Atrial Fibrillation – Part 1: Your Questions Answered

This two part program answers all your questions about Atrial Fibrillation. Part 1 covers types and progression of afib; causes and risk factors; symptoms; and diagnostic tests, including personal monitors or devices. The doctors then discuss how these factors are taken into account when deciding on ablation and the use of blood thinners.

Next week’s podcast (Part 2) provides answers to questions about medications, cardioversion, ablation, the hybrid convergent procedure and the WATCHMAN device. 

Questions are answered by atrial fibrillation experts Dr, Oussama Wazni and Dr. Mandeep Bhargava.

Learn more about our Atrial Fibrillation Center.

Transcript

 
Welcome to Love Your Heart. Brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Dr. Wazni:
Welcome to Ask the Heart Doctor about atrial fibrillation. I'm Oussama Wazni. I'm the section head of electrophysiology at the Cleveland Clinic. And with me is my great colleague and friend, Dr. Mandeep Bhargava. He's also an electrophysiologist in our section, and we're happy to be here to answer questions and concerns regarding atrial fibrillation.

So, Dr. Bhargava, let's start off. What is atrial fibrillation?

Dr. Bhargava:
Sure. I mostly tell patients that it basically is an arrhythmia where it affects the upper chambers of the heart, or the upper chambers, instead of going at the normal rate of 60, 70, 80, 90 beats a minute, start going fast, they're close to 304 beats a minute, and that is what drives this rhythm. And it can have different implications where it can cause rapid rates in the bottom chambers, which can cause symptoms like palpitations, or it can cause a loss of the squeezing capacity of the upper chambers which can cause the common symptoms of tiredness and fatigue. But a very important thing to know is that with such fast rates, it reduces the squeezing capacity of the upper chambers, causes traces of blood. So, that is what predisposes the risks of formation of clots and gives rise to the risk of strokes.

I know that it's a lot of things to say in one sentence, but what do you think about, how would you tell to your patients?

Dr. Wazni:
Yeah, so we have a lot of questions here. We're going to try to answer most of them. Just to summarize, Dr. Bhargava just told us that it's when the atrium or the upper chamber is going too fast. The good news is that the lower chamber, the ventricle can't go that fast because there's something called the AV node or relay station between the upper chamber and the lower chamber. So that rate in the ventricle cannot be 300 to 600 beats per minute, but it can be up to, depending on age and medications that the patients are taking, anywhere between 100 beats per minute to 160- 170 beats per minute. And the main concerns with atrial fibrillation as Dr. Bhargava mentioned are stroke, so that's the first thing we actually would like to address when encountering a patient with AFib is the risk of stroke, and there are certain algorithms and scores that we use to discuss with the patient and decide on whether a patient should be on a blood thinner.

The other aspect of atrial fibrillation that is very, very important is development of heart failure, and that's why we monitor the heart rate, the ventricular rate when in atrial fibrillation, because if a patient has an elevated heart rate for months at a time, or even sometimes, years, they can develop heart failure. The good news is that most of this is reversible. And the last aspect of management of atrial fibrillation is symptom relief. As Dr. Bhargava just mentioned, the patients will have symptoms of shortness of breath or palpitations or fatigue. And a lot of the times that we are sought after is because the patients have symptoms. And this is where we can jump onto the next things that we have, is it dangerous to leave your heart in atrial fibrillation? I think we just addressed this, provided we address the risk of stroke and the risk of heart failure, it's not particularly dangerous, but of course, you have to seek help so that we prevent those aspects of atrial fibrillation.

Does atrial fibrillation ever go into spontaneous remission?

Dr. Bhargava:
So that's an interesting question because it brings us to the types of atrial fibrillation. So there are different types of atrial fibrillation. People can either go into atrial fibrillation, and then, go back into normal rhythm. And that is what we call as having paroxysms of atrial fibrillation. That is what is paroxysmal atrial fibrillation.

And then, we have a more advanced version where people have persistent atrial fibrillation, where they go into atrial fibrillation, but stay in it for days and months, we have to shock them back into rhythm, and then, they may stay in rhythm for long periods of time. But most often, they have an ability or tendency to go back into atrial fibrillation, because unless people have atrial fibrillation, you do specific triggering factors like a recent surgery or recent infection, or things like that, most often, the [inaudible 00:04:59] variety of atrial fibrillation that we see, which is age-related, can always come back. So once a fever, always a fever, just like hypertension and diabetes.

But then, some patients may be in atrial fibrillation for long periods of time and may not stay in sinus rhythm or normal rhythm even after being shocked into rhythm. And when they have it for more than a year, we call it as long-standing persistent atrial fibrillation, or in some patients, where we feel that either it is not worth the risk to put them in normal rhythm because they're not very symptomatic, or we have tried all the times and they don't stay in normal rhythm, that is when we call it as permanent atrial fibrillation. So yes, it can go into spontaneous normal rhythm, but I wouldn't call it remission because it always has the tendency, or the ability to come back with age. So, that is something we have to respect.

Dr. Wazni:
So that's a very good, an important point is that the natural history of atrial fibrillation is that in most patients, it will be recurrent. And in some patients, it may become progressive. It is difficult to say that it goes to remission on its own unless it was triggered by specific factors that the patient had. For example, recent surgery like Dr. Bhargava mentioned, fever or acute illness, like any acute illness can trigger atrial fibrillation. And once the acute illness resolves, the atrial fibrillation can resolve.

Dr. Bhargava:
Dr. Wazni, what do you think about this question? I think it's interesting. Can a person with atrial fibrillation live a full, long life?

Dr. Wazni:
I think so. This is a very important question. And we encounter this question with our patients...

Dr. Bhargava:
All the time.

Dr. Wazni:
... all the time. And the question is whether this atrial fibrillation is going to kill me. And the short answer is if properly managed, it will not shorten a person's lifespan. So, as long as we're able to prevent stroke and heart failure, atrial fibrillation, on its own, should not shorten anybody's lifespan. And I think this is a very good message to our patients. But it's very important, again, to address these issues, which brings us to the next question. I think it ties very well with it. What is the most important information I need to know to monitor my AFib or about AFib in general?

Dr. Bhargava:
Yeah.

Dr. Wazni:
So now I... If I have AFib, what is the most important thing you want to tell me?

Dr. Bhargava:
Yeah. I think it ties up to all the previous questions we've had. So we know that atrial fibrillation is not a dangerous or life-threatening arrhythmia. We know that it can be well-managed. We know that to manage it, our goals are to prevent the risk of stroke and heart failure. So, if you are able to do all that, then, you should be able to live a full, long life and have a good quality of life as well.

Dr. Bhargava:
So, it is important to monitor it, monitor your symptoms, monitor the rhythm, but not sometimes to the point that it affects your quality of life so much that you are more distressed by the monitoring, rather than by the symptoms of the atrial fibrillation itself. Especially in today's day and age, where we have all these new gadgets, where we can try and pick up every single episode for few seconds or every single extra beat here and there. And then, the panic of atrial fibrillation, sometimes, tends to drive the quality of life of people rather than the atrial fibrillation, et cetera.

Dr. Wazni:
We do not want to exchange atrial fibrillation for obsessive compulsive disorder, basically. We're going to move on to the causes of atrial fibrillation. I think this is a very, very important...

Dr. Bhargava:
Yeah, I think that's a very important point.

Dr. Wazni:
... topic. And there's a big list here of things. But I think we want to concentrate on a few things that we know would have an impact.

Let's talk about sleep apnea, which also ties into obesity most of the time. So, what is the relationship between atrial fibrillation, sleep apnea and obesity?

Dr. Bhargava:
That's a great question. I think we have to know that when people have atrial fibrillation, there are certain factors that they have that they cannot change, age being one of them, their genetic makeup being the other, but there are a lot of things that we can manage to try and either reverse the atrial fibrillation, or reverse the changes in the heart that can reduce the risk of progression of the atrial fibrillation.

And two very important ones are obesity and sleep apnea. Because there is a lot of data that show that both these things put an extra stress on the left upper chamber, which is where most of the atrial fibrillation comes from. And there has been a lot of data to show that as people can lose weight or treat their sleep apnea, we know that their atrial fibrillation may just respond better to treatment, or they may have less episodes of atrial fibrillation, or even if they have more advanced atrial fibrillation, they respond better to the drugs and the ablation manoeuvres to treat the atrial fibrillation.

In fact, now, we have so much good data which shows that even from our centers, some great studies published by... Dr. Donnellan and Dr. Wazni and Dr. Saliba have all been part of it where it shows that those patients who lost weight and did an ablation did so much better than patients who did not show great strides on that account.

So, I think those are very important thing where it is important to know that just treating sleep apnea doesn't mean the atrial fibrillation will you go away. So it is not a direct cause and effect relationship, but it kind of adds spice to the situation.

Dr. Wazni:
It will decrease the burden. And it will decrease the burden of atrial fibrillation. Actually, we showed that losing weight will help with both sleep apnea and AFib, the burden of AFib. But also, we showed, on a bigger scale, that fitness also matters. So, the more the patients become fit, the less the likelihood of recurrence after an ablation. But also, that means that the more fit people are, the less likelihood that they'll have Afib, and that we can also have them reduce... There's a higher likelihood that we'll be able to let them reduce the burden of atrial fibrillation.

Dr. Bhargava:
In fact, a lot of these questions are on the same account that, you know, we talked about the fact that there are certain non-modifiable factors.

Dr. Wazni:
Yeah.

Dr. Bhargava:
But there are a lot of modifiable factors. So we can do a lot of good to ourselves and others by telling them that it is important that they manage their blood pressure, they manage their alcohol content, they manage their thyroid well, valve diseases, because all of these things will increase the risk of having atrial fibrillation. And if you work on these things, in addition to the rest of the management for atrial fibrillation, you're likely to get a bigger bang for the buck.

Dr. Wazni:
So, just to summarize, then, the fitter, the better, less weight is better. Less alcohol is better. Unfortunately, less of all of these things is better. So it's good. And then, there was one medical question here about valve disease, and once a patient develops atrial fibrillation because of valve disease, or the existence of valve disease, it is hard to manage. It's actually harder to manage. Of course, if we treat the valve disease, the AFib becomes more manageable, for sure. So, that's the answer to that question.

Dr. Bhargava:
Let me lead you to the next set of questions we have, Dr. Wazni...

Dr. Wazni:
Yeah.

Dr. Bhargava:
... on the symptoms. I have a lot of symptoms that have been listed here, but let me first guide you... Let me help you, first, guide the audience on what are the usual set of symptoms that you would see in most of your patients that you see in the clinic who have atrial fibrillation.

Dr. Wazni:
So the most common and tangible, I want to say, the most common and tangible symptom that patients come to us with are palpitations. So, those are the most tangible symptoms. But there are some other symptoms that the patients can have that are not so apparent, for example, fatigue and tiredness and loss of energy. And if we take that into account, actually, that's the most common symptom, but it's not very quickly apparent to the patient or to the treating physician that these are symptoms of atrial fibrillation. Sometimes, patients are already, or have been in AFib for months or even years, and they're feeling tired and fatigued, and they think it's due to either their medications or due to advancing age. And that could be the case. But a lot of times, we find out that once we restore sinus rhythm, the patients say, wow, this is the most energy I've had in years.

So then, we work backwards logically and say, "Well, then, maybe the symptoms were due to atrial fibrillation." And it is in those patients that we seek to maintain sinus rhythm. And other patients, they don't feel any difference. So, we get them back into normal rhythm, but there is no difference. Then, in those patients, we may not have the same inclination to continue to pursue normal rhythm, if there was no difference or no improvement in how they felt, whether they were in normal rhythm versus atrial fibrillation.

Dr. Bhargava:
Yeah. I think those are great points for our audience because as we know that in terms of palpitations being a symptom, it's a very specific symptom. Or if people have that, we know it is from the atrial fibrillation. But most of our patients will be having symptoms which they may not find attributable to the atrial fibrillation, and just the loss of stamina, loss of energy, it's almost like missing the fourth and fifth gear in a car, many times. That's why when we see Mr. Smith in AFib, we try to recreate sometimes a Mr. Smith in normal rhythm. And if the two of them feel different, that's a very good guide for us to know how aggressive we have to be in terms of treating them.

But again, as Dr. Wazni said earlier, even stroke, heart failure, shortness of breath, swelling in the feet, those are all secondary symptoms of atrial fibrillation that can happen, but important to know that not everybody may manifest the same set of symptoms. And that is why it is important to be checked out and assess every individual according to their own merit.

So, coming now to the diagnostic avenues, Dr. Wazni, let us take this question, which I think is very important in today's day and age. Can Apple watch or monitors be used to diagnose atrial fibrillation? And what... when they say they are inconclusive and doctors ignore their data... Or what do you think is your perspective in today's day and age on that?

Dr. Wazni:
This is a very important question, especially now that a lot of our patients, or before they become our patients, they're just consumers who buy a monitor, a consumer grade monitor, whether it's an Apple watch or a Kardia or anything like that. So those, yes, I think they can make a diagnosis as long as we can see the traces. As long as we can see... When we say tracing, it's like an equivalent of an EKG, and we can see the atrial fibrillation. What we will have some concerns about is that if we are given a diagnosis, written words saying atrial fibrillation but without the tracing, then, it's harder for us to accept it. Because remember, we're making here big decisions, we're making decisions on starting a new medication. We're going to be making a decision on maybe even doing an ablation in the future. We can't base it on something that we have not ourselves seen.

One of the reasons I became an electrophysiologist is because AP or electrophysiology is so objective, meaning, the data is there. So, as long as we see it, whether if it's from a consumerable or a consumer-based monitor, or it is a medical-grade monitor, as long as we have that strip that shows the AFib, then we make the diagnosis from this. We have no problem, and we're not biased with one against the other. But what we cannot take is just the word saying atrial fibrillation.

Dr. Bhargava:
Yeah. I think those are very important things for our audience to know that, you know, many times, people are wearing Fitbit monitors and they say my heart rate was 130 or 150, and it's important for people to know that they could be 150 and not be an atrial fibrillation. They could be 75 and still be an atrial fibrillation.

Dr. Wazni:
That's very important.

Dr. Bhargava:
So it's not only just the heart rate, but the rhythm that matters. And so, it is very important for us as Dr. Wazni said, to look at the tracing, because we are making decisions about whether you need a blood thinner or not. And if you need it, you might need it for the rest of your life or indefinitely or a procedure. And all those things have to be based on objective data. Similarly, the next question, which pertains to implanted loop recorders, and that's showing a duration of atrial fibrillation for 11 seconds or 30 seconds, so what exactly does the tracing look like? Why does it fit into the overall clinical picture? What is the total duration of symptoms? What will the total duration of the arrhythmia itself? Is it truly atrial fibrillation, or just some extra beats from the top or the bottom chambers of the heart?

All these things require objective thinking, objective evidence, and not one is just a corollary of the other. So, all two things are not always the same. All of these things, we have to put our mind to and try and come up with the right diagnosis and the right clinical perspective to be able to make the right decision for every individual patient.

Dr. Wazni:
So, in this section... We have other questions about the loop recorders and all that, but these are really specific and technical medical questions. But there is a question here that I like, and I would like us to address. So, I have AFib[inaudible 00:19:41]. This is the question from one of... And on that blood thinner and direct. What is the reason for continued heart monitoring if I'm feeling better? And I'm already, I've taken a blood thinner and a diuretic, and presumably a rate control medication.

Dr. Bhargava:
I think that's very important that we have to understand that for us as physicians, we want to treat the physician as a whole.

Dr. Wazni:
The patient.

Dr. Bhargava:
We don't want... the patient as a whole, I'm sorry. We don't want to be just plastic surgeons of your ECG. So, whether you are an AFib, whether you are a normal rhythm, whether you should be on rhythm control or whether you should be on rate control, whether you have heart failure, or don't have heart failure, whether you have heart failure that should respond only to the management of atrial fibrillation or other maneuver, all these things are important to know. So the most important goal is to try and make the patient feel better, or help him live longer. So it doesn't matter what your rhythm shows on a monitor, because if the right treatment for you is to manage your atrial fibrillation by just controlling your heart rate and managing your heart failure, that's the right treatment for you. The monitor doesn't matter.

If the right treatment for you is to try and put you back into normal rhythm and keep you there, and if you have a few extra beats here and there, or a few episodes of atrial fibrillation that you may pick up on a monitor off and on, but 95%, 90% of the times, you have normal rhythm, that may be good enough for you. So, I think the two important goals for us, or as physicians, as always, is that we want to try and help patients feel better, and we want to help them live longer. And if we are able to achieve those two goals and what exactly the monitor shows me, not always matter.

Dr. Wazni:
Yeah. So basically, the monitor is not that important, as long as the patient is feeling better and we're preventing stroke and heart failure and prolonging their life. So there is no need for ongoing monitoring.

Now, there are certain instances where the patient will say, "Well, I don't want to be on the blood thinner all the time. Can I just take it when I'm in atrial fibrillation?" This is an important question, and we want to talk about it a little bit, is that if a patient can feel they're AFib, and sometimes, they can't, and they really don't want to take a blood thinner and use it only as needed, so only as directed or as needed, then, monitoring may be important. But actually, we try to discourage that kind of management. Because even with the best monitoring, sometimes, we may miss some episodes of AFib and put the patient at risk for having a stroke if they're not taking their anticoagulant on a scheduled basis.

Dr. Bhargava:
So, I think that also brings us to the next section, which is on treatment and medications. And I think one of the most important treatment of atrial fibrillation is to reduce the risk of stroke and to reduce the morbidity of stroke in these patients. On that account, one of the very important part of management is to decide which patients should be on a blood thinner, what blood thinner they should be on. And I think a very important message there is that, first of all, it's important to know that many, many times, the risk of stroke in atrial fibrillation does not necessarily depend upon how much atrial fibrillation you have, or what type of atrial fibrillation you have, but depends upon the company that it keeps. And that depends upon what is the overall risk profile of the patient.

Now, we tend to define it by what is called as the CHADS2-VASc score, which is C for congestive heart failure, H for hypertension, A for age, D for diabetes, S for stroke and vasc for vascular disease. But on a nine point scale, we decide which patient has a low, a medium, or a high risk of stroke. And sometimes, if patients have a high risk of stroke, it doesn't matter how much atrial fibrillation they have, and they might need to be on blood thinner all the time, because they just have all those milieu inside their body which can put them at a risk of stroke, and atrial fibrillation is just a marker of that.

And sometimes, people may have more frequent episodes of atrial fibrillation, but may just be a lower risk of stroke. And then, those are the people in the intermediate range where we use this combination of how much atrial fibrillation they have, and they have atrial fibrillation, and we respect their preferences too, because some people, because of their lifestyle, or their preference or tolerability of medications, may decide or want to take medications like blood thinners or not. So, when do you find it useful for patients, for example, to decide when they can take their blood thinners as in when needed, versus when you think they should just be on it, and not question that decision every single time?

Dr. Wazni:
My inclination is that if we establish that an anticoagulant is indicated, that they just be on it all the time. Now, which brings us to the next section of these questions, and we'll start with ablation. So the question will be when is an ablation indicated? And the follow-up to that question is, okay, we did now an ablation, and we think that the ablation is successful. Should we continue taking the anticoagulant, or is this an opportunity to reassess the situation?

Dr. Bhargava:
So again, I'm sure that this is a whole discussion on its own. And I would like Dr. Wazni to pitch in whenever he has comments on this, too. So I think when should an ablation be done is a decision that starts off for, again, the same two things that are we able to help the patient feel better, or are we able to help them live longer? I think patients who have a much better quality of life when they are in normal rhythm, and when I'm talking about ablation, I want to specify that we are talking about the big ablation, which is in the left atrium and not the ablation of the, AV junction that we may sometimes talk about.

So, those patients who can establish or convince themselves and us that they feel much better when they're a normal rhythm, patients whose heart function is much better, their heart failure is much better than they're a normal rhythm, especially if either it is their strong preference that they would like to do an ablation rather than take medications, or if they have taken medications, fail them, or if they've taken medications, but don't feel good with the medications themselves and have side effects or intolerance to that, so I think those would be the three classic indications that come to my mind about patients who would be the best candidates for an ablation.

I think one important message is that many times, people feel that they should have an ablation because they want to get off of blood thinner.

Dr. Wazni:
Yes. So...

Dr. Bhargava:
Is that an indicator?

Dr. Wazni:
... if I have a patient who comes and says, "I have AFib for two years, three years. I can never feel it. I pretty much do everything that I want to do. I am having a full quality of life. Life is not different when I'm a normal rhythm versus atrial fibrillation, but I want to do an ablation because I want to get off blood thinners." I think it's very important for people to understand that an ablation of atrial fibrillation is not a substitute for blood thinners. And if you have a high risk of stroke, even if you stay in normal rhythm and have an ablation, you might still have to stay on blood thinners.

So that is where I would probably ask you this question for our audience, that in case people have a desire, or in case, they have some kind of problem with blood thinners, what exactly should they understand about the relationship between an ablation and blood thinners, and their options in case their primary goal is that they want to be off blood thinners?

So, I would start off by saying and reiterating that wanting to be off blood thinners is not an indication to have an ablation. The reason we do ablations are to improve quality of life and prevent worsening, or prevent heart failure in the first place. But now, we did an ablation because for these reasons, and the patients are asking questioning, well, we did an ablation, it looks like it's been successful. Should we continue taking anti-coagulants? And the answer now today is that because of some complexities with managing atrial fibrillation afterwards, and I'll hit on those in a bit, the recommendation and the guidelines say so is that we continue anticoagulation based on those other risk factors that Dr. Bhargava just mentioned, the CHADS-VASc score, irregardless of what we think the outcome of the ablation is.

And the reason is, is that... And it's been shown in many studies, that up to 50% of patients who report that they have no AFib based on symptoms, if we monitor them, they will have some degree of atrial fibrillation. And now, we stop their anticoagulant with a high risk of stroke, they end up with a stroke. So that is a problem of stopping anticoagulation after an ablation. And it becomes a dangerous situation for the patients.

Now, thankfully, now, we have some studies that are looking into this. One of them is actually the options in which we are enrolling patients in, and we're leading actually in the world, is that patients who get an ablation now and have a high risk of having stroke, we randomized them to continue taking anticoagulants versus closing the appendage with what we call a Watchman device. This study is almost halfway enrolled now. And we still have good ways to go to finish enrollment, and then, continue the follow-up, which is for three years. So hopefully, we will get an answer in the next five years regarding this. But for now, ablation does not equal, or even successful or presumed successful ablation does not equal coming off anticoagulation. And that's a very important message we'd like to disc-


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