You Asked, We Answered! – Atrial Fibrillation Part 1

Podcast Transcript

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Oussama Wazni, MD, MBA:

Hello everybody, and welcome once more to a podcast from Cleveland Clinic Electrophysiology Team. I'm Oussama Wazni, as you know, and I'm the Section Head of the Electrophysiology here at the Cleveland Clinic. Joining me today are the directors of the Atrial Fibrillation Center. I have Dr. Walid Saliba and Dr. Ayman Hussein.

Oussama Wazni, MD, MBA:

Welcome Dr. Saliba and Dr. Hussein, thank you for joining us. Today, we have a lot of your questions, a lot of them. And we have divided them as best as we can, into general category, types of atrial fibrillation, there's a lot of questions on atrial fibrillation triggers and associated conditions. And then, we have expectedly questions on the Apple Watch because I know that, that's been in the news. And we have some questions regarding that. And then we will go into the symptoms of atrial fibrillation and management of atrial fibrillation. And we have a lot to cover today. So we're going to start with you, Dr. Saliba.

Oussama Wazni, MD, MBA:

So first, welcome. And our first question is, based on an EKG, I was originally told I had atrial tachycardia, but then they say that I have AFib. What is the difference?

Walid Saliba, MD:

Okay. That's an interesting question. The tachycardia means that your heart rate is fast. That's all what it means. The heart rate is fast. Now there are lots of conditions that can make your heart rate fast. Atrial fibrillation is one of those condition that can make you have a fast heart rate. So if you have atrial fibrillation, you can have tachycardia, but there are other conditions that can give you tachycardia that we are not going to talk about here. But that's the main difference is that atrial fibrillation can give you or will give you tachycardia, which means a fast heart rate.

Oussama Wazni, MD, MBA:

Yeah. And atrial tachycardia can be a precursor of atrial fibrillation. So somebody may have on one monitor, atrial tachycardia, and then you repeat the monitor at some other time and it will manifest as atrial fibrillation. So that's really, what it is now to you, the patient that is, you may feel the same, except if you try to take your pulse, maybe in atrial tachycardia or feel that is more regular, but in atrial fibrillation, it's not regular.

Oussama Wazni, MD, MBA:

So we have a question here regarding the danger of atrial fibrillation. So Dr. Hussein, how dangerous is atrial fibrillation?

Ayman Hussein, MD:

That's a very important question. So when we approach the patients with atrial fibrillation, the two most important thing about AFib and understanding the risks involved, if it can affect the quality of life in many patients, and it can interfere with the ability to do things. But most importantly, if it comes with the risk of stroke. And it depends on what other conditions there are in the backgrounds, such as the patient's age, whether or not they have high blood pressure, whether or not they have diabetes, whether or not they had a prior heart attack or a stroke or vascular disease. We try to assess their stroke risk based on that. And that is the most important thing that we need to address in AFib and AFib management.

Ayman Hussein, MD:

AFib has been associated with increased mortality, statistically in patients with heart failure and in other conditions such as patients with structural heart disease, but that could be also because of the fact that AFib can coexist with other conditions, with other heart conditions. But overall, nobody just drops dead because of AFib. But the one thing that we worry about the most is the risk of stroke in AFib.

Oussama Wazni, MD, MBA:

So while we're on that subject, Dr. Hussein, the following question was about heart failure. And we have a patient who is concerned, now they have AFib and concerned about heart failure. So what is the incidence of heart failure in patients who have AFib? And how does one know that maybe they have heart failure?

Ayman Hussein, MD:

Yeah. So, and that's also an important question. AFib and the heart failure can coexist and one can lead to another, such as the presence of AFib can predispose to heart failure. And the presence of heart failure can predispose to AFib. We know nonetheless that the coexistence of the two conditions actually is not a good combination. And as a matter of fact, in patients with heart failure, AFib has been associated with mortality risk. And there have been multiple trials addressing this. And most recently, the CASTLE-AF trial which showed that if we control the rhythm with ablation procedures and trying to address the source of AFib, that these patients not only had improvement of their pump function of the heart, but they were also more likely to survive or live. So in patients with heart failure and AFib, we try our best to control AFib and maintain normal rhythm.

Ayman Hussein, MD:

That said, there are two types of heart failure. There is the heart failure with a weak pump function of the heart, but there are areas of heart failure that are related to inability of the heart to handle fluids, but more so related to stiffness of the heart muscle. So the two different...The implications are primarily and what we know about AFib and heart failure has been primarily in patients with weak pumps, but we know that patients who have heart failure with preserved pump function, but rather stiff muscle, that combination is also something that would need to be addressed, and to control both the AFib and the heart failure to improve the quality of life.

Oussama Wazni, MD, MBA:

That is very helpful. So basically, yes, there is a risk of developing heart failure with atrial fibrillation. It's really mostly associated with uncontrolled heart rates. So for example, if the heart rate is too fast or too long, a patient may develop heart failure. And the literature that is about, it's anywhere from 5% to even 15% of patients will develop heart failure at some point. But, how do you know that somebody developed heart failure. When they get more short of breath, they start retaining fluid, swelling in their legs or in their feet. So those are some of the indications that a patient may have heart failure.

Oussama Wazni, MD, MBA:

Dr. Saliba, I know that, this one, you like this. You're going to have to unmute yourself because I've muted you, because we're getting echo. So this is the question. Does AFib ever go into remission on its own, spontaneously, and will I always have AFib?

Walid Saliba, MD:

The quick answer to this question is, once you have AFib, you'll always have AFib. And unfortunately, it's our poor understanding of AFib that makes us say that we cannot cure AFib, but we can do a lot of things about it. Now, if you have some conditions that predispose you to have AFib and you remove those conditions, like thyroid disease, and what have you, then yes, it is possible that you might not have AFib down the road. But generally speaking and in the majority of the population, AFib is a progressive disease. And our goal of treatment of atrial fibrillation is to reduce the burden of the arrhythmia by reducing the frequency of the recurrence and reducing the length of these episodes. So we're treating you because we want to take you from having this much atrial fibrillation to having this much atrial fibrillation.

Walid Saliba, MD:

And that is the goal of therapy, in addition to a reduction in risk of stroke and reduction in risk of heart failure and what have you. So we are reducing the amount of AFib so that to improve your quality of life. Because the more AFib you have, the more symptoms you have, the more frustrated you are. And by having less AFib, you have a better quality of life. So all the treatments that we will talk about a little bit later, be it anti-arrhythmic medication, be it surgery, be it ablation, is to reduce the burden of AFib and improve the quality of life.

Oussama Wazni, MD, MBA:

That's excellent. Thank you so much. So I have a few questions here on types of atrial fibrillation and correlations with other diseases. So let's take one question, here. I think I'll start with Dr. Saliba. And these are about heart valves. So somebody with atrial fibrillation and mechanical heart valves or prosthetic heart valves, and now they have chronic atrial fibrillation. What are some of the options for treatment in this situation?

Walid Saliba, MD:

So, definitely valvular heart disease is one of the predisposing factors to have atrial fibrillation. And the patients who have that, tend to have a lot of symptoms and we're fairly aggressive about treating patients with valvular disease and atrial fibrillation. And clearly, the treatment, be it with anti-arrhythmic medication or with ablation, can actually confer a certain degree of improvement in the burden of atrial fibrillation. That is on one hand, but also on the other hand, patients who have usually rheumatic heart disease requiring prosthetic valve replacements, sometimes they progress fairly, quickly downstream down that progression of atrial fibrillation. And it is possible that at some point, no matter what we do, we are not able to get rid of the atrial fibrillation and then we'll have to treat them predominantly with controlling their heart rate in response to atrial fibrillation.

Walid Saliba, MD:

So patients who have, for example, severe mitral stenosis or they had mitral valve replacement for mitral stenosis, these are the patients who actually tend to have the worst kind of atrial fibrillation in terms of being able to put them back in normal rhythm. Whereas mitral regurgitation and aortic stenosis and what have you, we have a fair chance of maintaining normal rhythm with whatever procedures we do and strategies we involve here.

Oussama Wazni, MD, MBA:

All right. So a question to Dr. Hussein. Actually, these are a few questions that I collating together here. Is there a first-line treatment, what is the primary first-line treatment for persistent AFib? That's one. In that same question, are there any innovations for permanent AFib? And then finally, what are the complications from ablations that we need to know, first of all? That's what the patient asked. So basically, the indication of first-line treatment for persistent AFib, any innovations for permanent AFib, and any anticipated complications.

Ayman Hussein, MD:

Excellent. Okay. So when it comes down to first-line of treatment, we have more and more evidence that ablation is better than medications as a first-line. And most of the evidence so far is about patients with paroxysmal AFib. But more and more studies are being done in this field and we still believe that ablation is better in the long-term for rhythm management, especially when there is heart failure or other conditions.

Ayman Hussein, MD:

In terms of innovations in permanent AFib. I mean, permanent AFib refers to AFib that is being left alone, not being reversed. If we're talking about persistent AFib, that is different, when we try to ablate persistent AFib, it's a bit more challenging and it involves actually ablation of the veins on the left side of the heart and some additional mapping on substrate. To this date, it's still an area of research. We have here at the Clinic, started many research protocols, looking at specific mapping, mapping information, looking at areas with low voltage, rotational activity, abnormal activation outside of the typical and standard targets. So that's an area of ongoing research.

Ayman Hussein, MD:

When it comes down to complications, especially in high-volume centers, AFib ablation has become a very safe and effective procedure. And what we do is that we give blood thinners around the time of procedure to reduce the risk of stroke. But overall, the risk of something serious happening from an ablation procedure is in the range of 1-2% or less. There's small risk of bleeding in the groin, half-percent risk of bleeding around the heart. But you know, it's been a safe procedure in our practice.

Oussama Wazni, MD, MBA:

So, just quickly, ablation is becoming first-line therapy for symptomatic persistent AFib. A permanent AFib means that somebody thought that it's futile to try to restore sinus rhythm. And the complications, they're very rare, but if they happen, they can be serious, mainly perforation of the heart or damage to adjacent structures.

Oussama Wazni, MD, MBA:

Now, I think we're done with the second part of the procedures. There was one question here, since we talk about ablation. I will answer this one quickly. Why and when should I consider an ablation? Why, it's because ablation is much more effective than medications. When, is whenever you think that it's affecting your quality of life to an extent where you want to have this problem taken care of. There is another when. If, for example, your quality of life is good, but you find that or your doctors find that you're developing heart failure, then that may be an indication that it's time to proceed or consider an ablation.

Oussama Wazni, MD, MBA:

Okay, we're moving on to triggers and associated conditions. There's a lot of questions here. I'll make them into one question for Dr. Saliba. The question is, how is eating and drinking wine related to atrial fibrillation. So eating, mostly they're talking about eating fatty foods or salty foods. And also, one, last one is, vitamin D, have you heard of any links between taking too much vitamin D and atrial fibrillation.

Walid Saliba, MD:

Yeah. So again, for the purpose of being brief, everything in the human body is connected. And I tell my patients that there is enough data to say that alcohol and wine and red wine can be a trigger for atrial fibrillation. But you have to understand that atrial fibrillation is a manifestation of different diseases. And everybody has a different kind of atrial fibrillation. And it is very possible that, what is a trigger of atrial fibrillation in Mr. Smith is not a trigger for atrial fibrillation in Mr. Jones. And it becomes a matter of essentially, mostly trial and error. If you know that when you drink wine, you go into atrial fibrillation within few days or within the first week, then you know how to avoid it, to try to not have this problem. Having said that, excess alcohol, overall, it does and is essentially a trigger for atrial fibrillation on the long run.

Walid Saliba, MD:

When it comes to eating, well, fatty food and eating, we have, there is subgroup of patients who, when they eat a fatty meal and that triggers what we call a vagal kind of state, can develop atrial fibrillation. It doesn't mean it happens in everybody. But the fact, when we talked about eating is, overeating and obesity and overweight, is definitely one of the risk factors, not to trigger AFib, but to progression of atrial fibrillation over the years. And on the other hand, maintenance of cardiovascular fitness and weight-loss is actually something that we recommend to maximize the chances of remaining in normal rhythm.

Oussama Wazni, MD, MBA:

That's excellent. Thank you. Thank you. So then we have a few questions. I'm going to also summarize them into one. And those questions are about some other things. Let me address one question here. There's a question on neuropathy. We actually do not know much about neuropathy and chemotherapy, so we're not going to be able to answer that one. That's probably something that should be addressed by a neurologist, together with your oncologist.

Oussama Wazni, MD, MBA:

We have a question regarding nocturnal hypertension. And that's probably related to something called sleep apnea. So there's somebody here asking about her husband's condition with permanent AFib and hypertension, but they have nocturnal hypertension, so probably that's related to a condition called sleep apnea. So if your husband is snoring loudly or even not so loudly, and they should be checked or he should be checked for sleep apnea, because we know that sleep apnea can adversely affect the heart with high blood pressure, with heart failure and also with atrial fibrillation.

Oussama Wazni, MD, MBA:

One last one, I'm going to answer myself. This is a question about the ZAAZ whole body vibration machine, and health and fitness. I have not heard of it. But is it okay to use. I think it's okay to use with atrial fibrillation.

Walid Saliba, MD:

Dr. Wazni I did not address the vitamin D, say something about the vitamin D.

Oussama Wazni, MD, MBA:

Vitamin D. Yeah. Yeah. Could you, could you...I'm not aware of vitamin D and atrial fibrillation, but since we're talking about, have you?

Walid Saliba, MD:

No, no. But, because we live in Northeast Ohio and we're all deficient in vitamin D, there's no surplus of atrial ventilation in Northeast Ohio.

Oussama Wazni, MD, MBA:

Yeah, so we need vitamin D. But talking about supplements, so this is good, we're talking another supplement. We did not get a question on this, but fish oil, fish oil, you should not take fish oil for any reason. It's actually shown that it is not helpful. And in some cases it may be a risk factor for atrial fibrillation. So if you're taking fish oil, please do not take fish oil.

Oussama Wazni, MD, MBA:

Then, I'm going to talk about AFib and exercise. So our colleagues here from the exercise department and the stress test department have shown that exercise is actually very good. And there is no upper limit of how much exercise we do. The more exercise we do, the better the outcomes. And especially pertaining to atrial fibrillation. The question is, what kind. Mostly, aerobic. If you do not have heart failure, you can also do some weights, within reason. When to stop. Well, I mean, you don't want to go to exhaustion. So if you feel very tired and very short of breath, maybe that's your indication to take it easy during exercise.

Oussama Wazni, MD, MBA:

So then, we talked about this, but I'm going to forward and ask Dr. Hussein to answer this one. I have obstructive sleep apnea and AFib and heart failure with preserved ejection fraction and chronic kidney disease. What can be done to improve my activity tolerance?

Ayman Hussein, MD:

Yeah. So that, when we approach these situations, we need to address the sleep apnea typically with a CPAP, optimize the heart failure medications including diuretics. Make sure that you have good sleep hygiene and eating healthy, avoiding salt. And on our side of things, on the AFib side, we do our best to try to control AFib and maintain normal rhythm. That could be certain time with medication, sometime with ablation, with ablation being preferred overall. A combination of all the above can result in improvement in quality of life.

Oussama Wazni, MD, MBA:

Dr. Hussein, thank you. That's excellent. Now, we talked about sleep apnea just, because we have some more questions on sleep apnea. Yeah, sleep apnea can be a trigger for atrial fibrillation. So please, if you're overweight and you snore, and there's a question, please get tested for it. And if positive, please use a CPAP to treat your sleep apnea, that will improve your overall health and also decrease the risk of having atrial fibrillation. Or even if you already have atrial fibrillation, it'll decrease the burden of atrial fibrillation.

Oussama Wazni, MD, MBA:

Somebody's mom has an AFib and the person asking the question has an enlarged left atrium. What can I do to avoid atrial fibrillation? Dr. Saliba.

Walid Saliba, MD:

Well. There is something to be said about genetics, that we cannot change, but what you can do is follow the good rules of medicine, exercise, have a good cardiovascular fitness, eat well. Don't gain weight. If you have any of the risk factors for atrial fibrillation, such as hypertension, diabetes, sleep apnea, treat them aggressively. And be nice to your doctor, and that will get you away from atrial fibrillation as much as possible.

Oussama Wazni, MD, MBA:

That's excellent. And then, we have a question here. I will answer this one. I like this question. Should I travel from San Diego to Cleveland for a wedding when I have AFib? If you're feeling okay. Yes. We would like to have you in Cleveland. If you're feeling fine, there is no… so just also to clarify to our listeners and patients, there are some patients who are in atrial fibrillation permanently and they're completely functioning. They can do whatever they want and they can enjoy life to the fullest. I have patients who ski and hike and bike and go to weddings, all the time they're in AFib. Now, the key is that they should be feeling up to those activities and they're feeling okay and well managed. So yes, please come and visit us in Cleveland.

Oussama Wazni, MD, MBA:

Is drinking alcohol dangerous to the heart? Yes, it is dangerous to the heart. In fact, a lot of studies now have shown that any amount of alcohol is not good for you. So if you are worried about the consequences of drinking more than you enjoy alcohol, don't drink at all. Now, with moderation though. But in general and because we know of the social environment we live in, I think every once in a while is okay. But yes, in general, alcohol is not good for the heart.

Oussama Wazni, MD, MBA:

Okay, this is a good question for Dr. Hussein. We have a patient who has a mitral valve, that's leaky, I'm assuming, and the patient has persistent atrial fibrillation, and he's had ablations already. So what do you think, how should we approach this problem? So somebody who's had ablations, but continues to have persistent AFib with a faulty mitral valve.

Ayman Hussein, MD:

So that depends also on how leaky the valve is. If the valve leak is severe to the point that would require surgery, then the answer is to do the surgical valve replacement or repair. And then at the time of the surgery, the surgeon can do something called the Maze procedure to try to address the AFib triggers and substrate. If the valve is not too leaky and AFib is still happening despite multiple ablations, then we either use stronger medicine or actually can still take a look with an ablation and see what's the residual to ablate and if the veins and the back wall are all connected or reconnected, or need touch-up ablations. The idea is that in those case scenarios, controlling the AFib, may improve the leaky valve, in some scenarios, depending on the type of leak. The short answer is that surgery for severe valve leak with AFib ablation surgically, if it's less than severe, then catheter ablation would be preferred.

Oussama Wazni, MD, MBA:

So, okay. Thank you. So basically, will repair of the valve cure the persistent AFib. It probably will help, but it'll not cure it. So that's why if you're having surgery, should ask the surgeon to consider doing a maze procedure, preferably also with the left atrial appendage clip. I think that'll help. The same person asked about acid reflux and AFib. Yes, it is possible that sometimes acid reflux can be a trigger for atrial fibrillation. Is it true that stress can cause irregular heart beat? Yes, it can. And will it go away? It could, but you have to watch for that.

Oussama Wazni, MD, MBA:

We have a patient who had an ICU hospitalization for COVID and developed atrial fibrillation. I'll answer this one. It's very common to develop atrial fibrillation in the setting of acute illness. So that is not something that's unanticipated. And you are on the correct medication, metoprolol, for atrial fibrillation.

Oussama Wazni, MD, MBA:

Last question in this section, has to do with fasting. I'll give this to Dr. Saliba, because I know he does a lot of fasting. So, will fasting improve my atrial fibrillation?

Walid Saliba, MD:

I am not aware of any studies that address this issue. But if fasting is a part of a weight reduction program and if somebody who is overweight or obese, then I think that whatever it gets the weight down is probably something that would be good for AFib. Not whatever, it's one of the things that will get the weight down. You have to be, to have to eat the right food and the nutrients actually to keep your weight down.

Oussama Wazni, MD, MBA:

So I think it's the same goes for a plant-based diet. If these diets or fasting result in adequate or appropriate weight loss. I think that'll help the atrial fibrillation. To what extent. Well, it depends on how much weight loss. So we actually quantified that and we showed that the more weight loss that is achieved, the better the outcomes and the less atrial fibrillation patients have to the extent of an ablation. So in Australia, there is a study where they showed that if patients lost a significant amount of weight, they may not need an ablation. So that means that is as effective as an ablation, the success of an ablation is 60% to 70%. So I think you can never go wrong with weight loss, whether you achieve that with intermittent fasting or with plant-based diets, that's up to you.

Walid Saliba, MD:

Or with bariatric surgery. Or even with surgery or medications.

Oussama Wazni, MD, MBA:

Or bariatric surgery. We wrote about this. Yes. In morbidly, excessive weight. Yes, you can do bariatric surgery. Okay. We're moving on to the next section. Thank you very much. This has been, I think, very good questions. And I hope the answers have been clear enough for you guys so that you can get a lot of information from this.

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