HeartBeats Episode 1: Atrial Fibrillation (Part 1)

Hello and welcome to HeartBeats. I’m Cathy Murtagh-Schaffer and I am your host for this episode of HeartBeats. This podcast is brought to you by Shipley Cardiothoracic Center - an educational series dedicated to providing our patients and the community with information and education about our Cardiothoracic Surgery program.

Today we begin our 2-part series on atrial fibrillation and we have Dr. Paul DiGiorgi a heart surgeon with Shipley Cardiothoracic Center with expertise in the surgical treatment of atrial fibrillation Welcome Dr. DiGiorgi, so glad you are able to join the podcast today.

1. Perhaps it would be helpful to our listeners if you would talk a little bit about what the prevalence of atrial fibrillation, what it is, risk factors and some of the symptoms patients may experience.

a. Thanks for having me Cathy. Atrial fibrillation is one of the most common cardiac arrhythmias, or heart arrhythmias, which is an irregular beating of the heart that exist. It is extremely common, millions of people in the United States have it and half of them don’t even know they have it. Estimates can be between 3-5 million but it is likely that more people have it and don’t know. It is more common as you get older, and it’s common with certain risk factors, especially sleep apnea but many other risk factors as well. Because it is so common and many times people don’t know they have it, it has also become a major source of disease for patients, meaning there is a high prevalence of stroke and heart failure from it. Therefore, it’s a very important disease to get recognized because sometimes it’s only the physicians that happen to stumble across it because they were looking for something else and found out that the patient had afib in the first place. We have put forth, along with many other people, significant educational effort to inform the public about this disease process, which is associated with many other diseases so that people can at least get checked out by their physicians and come up with a game plan that is best for them. One of the complicated matters with atrial fibrillation is that it is complicated and the options for treatment vary significantly from patient to patient. It is important to have an individualized treatment plan formulated before embarking on something that could be significant intervention.

2. What kind of symptoms do patience have with atrial fibrillation?

a. Again, half the time a patient doesn’t have any symptoms but for the patients that do have symptoms, it is commonly associated with palpitations, shortness of breath, fatigue. Sometimes they have trouble bending over to tie their shoes or trouble climbing stairs and unfortunately because the onset of this can be rather insidious they can often times chock it up to getting older or being out of shape, or something other than I have a problem with my heart. It’s just the way a lot of these diseases that come on gradually go and we’re able to mentally compensate for It if not physically and brush it off. When unfortunately, by the time it is so bad that you come to medical attention you now have a significant problem. That is why understanding what you can feel and that you might not feel anything is so important. Definitely palpitations, shortness of breath and fatigue are the most common symptoms of Afib. Unfortunately, sometimes the first symptoms you have of AFib is stroke. There is a very common cause of stroke, especially in people over 80, it is the most common cause of stroke and many people who are asymptomatic didn’t even know they had it, first present with a stroke and then we find out they actually had atrial fibrillation the whole time and the stroke could have been prevented had they known about their afib and it had been treated appropriately

3. What is the team approach to the care of atrial fibrillation?

a. The team approach for atrial fibrillation covers the entire gamut of what you can imagine a team might be. The reason for that, is like any heart disease problem it starts with lifestyle changes and adjustments at home, rather than coming in for surgery. It starts with people like nutritionist, dietitians, physical therapist, and respiratory therapist. People you wouldn’t necessarily attribute to a cardiac arrhythmia, but in fact those people are critical to the treatment of this disease because without proper basic treatment of your lifestyle, many of the more invasive treatments won’t be successful. The team really starts with nutrition diet exercise, whether that’s up to the individual or with help from a professional, and then it works up the latter towards the internist, cardiologist, electrophysiologist and potentially the cardiac surgeons and everyone in between to come up with the proper treatment plan for that patient

4. What are some of the first treatments to try in treating atrial fibrillation? Should a patient expect that these treatments will “cure” the afib or just control it?

a. After lifestyle, which can have a huge impact, but after lifestyle once you get into medical treatment it begins with medication and typically it is what we call rate control or rhythm control medication that can help at least keep the heart rate down, because a fast heart rate is very damaging to the heart very quickly. And rhythm control and some medication can help get the heart back into its normal sinus rhythm. Those medications are the base line medical treatments. There are a whole host of medications in different sort of classes that address both heart rate and heart rhythm. On top of that you have stroke reduction medication, which are blood thinners. And now there are several options not just Warfarin or Coumadin, which for some people are a better choice. Those are the basis for medical treatment throughout the course of any atrial fibrillation treatment plan. Our goal is to limit that as much as possible but at some point medicines are often necessary and certainly are associated with better outcomes, especially when it regards to stroke.

Do these medications cure atrial fibrillation or just reduce symptoms?

I wouldn’t think of atrial fibrillation as something that is ever cured, because your body has the propensity to have atrial fibrillation no matter how well behaved it may be after you take a certain medication or certain lifestyle change. You have to always feel that you had atrial fibrillation and it can come back at any time and you’re in the business of controlling it for yourself, that maybe something as simple as weight loss, and sleep apnea control. And maybe something through medications and ablations. You always have to have it in the back of your mind that afib is something that can come back at any time, hopefully unlikely, but if you forget about it, that’s probably the time it will come back.

5. What type of lifestyle changes should someone with atrial fibrillation expect to make? For example, are there nutrition changes that might help? Can patients with atrial fib exercise? What about using alcohol?

a. They have to be serious about everything in their lifestyle, somethings are more important than others and some people really have an alcohol or caffeine related trigger for atrial fibrillation, as you go through your own assessment with your physicians, you will be able to come up with the kind of things that are involved in that. For example, if you’re someone who drinks 3-4 drinks a day and you have atrial fibrillation, it’s probably a good idea for many reasons to stop drinking so much. If you had one a week, it’s probably not the problem at hand. Weight loss is very well associated with atrial fibrillation and the improvement in atrial fibrillation in people who are overweight. It does not take much in the way of weight loss to significantly impact your atrial fibrillation burden, so that is an important one as well. But, there are other things, smoking, caffeine for sure, these are the things that we track, diabetic control, high blood pressure control. There is a whole host of things that, not just for atrial fibrillation but for your general health overall, you need to be keeping an eye on. If these things are becoming issue they have to be addressed and treated. Although, they might not seem that they’re a problem on the day to day basis, they very well may catch up to you later, at which time you’ll have a much more significant problem on your hand.

6. What role does cardiac ablation play in the patient with new onset atrial fibrillation? Does a patient need to fail multiple ablations before having a surgical procedure?

a. Ablation is very successful in treating atrial fibrillation in the right patient. It is not necessarily the first line treatment, certainly we start with lifestyle and medications. But, if patients are still symptomatic and we’ve tried different medications and they tried cardioversion, which is a shocking of the heart to bring it back into sinus rhythm, and the atrial fibrillation continues to be a problem, then we get into a realm of ablations. An abolition, whether it’s catheter based or surgical based is essentially creating a scar line within the heart tissue, somewhere strategically that is able to block the electrical impulses of the drivers of atrial fibrillation. By doing that you can dramatically improve the burden of atrial fibrillation to the point where patents can go years without having any, or at least have a significant reduction where their lifestyle has been significantly improved. The way that we test for that is really by talking to the patient and doing different kinds of dilations of their arrhythmia whether it’s through a pace maker or other types of monitoring devices and we can tell just how successful our medical treatments and lifestyle changes are. But again, if they are still symptomatic and symptomatic is an important term because we are looking to do ablations in symptomatic patents who are actually having trouble from the atrial fibrillation not just in people who are having a great life, no symptoms and their hearts are doing fine. It’s more like starting with who are the candidates for ablation, and the candidates are the more symptomatic patients. Now, some of them might think they’re asymptomatic but in fact we’re looking at their heart on an echo or some other type of monitoring device and we realize the atrial fibrillation is causing damage to their heart, then those patients too will be a potential candidate for ablation. Also, you can’t underestimate the side effects of different medications. Some people cannot tolerate the medications that they’re on despite the fact that the medications may appear successful and that the patient is actually in sinus rhythm, they may not feel so well. There are a lot of different symptoms they may have from different medications, but medications are not without side effects and that has to be looked for and dealt with accordingly.The successful treatment of a patient is not how their EKG looks, it is how the patient is feeling.

7. There are serious consequences if afib is left untreated – can you talk a little bit about those consequences and the impact on patient’s lives? DO all patients with afib need to be on blood thinners?

a. No, there is a CHADS VAS risk scoring that physicians have come up with that is pretty predictable regarding their patient stroke risk. For certain patients, especially younger patients they do not meet the criteria of needing blood thinners. Like other medication blood thinners have their own side effects, mainly bleeding. At a certain point the risk of bleeding from blood thinners is greater than their benefit of stroke reduction from the atrial fibrillation. Patients will go through an evaluation by their medicine physicians to determine whether or not they are in need or would benefit from blood thinners.

Dr. DiGiorgi thank you so much for being here today – this has been so informative. For our listeners please check out part 2 of our afib series where Dr. DiGiorgi will discuss surgical treatment for atrial fibrillation – When is it time to seek a surgical solution to afib?

I’m Cathy Murtagh Schaffer and this has been HeartBeats, Shipley Cardiothoracic Center’s podcast dedicated to bringing research, innovation and education to our patients and the community.