and Vascular Institute in Baltimore. Thank you, Dr. Jones, for sharing your expertise with us here on MedstarHealth. Doc talk. For more information on AFIb, go to medstarhealth.org and put Afib in the search box or for an appointment with Dr. Jones, call 410-554-6727

>> Speaker B: 47:06

close.