Atrial Fibrillation with Dr. Wazni and Dr. Saliba

Podcast Transcript

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Dr. Wazni: Good afternoon. I'm Oussama Wazni. I'm the section head of Electrophysiology at Cleveland Clinic and with me is Doctor Walid Saliba, who is the director of the AFib center and also of the EP procedure labs. We just finished a web chat, a very interesting web chat, thank you for joining us, where we answered a lot of questions regarding Atrial Fibrillation. We'd just like to highlight some key points that were asked in the web chat.

I'd just like to point out and summarize that Atrial Fibrillation is very common. The reasons for treatment are... three important aspects of treatment or management. The first one is prevention of stroke and that depends on the CHADSVASC score. The second one is rate control to prevent the development of heart failure, and the third one is symptom relief. Treatment with Antiarrhythmic Drugs is indicated to provide symptom relief and if those do not work, then an Ablation can be considered so that we alleviate those symptoms.

Now every once in a while, we are faced with different scenarios, and this was actually born out in the web chat today. So I'm going to direct this question to Doctor Saliba. A patient who has Atrial Fibrillation but describes no symptoms, what is the current approach for that kind of patient?

Dr. Saliba: So this is a very interesting question and we've had a fair amount of questions to that effect that “I have Atrial Fibrillation but I feel okay. What do I need to do?” It is a difficult question for the physician and for the patient, but most importantly what we tell our patients is that: are you sure you're not having any symptoms? It is possible that you got accustomed to Atrial Fibrillation and this is the way you feel and it is not actually a very unreasonable idea to try to at least get yourself back into normal rhythm and we have easy ways to put you back into normal rhythm and see. And we have patients who actually after we put them back in normal rhythm, they feel wonderful. They say “Whoa, I didn't know that I would feel that much better.” And in those patients, we are aggressive at actually trying to restore normal rhythm with whatever means we have.

Dr. Wazni: So this is a patient now that we've established that even though they thought they did not have too much symptoms, now they are symptomatic and therefore it's better to maintain sinus rhythm in that patient. But suppose again, you have a patient that after some meaningful time in number then they say, "Well, there wasn't much of a difference between number Atrial Fibrillation."

Dr. Saliba: So this is where things are a little bit more difficult. Decisions are a little bit more difficult to make in this situation, but we have certain things that will guide us and we'll actually through a discussion with the patient, we can formulate the strategy of treatment. There's a big difference if somebody is eighty years of age and has Atrial Fibrillation and is asymptomatic versus somebody who is forty years of age and is believed to be asymptomatic. We do not know what thirty or twenty or thirty of Atrial Fibrillation is going to do to that patient who is forty years of age, and whether it's better for that patient to be in normal rhythm or to stay in Atrial Fibrillation. We do not know what is the effect on the development of heart failure. We do not know what is the effect on mortality. We do not know what is the effect on stroke prevention in that patient.

However, we know that at least from patients who have some left ventricle disfunction, even though they're asymptomatic, those patients are much better off being in normal rhythm, because there is some signals that those patients have a better survival and actually do better on the long term as opposed to if they stay in Atrial Fibrillation. So, age plays a factor. The heart function plays a factor. Patients' willingness and aggressiveness of the therapy plays a factor. And it's not just one or the other thing. It's more of a team approach with the patient playing the mid actually in this decision making going forward.

Dr. Wazni: So I think the key message here is that even if we decide that even if we decide that somebody's going to stay in AFib because they do not have symptoms, the key important thing to continue to do is surveillance and to check left ventricular function. And that can easily be done with an echo or an MRI. We look for two things, that is the size of the left ventricle and also the ejection fraction of the left ventricle, and if we feel that in a younger patient these are becoming are declining or getting worse, then maintenance of sinus rhythm becomes very important.

Dr. Saliba: I agree with that. The only potential problem with this is that if we wait too long and the patient has been in Atrial Fibrillation for so many years before these things start to develop, then with the patient's having had Atrial Fibrillation for such a long time, it becomes harder for us to put him and keep him in normal rhythm, and that is something that always need to be discussed up front at the time of decision making.

Dr. Wazni: I think this is still a work in progress. We still have a lot to learn. I think very important key studies are being done right now to answer these questions-

Dr. Saliba: That is correct.

Dr. Wazni: For now, a patient, an elderly patient, who has asymptomatic Atrial Fibrillation, the most important two aspects are prevention of stroke and rate control. For a younger patient, this is a more difficult decision and it has to be individualized based on patients' preferences and values.

Dr. Saliba: I perfectly agree and I also want to stress what Doctor Wazni said that the treatment of Atrial Fibrillation is stroke prevention, rate control, and also persuasion of normal rhythm. To improve symptoms, something also that we always should never forget is risk factor modifications. The same risk factors that are predisposed for coronary disease and other heart disease, be it diet, exercise, cardiovascular fitness. These things, actually if we take care of ourselves, we can actually reduce the potential burden of Atrial Fibrillation going forward. And this is something that has not been too much stressed over the past few years, but now is gaining a lot of traction and you're going to hear much more about that. And we have certain studies at Cleveland Clinic looking specifically at modifications of risk factors to reduce the amount of Atrial Fibrillation going forward.

Dr. Wazni: Well thank you very much for participating in the web chat and we look forward to having as our guest in the future web chats or video chats with our team. Thank you very much-

Dr. Saliba: Thank you very much.

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