You Asked, We Answered! – Atrial Fibrillation Part 2

Podcast Transcript

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Oussama Wazni, MD, MBA:

Welcome back, everybody, to section two or part two, of this discussion on atrial fibrillation. I am Oussama Wazni, the section head of the EP Section here at the Cleveland Clinic and I'm joined by Dr. Walid Saliba and Dr. Ayman Hussein, both directors of the Atrial Fibrillation Center here at the Clinic. In this section, we're going to talk about diagnosis and treatment. And so, a quick question here to Dr. Saliba, it's mostly regarding monitoring. How do we diagnose atrial fibrillation? Also, in this question is the Apple Watch sometimes says inconclusive and other times sinus rhythm, should this be concerning?

Walid Saliba, MD:

Well, atrial fibrillation is diagnosed by an EKG. You have to have an electrocardiogram that shows evidence of atrial fibrillation. People can have irregular heart rates or irregular pulse. It doesn't mean they have atrial fibrillation. They can have extra beats here and there, but that means that you have to have an EKG documentation and read by a physician to document that it is atrial fibrillation.

Walid Saliba, MD:

Now Apple Watch, the way it is read, it's based on the regularity or the irregularity of the heart rate. This is how the Apple Watch can tell if you're in atrial fibrillation or not. Now, as you know, the recordings can have a lot of background noise. Sometimes, your heart rate is fast and the irregularity is not that pronounced and this is why sometimes the Apple Watch say inconclusive. You can have atrial flutter. Atrial flutter is a manifestation of atrial fibrillation and your heart rate can be very regular, fast and regular. This is where the Apple Watch will actually not recognize the fact that you're in atrial arrhythmia and will tell you that probably your heart is fast and you're probably in normal rhythm. There are some pitfalls to relying on the Apple Watch and this is why it always needs adjudication. But, it's a good way to start up the monitoring so to investigate if you're really having, and how much atrial fibrillation you are having.

Oussama Wazni, MD, MBA:

That was excellent. We have a question on what's the difference between the Apple Watch and the Kardia app with the fingers? I'll take this one. It just depends on how many leads we have. One of them just has one lead. On the Apple Watch, you can see it on your watch and some of the Apple Watches do not show the rhythm, the tracing I should say, and some do. The newer Apple Watch has the tracing and that is what Dr. Saliba is talking about is that we have to see that tracing. The Kardia app is also very similar and you can use it with your phone, so there's not much difference between them.

Oussama Wazni, MD, MBA:

Now, we go into a big section here on symptoms and I'm going to try to collate these into quick questions here. I'm going to answer this first group together. Basically, it's what about symptoms? I'm going to quickly name them here for you because there are a lot of questions here. Symptoms of atrial fibrillation can include palpitations, shortness of breath, a decrease in energy, and less endurance. It can cause swelling in the ankles and in the legs. Now, all of these can be symptoms of atrial fibrillation, but it's very important to remember that they can be symptoms of other things. We're not going to go into those other things. Just that when you have these, it is possible that you have atrial fibrillation. We cannot just go by those symptoms and say, "Yes, you have atrial fibrillation." We have to have documentation of a tracing showing atrial fibrillation.

Oussama Wazni, MD, MBA:

All right, so now we're going to go to another question. Why does the pulse shoot up right after I fall asleep or right before I wake up? I am guessing that this is somebody who has a watch that they're watching, Apple Watch, because otherwise how would they know that their heart rate goes up before they sleep and before they wake up? Does anybody have any suggestions?

Walid Saliba, MD:

Well, it's...go ahead.

Ayman Hussein, MD:

Go ahead, Dr. Saliba.

Walid Saliba, MD:

I think that it all depends on how often you're having atrial fibrillation. Are you in AFib all the time, or do you go in normal rhythm and go back into atrial fibrillation? It is possible that if you're in normal rhythm and then, when you go into atrial fibrillation, yes, your heart rate's going to go up. And in the morning, typically there is no variation in the heart rate, even if you are in atrial fibrillation, has a tendency to have an increase in heart rate right when you wake up. It all depends on really what kind of rhythm you're in and what medications you're taking and how are you measuring your heart rate. But, it doesn't really signify anything. If you have a fast heart rate in atrial fibrillation it needs to be treated.

Oussama Wazni, MD, MBA:

Very good. Then there's a big group of questions here I'm going to answer all about palpitations. Palpitations just mean that you can feel your heartbeat. Most of the time, people will feel their heartbeat when it's going fast. It does not mean that you have atrial fibrillation. To make a diagnosis, you're going to have to wear a monitor and we have to see a tracing showing that there's atrial fibrillation. So, these questions about having a lot of palpitations before falling asleep or after falling asleep, you have those symptoms and they are present, but we really cannot make a diagnosis unless we put a monitor. If you're worried about this type of issue, please talk to your doctor and they will surely put you on a monitor to see what these palpitations are about.

Oussama Wazni, MD, MBA:

Then, there are some questions about heart rates. Yes, the heart rate, when it's too high the blood pressure can drop. The key is not to allow the heart rate to become too high. How do you do that? We usually prescribe something called metoprolol or a calcium channel blocker such as diltiazem. If the heart rate is still not well-controlled, then please talk to your doctor to optimize these medications and see how this heart rate can be better controlled.

Oussama Wazni, MD, MBA:

Okay, we talked about that. The warning signs of atrial fibrillation we talked about them when I talked about the symptoms. Again, any symptoms of palpitations, shortness of breath with exertion, swelling in the legs, decreased energy, and decreased endurance can all be related to atrial fibrillation. But again, once more, you're going to have to get a monitor that shows a tracing of atrial fibrillation.

Oussama Wazni, MD, MBA:

This is a good question here and I'll send it to Dr. Hussein. What should I do if I'm having an atrial fibrillation episode? I woke up at 2:00 in the morning with an episode and now it's 9:00 in the morning and I'm still having AFib. What should I do?

Ayman Hussein, MD:

Well, that's all going to depend on how bad the symptoms are. If the symptoms are bad to the point you're not tolerating, you're having chest pain or bad shortness of breath or having a passing out spell or a near passing out spell, those are scenarios where we ask you to go to the emergency department. If the AFib symptoms are otherwise manageable, it's okay to wait because the AFib may stop on its own. And if it doesn't and even though it's manageable and the symptoms are mild, if it sustains for a day or two, then also let your physician know. And in that setting, for AFib that sustains, your physician would schedule what we call a cardioversion, a resetting of the heart, or make some adjustments to your medications.

Oussama Wazni, MD, MBA:

All right, that was excellent. Now, just a quick summary here. Again, the symptoms of atrial fibrillation can be varied. We talked about them. We have to get a diagnosis through a tracing with a monitor and that's the only way really we can know that we are treating atrial fibrillation. And it's important to do that because then that will tell us what kind of treatment we should offer you when you have atrial fibrillation.

Oussama Wazni, MD, MBA:

Now, we have a lot of questions. We're going into now the types of treatment and I will try to summarize a few of them. One, there's a question regarding whether or I should see a cardiologist after having an AFib episode 20 years ago. Well, it depends. If you're doing very well, then you can just stay with your primary care physician. But, if you feel that you're having more episodes, yes, a cardiologist would be helpful.

Oussama Wazni, MD, MBA:

What is the best course of action after getting a new diagnosis of atrial fibrillation? I'll summarize this quickly. One, we have to figure out the risk of stroke and manage accordingly. Two, make sure the heart rate is not too fast when you're in AFib. And three, if you're having a lot of symptoms, then we have to suppress the AFib, and that can be done either with medication or an ablation. So, that takes me to the next group of questions and this is for Dr. Saliba. How can you control AFib without taking medications?

Walid Saliba, MD:

Well, if you have AFib and you're having symptoms from atrial fibrillation you need, as Dr. Wazni said, you need to make sure that you take medication to control your heart rate and to decrease your risk of stroke. Now, are there alternatives? Yes, of course. There are alternatives, but we have to be careful because alternatives also are expensive from the standpoint of having risk. For example, if you do not want to take anti-arrhythmic medication to suppress your atrial fibrillation, then there is the option of having an ablation. Even though you might take some medications around the time of the ablation, the ablation has a chance of not making you take medications. Similarly, if you do not want to take blood-thinning medication for the purpose of reducing the stroke, there are now more and more being used, what we call, left atrial appendage occlusion devices, where we plug that small area in the left atrium, where the clots tend to form. And these devices are becoming used more and more.

Walid Saliba, MD:

In the United States, they're only now approved for patients who are having bleeding and cannot take blood-thinning medication. But, there are studies ongoing currently for patients, who even do not have bleeding, where we randomize them into continuing blood-thinning medications versus getting that plug placed and getting off blood-thinning medication. There are options where you don't need to be on medications, but they involve having procedures done to be able to reach that goal.

Oussama Wazni, MD, MBA:

Okay. That is excellent. I think that answers unless you disagree Dr. Saliba. The question is, what is the best treatment other than an ablation for atrial fib?

Walid Saliba, MD:

Other than ablation? Well again, as Dr. Wazni said, your choices are I don't want to do anything because I feel okay or having medication to suppress the arrhythmia or having an ablation to suppress the arrhythmia or surgery. I mean, there's always the option of surgery. Now, nobody wants to have their chest opened, or cut open, or whatever, to treat atrial fibrillation by itself unless you're having surgery for something else at the same time. But, these are the options to suppress atrial fibrillation and treat it.

Oussama Wazni, MD, MBA:

I think we answered a lot of the questions regarding treatment with this answer, so thank you very much. Once more, just summarize three things. One, make sure the risk of stroke is managed. Two, make sure the heart rate is not too fast and that's with the medications we've already discussed like metoprolol or calcium channel blockers we call them, like diltiazem. Three, if you're having a lot of symptoms and you want to stay in sinus rhythm, well, you have to do something about it. If you've lost weight, your blood pressure is controlled and you're still having symptoms, then it's either medications or an ablation or surgery in some cases.

Walid Saliba, MD:

And then four, address the risk factors that will make your atrial fibrillation progress. And we've talked about that. The weight reduction, exercise, fitness, sleep apnea, hypertension and so on and so on.

Oussama Wazni, MD, MBA:

Okay. Very good. So then, there is this question about you know I've had atrial fibrillation since 2016. Medications are controlling it and I've not had a problem since then. Could it mean that I may not go back to AFib anymore and be able to stop some of these medications? So, this is somebody, Dr. Hussein, who is controlled on medications. And what they're asking, and I think this is a reasonable question, is okay, well I'm doing so well, and I haven't had any issues. Should we try to stop some of these medications?

Ayman Hussein, MD:

The reason or the explanation why they're not having AFib in this setting is the fact that they are on medication. Some patients may want to try to come off the medicine and see what happens and there's nothing wrong with that, with the exception of the blood thinners. If they have other risk factors for stroke they need to be on the blood thinner. I would not favor discontinuation of the blood thinners in that setting. But, if they are on medications to control the heart rhythm and it's been behaving okay for three or four years, and they wish to come off those medicines, it's okay. It's reasonable to try. And if it comes back, then we either resume those medications or talk about an ablation procedure.

Oussama Wazni, MD, MBA:

Very good. Thank you so much. There's a question, I'll answer this one, about someone who has atrial fibrillation, but also has a quadruple bypass, but now has another blockage. Taking Xarelto. What more can I do? Well, the blockage has nothing to do really. This blockage that they're talking about has nothing to do with taking Xarelto or not. This is more about the accumulation of cholesterol, so you should be on a cholesterol-lowering medication. Those are usually statins. You walk a lot every day, so keep doing that. That's very important. Again, like Dr. Saliba said, all these other risk modifications, meaning lifestyle modifications, if you have not done them, I'm sure you have, but for the others listening, losing weight, managing diabetes, managing hypertension. All these are going to be very important in patients who have coronary disease or have had bypass in the past.

Oussama Wazni, MD, MBA:

We're going to move on to a few more questions here. This is a very important question and that's why I always list it on the top. What actually lowers the stroke risk? Well, the risk factors, those are congestive heart failure, hypertension, and diabetes. Then, there are other ones. Age, which we can't control. But the other ones, if we can control that, will lower the risk of having a stroke. But if you have them, the most important aspect is to take a blood thinner to decrease the risk of stroke.

Oussama Wazni, MD, MBA:

And there's a question of is it okay for a man to have one alcoholic drink per day or week, or will this increase the chances of AFib? Dr. Saliba I think addressed this earlier. If you find that every time you have a drink you have AFib, then it may not be okay for you to have a drink unless you like the drink more than you hate the AFib.

Walid Saliba, MD:

Exactly.

Oussama Wazni, MD, MBA:

It's a balance always. And I actually see it in my clinic every day. They'll say, "Well, if it really was not that bad and I really enjoy that drink." I say, "Okay, well that's a personal choice."

Oussama Wazni, MD, MBA:

What can Cleveland Clinic offer AFib patients to address anxiety? This is actually a very important point. Atrial fibrillation does cause a lot of anxiety. I think the way to decrease anxiety is through information. Education and information. If we give you all the information that is there and we manage your atrial fibrillation properly, then hopefully the anxiety level will be reduced. Now, if it is not reduced, then we can refer you to some of our psychologists or psychiatrists that we have actually embedded in our team in electrophysiology here at the Clinic. They're very well-versed in what we do and they know which medications they can give you to decrease the risk of anxiety. I hope that helps.

Oussama Wazni, MD, MBA:

If I have AFib, will I need medications for life? Not necessarily. Not for life. What I'm trying to say is that maybe in certain periods of your life you will not need any medications. But realistically speaking, you will need some medication at some point in your life. It's not all or none. So, sometimes, yes, and sometimes, no, depending on how you're doing. Dr. Saliba, do you want to clarify a little bit on that?

Walid Saliba, MD:

I wouldn't say the question is not whether you need to be on medications for life or not. What I tell my patients is that if you have atrial fibrillation, it is something that you always have to think about throughout your life. It's not something that you can close the door and say, "I'm done with an ablation or what have you." You always have to be on the lookout. Is it going to come back? When it comes back how often is it coming back? You have to have a strategy in place as to, if I have AFib, what is my next step? If I have this much AFib, what is it that I need to do or I can do? It's not like something that you have to get anxious about, or what have you, but you have to have a strategy for the treatment of atrial fibrillation because it's not something that's going to just go away by itself.

Walid Saliba, MD:

Now, if you happen to be one of those patients who do not have too much atrial fibrillation, then that's good. Then you don't need to think about it too much. But, there should be a strategy in place and that's what you should discuss with your physician.

Walid Saliba, MD:

Dr. Wazni, there are a good few questions about post-ablation can we stop our blood-thinning medication? Maybe you or Dr. Hussein will address this.

Oussama Wazni, MD, MBA:

Yeah. Let's address this in the next section just quickly here because I want to finish this section here quickly. There's a question about someone who has had AFib and not feeling well. What can be done? We already talked about this. We can do medications or ablation. Someone has had AFib seven years ago, but now doing great. That's good. I would say continue with what you're doing because it seems like whatever you're doing is working.

Walid Saliba, MD:

Can I just something that ... We see a lot of patients who come in with AFib and they have symptoms, but also they have lots of other problems that can cause these symptoms. And we have to be careful how aggressive we treat the atrial fibrillation before making sure that it is atrial fibrillation that is contributing to the major part of these symptoms. Otherwise, you go through an expensive and potential risk of treatment of atrial fibrillation, and then you don't feel significantly better. There are certain things to sort out how much atrial fibrillation is really giving you symptoms. And then, that needs to be addressed at the time of the visit.

Ayman Hussein, MD:

That's very important.

Oussama Wazni, MD, MBA:

And then, what is the latest treatment for AFib with rapid ventricular response? I think we addressed that. We talked about beta-blockers like metoprolol and calcium channel blockers like enalapril. Or, just treat the AFib itself, which is with medications or with an ablation. All right, we're going to go down now to medications. We have a few questions here. Once you've had AFib and had it cardioverted, do I have to stay on Eliquis or and metoprolol for the remainder of my life? Dr. Hussein?

Ayman Hussein, MD:

That, as we said earlier, that's going to depend on risk factor estimate and the background. And depending on what other conditions they have that could predispose to stroke. And if there are many risk factors, then the answer is to stay on the blood thinner. For the metoprolol, we prefer to keep it and re-assess in the future. And depending on how the AFib behaves, we'll make decisions regarding that. But, the decision regarding anticoagulation or blood thinner is not going to depend on how frequent the AFib is happening. If it's only one event in a young person and without other risk factors and say it was triggered by a dehydration event or acute illness, maybe we don't necessarily need to make a lifelong commitment based on those. But, if it's happening in somebody who's older with some high blood pressure, diabetes, and structural heart disease, those are our scenarios whereas we commit long-term to at the least the blood thinner and possibly something else.

Oussama Wazni, MD, MBA:

Very good. I think that's it on the medications. I'm going to go to rate and rhythm control. How dangerous is amiodarone and under what circumstances have you prescribed it? Amiodarone, it depends. The question is how dangerous. It's not a dangerous medication by itself. It's just that after long-term use you can have some side effects that are not reversible. It really depends on the age of the patient. It depends on how we anticipate someone to be on amiodarone. It's okay to use amiodarone for a short period of time, for example, to get them through an ablation. But staying on it for years and years and years is probably not a good idea.

Oussama Wazni, MD, MBA:

Then, the other questions are, yes, in medicine, in general, we should use the lowest possible effective dose of any medication. And this is in relation now to rhythm control, not blood thinner so please be very careful. I'm talking about the medications for rhythm control such as Rythmol, flecainide, and metoprolol. We use them in the lowest effective dose. And if we have to, we can increase them over time. But then, if we find that they're not working, then an ablation is something that should be considered. Now, with respect to the blood thinners, those we cannot. Those have set criteria and we have to use them as indicated or as prescribed in those patients. These are very important because if we don't then it can end up with a stroke. Then, there's the question of whether you need to be on medication before insurance will cover an ablation. The answer is no. Now, more and more, we know that first-line ablation may be actually better, safer, and more cost-effective than trying medications first. This is, Dr. Saliba, for you. Somebody who took flecainide, but now had a blackout. Is that something that is common or should we be concerned?

Walid Saliba, MD:

What happened? When somebody blocks out, always you have to investigate what is the reason of their blackout and then come to a conclusion. But, all these medications, antiarrhythmic medications that we use, they do have a potential side effect of causing rhythm problems that can be serious. This is why in some of these medications when we start them, we start them in the hospital or we monitor the patients very closely when we start these medications. A blackout in flecainide would be very concerning to me. Definitely, it depends on what kind of blackout, what is the rhythm, and then what is going on. But that is something that would definitely be very concerning to the point I would stop the flecainide and probably seek alternative treatment options.

Oussama Wazni, MD, MBA:

Okay. Next, I'm going to combine this next group of questions with the WATCHMAN questions. We're coming to the top of the hour, you guys. I think we're going to have to stop after this section. This section has to do with the blood thinners and alternatives to blood thinners. Basically, there's a lot of questions, a lot of them, and these are very good questions, you guys, our listeners. These questions are, "I had an ablation, it's successful, why should I continue taking a blood thinner?" This is for Dr. Saliba. And in the meantime, talk to us about left atrial appendage closure because there are a lot of questions on WATCHMAN. Somebody had an ablation, the ablation is successful. Why would we continue taking any blood thinner?

Walid Saliba, MD:

To date, even if you have a successful ablation, if you had indication to be on blood thinner before the ablation, those risks carry over to after the ablation and you need to continue blood-thinning after the ablation. We do not stop it even if your ablation is successful. Because we do not have any evidence scientifically speaking that the risk of stroke is actually reduced following an ablation. Having said that, the rationale behind it is that stroke and atrial fibrillation can be two separate and parallel manifestations of the same disease of the atrium that causes atrial fibrillation and that increases your risk of having atrial fibrillation. And increases your risk of having a stroke. Getting rid of one does not necessarily mean that the other one is less. They feed into each other. If you have AFib, your risk is high. But, if you don't have any more AFib it doesn't mean that your risk of having a stroke is low enough that precludes using anticoagulation. But there are lots of research happening in the future to address these issues and actually, we just finished research we will have probably the results within the next few years.

Walid Saliba, MD:

Dr. Wazni is the principal investigator on that research whereby patients who had an ablation either they continue on oral anticoagulation and half of them, instead of continuing on oral anticoagulation we put in a WATCHMAN device, a left atrial appendage occlusion where we occlude that small pocket. And we are going to see at the end of the three years' follow-up if the risk of stroke is the same, better, and risk of bleeding the same, better between these two groups. There's a lot of research and a lot of answers that we didn't have within the next three to four years, so stay tuned to that effect. In the meantime, you stay on blood-thinning medications if you had an indication for it.

Oussama Wazni, MD, MBA:

All right. We have reached the top of the hour. I want to thank you all for your attention. I'm going to try to summarize everything we just said in two minutes or less. Atrial fibrillation is very common. Symptoms of atrial fibrillation can be palpitation, shortness of breath, decrease in urine, and fatigue. If you have what you think is atrial fibrillation you should get a monitor to document it using a tracing like an EKG or tracing on Apple Watch or Kardia. The most important aspect of AFib management is decreasing the risk of stroke. That can be ascertained or you can find out what the risk is based on certain risk factors. We mentioned them. Namely, congestive heart failure, hypertension, age, diabetes, and a previous stroke. Then, we have to control the heart rate. Finally, if you're having a lot of symptoms from the AFib and you want to not have AFib and maintain sinus rhythm, then your choices are medications versus an ablation. Both are safe. Medications are less effective and ablation, we had many questions on ablation. Ablation is very successful if done soon or early after diagnosis, up to 80 to 85%.

Oussama Wazni, MD, MBA:

If you wait longer, then it drops to 60 to 70%. They are very safe depending on where you go to. If you decide to go to your local hospital ask them what their outcomes look like. They should have a major complication data of less than one percent. Hopefully, one to two at the most. What are these complications? They are perforation of the heart, which can usually be managed. Dying from an AFib is very, very, very uncommon. Very uncommon. In our experience, it's less than 0.01%, so less than one in 10,000. It's very safe to have an ablation. After an ablation, you can probably start the antiarrhythmic drugs. But, to start, the blood thinner is trickier. Because if you've had those risk factors, you may have what we call silent AFib and you may end up stopping the blood thinner thinking that you don't have AFib, then you get a stroke. But, you're right. Some of you are right. What if we don't have AFib and we continue taking the blood thinner and then we have bleeding? Then, you are taking a medication you didn't really need, but you ended up with a complication.

Oussama Wazni, MD, MBA:

That's where the study that Dr. Saliba is talking about. It's called OPTION study. Hopefully, we will get some answers in the next two to three years. I hope this was insightful and helpful. And we look forward to see you in the next podcast from Cleveland Clinic EP team. Thank you so much.

Walid Saliba, MD:

Thank you very much.

Oussama Wazni, MD, MBA:

Thank you both, Dr. Saliba and Dr. Hussein.

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