Treatment of Atrial Fibrillation with Dr John Mandrola

Dr. Thomas Nero interviews Dr. John Mandrola on his approach to treating atrial fibrillation.  In addition to a nuts and bolts approach they discuss how to assess risk and shared decision making.

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Atrial Fibrillation with Dr John Mandrola

Dr Nero: Dr. Mandrola, welcome to patient pulse. Thank you again for joining us today. , so you are well known as a, medical conservative. , I think that's doing you some injustice, it makes you sound more like a curmudgeon than, someone who's actually looking, hard at the clinical data.

 You are an expert in atrial fibrillation. And , The way that I see this is that you're carrying the torch on evidence based, , decision making. And I think that's an extremely important skill given all of the data that we, , are inundated.

 For this, I wanted to talk a little bit about, your approach to patients . And so a patient comes in and says, Dr. Mandrola, I have atrial fibrillation. How do you approach them? What do you do? Transcripts

Dr Mandrola: thing with AFib is that you cannot put patients into one box. I always tell patients that it's a very difficult condition to Google and say, the best treatment for AFib is X, Y, Z, and the reason that is, Tom, is because atrial fibrillation affects people in so many different ways.

You're going to have a 30 year old healthy runner have AFib, an 80 year old with heart failure, , with AFib, and their treatments are totally different. So, what I always tell patients initially is that I need to gather a lot of information about who you are. How this, , is affecting you because we have to individualize your treatment to you.

And the other thing I say is that AFib is not like an appendix. , it's rare that I can just cut it out and see you one time. I say that this is a condition that we have to manage and that you and I are going to have to just be friends and work together for this.

But I always, try and reassure patients that there are solutions and usually it takes time. So the, I guess the first thing is just that framing of, of the nature of AFib and how it is so diverse, and affects people differently.

Dr Nero: Yeah, I've been always intrigued by the fact that 50 percent of the patients who have atrial fibrillation don't know that they have atrial fibrillation and that they're actually going to be a different group, the way that we treat them, the way that we're going to approach them, then the people who are symptomatic.

And then the people who are symptomatic when they think they're having symptoms, they're only correct about 50 percent of the time. And so you have to walk through what's really happening to them , and decide, all right, you know, you're symptomatic, we're going to treat your symptoms. And then there's different pathways in treating your symptoms.

And then the patients who are asymptomatic, a completely different discussion. fast, slow, decreased heart function or not. , are you having other symptoms that might be related, but, you know, as far as atrial fibrillation is concerned, it's not the AFib for you, right? It's the stroke risk. 

And, , the symptoms that we're treating,, how would you, how do you initially approach anticoagulation with them? , what do you use to talk to them about AC?

Dr Mandrola: , I guess I would just start by saying reiterate what you said is that it it's not well known that probably more than half the people don't feel their AFib , and are asymptomatic. Although the one caveat there is that we really need to tease out symptoms because sometimes patients say they don't feel their AFib.

And they're labeled as asymptomatic, but they actually have fatigue or a decreased exercise tolerance or something like that. So there's that nuance. And then as far as the, as far as the whole treatment goes, I actually think that you can think of it as four legs of a table, right? So I always tell patients four legs of a table.

One leg is stroke prevention. And so when someone's stroke risk gets high enough, if they have enough factors, like diabetes, high blood pressure, heart failure, older age, whatever, then there comes a point where there's a net benefit to taking anticoagulants. So stroke prevention is one leg and we have that conversation and sometimes it's easy and sometimes it's not so easy because some patients fear bleeding more than they do stroke.

And so we have that conversation. Second leg of the table is prevention of heart failure. So why do patients get heart failure with AFib? If they are 140 beats a minute and they don't feel it, and they've had that for a month, they can have a weak heart. Most patients don't get into that, but sometimes we have to use a drug to control rate.

The third aspect is the least talked about aspect. And the third leg of the table is, where does AFib come from? Usually, it just doesn't come out of the clear blue sky. Usually it comes because there are risk factors. We call them cardiometabolic, but they're basically overweight, obesity, sleep apnea, alcohol, lack of exercise, high blood pressure.

And so we talk about those things. And so the, the interesting thing is that sometimes An electrophysiologist, which is a subspecialist, is actually, really have to be focused on primary care, basic stuff. And a lot of times, correcting those basic things, like drinking less wine, or, , , losing some weight.

Those things are sometimes enough. And then the fourth leg of the table is what you were leading at, which is the, symptoms. And then this is where evidence comes in. So we have evidence that, um, we have evidence that if patients are asymptomatic and their rate is not elevated and they take anticoagulants, there may not be a great advantage to, to going full gas with, , what's called rhythm control strategies, such as ablation and cardioversion and drugs.

But that fourth leg of the table, which I labeled as rhythm control is really dependent on how much the AFib affects that person. And if they're just totally beaten up by it and they're willing to undergo procedures and drugs and cardioversions and all these other things, then yes, but other patients are just like, Doc, I can do everything I want to do.

 I'm 70 years old. Just give me that pill. I'll see you once a year. And that's okay too. And so that's where, that's where the whole relationship between doctor and patient comes in.

Dr Nero: So one of the risks that you, didn't include, unfortunately, is probably the main risk is age. , and as we get older, , we do have more fibrosis in our atriums and that's probably what's driving a lot of it. And I hate to say that because it sounds like we're just giving up and I don't think it's that.

It's just that we do have to accept that that is one of the things that are pushing it. 

And then, you know, as you were saying that, the piece with anticoagulation is that the biggest risk that I see isn't the bleeding risk, although bleeding is definitely there. , but it is the stroke risk that we are worried about. That's going to be the one that's going to be more debilitating.

And when people are worried about, , how we're going to treat this, the first thing we want to do is let's look at, , on a patient level, what's going to be the most debilitating thing that could happen, right? And if stroke is it, and stroke is pretty bad.

Dr Mandrola: Yeah, and I think that that's a really good point and it's a great point that I talk with patients all the time and some people say, well, what's the stroke reduction? And I might say, well, it's, , it's a 50 percent reduction and it's goes from 5 percent to 2. 5%. And they look at that and they say, doc, I'm not.

Taking a pill that could increase my bleeding for that. And so what I, try and discuss is, , is the asymmetry of risk. So Nassim Taleb talks about this. He's a mathematician. He's always talking about the asymmetry of risk. So yes, the stroke reduction might be small with an anticoagulant. The consequences of a stroke are so bad.

And so I try not to bully patients. I say, look, this is what doctors think. This is what, this is why we think it's really, uh, important. The, the absolute risk reduction might be modest, but the, avoidance of the stroke and, and is so large because strokes sometimes are so debilitating. And I always say, , hey, nobody checks in the ER at three in the morning to say, I'm here to just tell you, I'm, I'm thankful for not having a stroke.

So if you don't have a stroke and you're on anticoagulant, it's, it's just a great thing. Uh, we only see people and people only hear about people who have problems with their anticoagulants. And so that's where evidence comes into play. Is is we have trials where 20 to 30, 000 patients have taken in the anti-coagulants, 20 or 30, 000 people that haven't and we can tally up average effects.

Dr Nero: That's one of the important parts of preventive medicine that people don't realize is that we'll only identify when we're wrong,

Dr Mandrola: Correct. And

Dr Nero: you know, or if I don't give them anticoagulation, how dare you not give my mom anticoagulation?

She just had a stroke. . So we only see that we only see the downside, sadly, and it does take a broader picture, broader scope to be able to get that across. And, we talk a lot about, shared decision making, but I think that's, you know, unfortunately, I think that's , it's easier said than done.

, and it's a much harder decision than just, like you said, you can't Google it. 

Dr Mandrola: I think this is really the, this is the really hard part about. Being a physician and , making dots in the left atrium and isolating pulmonary veins and doing a affiblation is the easy part. And, you know, you can teach anybody to do that, but really working with patients and having helping them make the best decision for them with bringing in evidence.

That's the. That's the hard part. Clinic, as you probably know, is a much harder day for us than a day in the lab.

Dr Nero: So, , the last question I did want to ask you is a little bit about , AFIB ablation. This is a procedure that you do. , I hear you're pretty good at it. Um, so.

Dr Mandrola: not fancy. I mean, pretty much everybody gets good at it.

Dr Nero: , so when do you decide to go forward with atrial fibrillation ablation? Um, there's now an indication for doing it earlier as a primary treatment for atrial fibrillation. , when do you decide to, pull that trigger? Okay.

Dr Mandrola: Yeah, so, uh, good question. Where I like to use afib ablation is, after I've had a relationship with a patient, And we've decided that AFib is the primary cause of the, of the quality of life, , issues. So there's got to be quality of life impairment and, , we've tried other things that haven't worked such as, , cardiometabolic risk factor, , changes, weight loss, sleep apnea treatment, reduction of alcohol intake, and these, these very basic things, and we have a relationship.

And we're like, this isn't working, and we shouldn't just let this AFib progress for months on months and years on years, and then When patients have symptoms, we, we discuss , the pros and cons , and go forward. And so, , I mean, I, AFib ablation is probably the number 1 procedure that I do.

There's so much AFib in Kentucky. , it's very, very common. I, I am a medical conservative and I think that we sometimes pull the trigger too fast on patients, but, uh, also there's, there's definitely a role. Uh, for it, although Tom, I will say I'm a reluctant ablator because I always try and think to myself in 25 years or in 50 years, what will the physicians of the future think about what we're doing?

And I think that caring is going to hold up. Empathy is going to hold up. Pacemakers for heart blocks, going to hold up PCI for heart attacks, going to hold up, but I am not sure how well PVI. For a fib ablation is going to hold up because mainly people ask, how do you know where to burn? And the answer is we don't, we just do our best.

Dr Nero: Which, which is a great point to end on I, , I, I don't think anyone could have said it better. , so I really want to thank you for taking the time to speak with us today and, uh, I look forward to having more discussions with you in the future. Thanks again.

Dr Mandrola: All right. Awesome. Thanks for having me.