Atrial fibrillation (or AFib) is a type of arrhythmia or irregular heartbeat that’s both common and serious, affecting more than 2.5 million people in the United States. In this episode of HEALTH Yeah!, cardiology experts from Stony Brook Medicine come together to discuss signs and symptoms of AFib, as well as risk factors, treatments and more.
The Experts
- Eric J. Rashba, MD, MHCM, FACC, FHRS
- Ibrahim Almasry, MD, FHRS, FACC
- Roger Fan, MD, FACC, FHRS
- Abhijeet Singh, MD, FHRS
What You’ll Hear in this Episode
- 00:00 Opening and Introductions
- 1:10 Signs and Symptoms of AFib
- 2:55 Causes and Risk Factors
- 3:45 Screening and Diagnosis
- 7:32 Treatment
- 11:35 Stroke Prevention
- 14:00 Lifestyle Interventions
- 15:22 Caffeine and AFib
- 16:35 Smoking and AFib
- 16:55 Important Things to Know
- 18:00 When to go to the ED
- 19:25 What to Look for When Seeking Care
- 21:00 Closing Remarks
Full Transcript
00:00 Opening and Introductions
Welcome to Health Year, where experts from Stony Brook Medicine come together to discuss topics ranging from the complex inner workings of an infectious disease to tips and tricks for staying safe and healthy all year long.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Hello and welcome. I’m Dr. Eric Kasper. I’m the director of the Heart Rhythm Center at Stony Brook Heart Institute and today we’ll be discussing atrial fibrillation, which is an irregular type of heartbeat and the most common type of heart rhythm disorder. We’ll be discussing with our board-certified electrophysiologists.
Electrophysiologists are cardiologists who specialize in the electrical activity of the heart. Today we have Dr. Ibrahim Almasry, Dr. Roger Fan and Dr. Abhijeet Singh, who will share the latest developments in the prevention, detection and treatment of atrial fibrillation commonly referred to as AFib.
Ibrahim Almasry, MD, FHRS, FACC
Well, good morning, everybody. I’m Dr. Ibrahim Almasry. I’m one of the EP attendings and faculty members here on staff at Stony Brook University Medical Center.
Roger Fan, MD, FACC, FHRS
I am Roger Fan. I’m also one of the clinical cardiac electrophysiologists at the heart rhythm Center at Stony Brook.
1:10 Signs and Symptoms of AFib
Eric J. Rashba, MD, MHCM, FACC, FHRS
So first, Dr. Fan, can you tell us about the signs and symptoms of atrial fibrillation?
Roger Fan, MD, FACC, FHRS
Sure. For AFib, the most common symptom is palpitations, a sensation of fluttering or irregularity in the chest. Some patients may also feel chest pressure, shortness of breath, dizziness. Others may feel fatigue or weakness. But what’s important to know, every patient is different. Everybody feels AFib differently. Some may have symptoms and there are some patients who have no symptoms at all.
But what’s important is to make a distinction between symptoms, what you actually feel from the AFib and what AFib is actually doing to the body, because there may be risks from AFib that may be silent. So it can weaken the heart muscle, it can increase the clotting risk in the body, causing strokes. And so there is not clearly a connection between the symptom, intensity and the risk.
For example, you may have a younger patient who doesn’t have many risk factors who is healthier, but has AFib and they have really intense symptoms from the AFib.But that doesn’t necessarily mean that they’re in danger. On the other hand, you have some patients who have AFib and they’re living it all the time, but they may not have any symptoms, but that doesn’t mean that they’re not at risk for developing heart failure or strokes. So that’s why your work up should be individualized to assess these risks.
Eric J. Rashba, MD, MHCM, FACC, FHRS
And I think that’s an important point, that some patients feel that if they don’t have severe symptoms, they don’t necessarily need to take care of this, and that’s clearly not the case.
So, Dr. Fan, can you tell us something about the causes and risk factors for atrial fibrillation?
2:55 Causes and Risk Factors
Roger Fan, MD, FACC, FHRS
Yeah, sure. There are no single causes for AFib; it’s a multifactorial process, but clearly genetics has a component. For example, the younger the AFib manifests in a patient, the more likely there’s a genetic component. But this is not something we routinely test because we don’t understand all of the genes involved and there’s not much we can do to modify it.
We can modify other risk factors that are commonly associated with AFib. So keeping diabetes under control, high blood pressure, thyroid disease, obesity, sleep apnea is an important cause and also alcohol consumption.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Dr. Almasry, can you tell us a little bit about how A-fib is diagnosed?
3:45 Screening and Diagnosis
Ibrahim Almasry, MD, FHRS, FACC
Ultimately, it’s a documentation of the actual arrhythmia on either an EKG or some form of telemetry. Symptoms alone are not enough to diagnose atrial fibrillation.
However, the symptoms can heighten your physician’s or your doctor’s suspicion to rule out atrial fibrillation. So depending on what the patient presents with, sometimes it can be as simple as showing up to a doctor’s office without much in terms of symptoms and having AFib on your EKG.
If you do have symptoms, and they can vary quite a bit, as Dr. Fan had mentioned, that may prompt your doctor to get a cardiac monitor. Cardiac monitors can vary in terms of their length and duration, but typically it’s anywhere between two weeks and a month, and that can help diagnose atrial fibrillation.
But if your symptoms don’t occur every month, then at that point, another option will be to give the patient an implantable loop recorder, and that’s an implantable monitor. It’s a very simple procedure to do, really takes under five minutes and is done with local anesthetic and doesn’t require sedation. It’s very effective and what we would consider to be state-of-the art when it comes to diagnosing atrial fibrillation because it allows long-term monitoring for up to four years on a daily basis. And the results of that monitor are transmitted to your doctor’s office, who can then look at them and maybe give you a call if they see something that’s noteworthy.
Having said that, now there’s a lot of push towards consumer market gadgets, things like Apple watches and Fitbits and even the Samsung Galaxy phones. There might also be options in terms of the App Store, you know, certain applications that you might have seen commercials for on TV, like the Cartier mobile app. These are ways for patients to try and diagnose or capture their symptoms and they can alert patients about whether they have atrial fibrillation or not.
The accuracy of these watches and other gadgets can vary, but in general, it’s about 60 to 80 percent. And while it’s not medical grade, it’s enough to basically get you to the doctor’s office and help prompt a more thorough investigation.
Sometimes patients, unfortunately, show up with a stroke, and there’s no obvious reason as to why that is. And in that case, atrial fibrillation is one of the leading reasons why that can happen. An implantable loop recorder can be invaluable because patients don’t necessarily have atrial fibrillation every day or every week. And sometimes the episodes can vary quite a bit. And so an implantable loop recorder has actually been shown in trials to be very beneficial in diagnosing atrial fibrillation in those patients.
Eric J. Rashba, MD, MHCM, FACC, FHRS
One note about the consumer devices – a lot of times patients don’t realize how to actually record the EKG, like with the Apple Watch. So if you’re going to actually buy it for that purpose, I would suggest reading the manual and figuring out how to record it because it just gives you a percentage of AFib.
But that might not be true AFib, and if you’re going to use this and bring the record to your doctor, we need to see the actual EKG.
Ibrahim Almasry, MD, FHRS, FACC
Yeah, I agree. But I think even when you do see the EKG, sort of a more cardiac type monitor, a more medical monitor is needed to confirm the findings.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Yes, it’s the initial screening test. A very good one at that.
Dr. Almasry, can you tell us more about how AFib is treated and the latest treatment guidelines came out within the past year?
7:32 Treatment
Ibrahim Almasry, MD, FHRS, FACC
That’s actually a pretty big question and there’s a lot to cover when it comes to that. But for decades, the main strategy of treatment for AFib has either been a rate control strategy or rhythm control.
And what that simply means is that with rate control strategies we use medications that slow heartbeats down regardless of whether the patient is in atrial fibrillation or not. So we accept that the patient will be in atrial fibrillation. A rhythm control strategy, on the other hand, tries to keep patients in normal rhythm. And the reason that this distinction is important is that for many years, it was thought that there was no significant advantage in terms of trying to keep patients in normal rhythm.
All the latest trials and all the latest data actually tell us that’s not true, that there is an inherent benefit of maintaining normal rhythm in most patients. And the reasons are that there is a benefit in terms of mortality, which means that patients actually get to live longer. There are advantages in terms of reducing patient hospitalizations for heart failure or other symptoms, and also a reduction in stroke.
And so there’s a great emphasis on trying to keep patients in normal rhythm. And in fact, some of the recent data shows that if you intervene within the first year of the diagnosis, you can actually get patients to live longer.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Can you talk about how to get to normal rhythm because there’s different ways, some of which may have the benefits you stated and some may not.
Ibrahim Almasry, MD, FHRS, FACC
Sure. Traditionally we’ve used antiarrhythmic medications. Those are a class of medications that work at the level of the cell to try and keep the patient in normal rhythm. The medications have been around for a very long time, and there really hasn’t been very many in terms of newer types of medications that we can try.
For the most part, unfortunately, the efficacy of these medications tend to be somewhat lower than what we would like. I would say on average, somewhere between 30 to 50 percent. And of course, a medication is always going to have the possibility of having side effects, and those side effects can vary quite a bit based on the patient and the drug that we choose.
Alternatively, though, there is something called an ablation procedure, which is a cardiac procedure utilizing catheters that can help target areas that trigger atrial fibrillation or promote atrial fibrillation within the heart. Using a catheter that can deliver different types of energy, you can try and eliminate those areas and therefore control the atrial fibrillation. And in my view, there is a significant advantage to using that.
A lot of the previous trials failed to demonstrate keeping patients in normal rhythm. And we believe that it’s likely related to the side effects and the toxicities of the medications that we used to use to try and keep patients in normal rhythm. Catheter ablation does not have that drawback, and therefore you actually see better efficacy with catheter ablation compared to medications, and you don’t see any of the toxicity.
In general, the complications related to an ablation procedure are actually quite low. And when they looked at that in terms of comparing strategies using the antiarrhythmic drugs or medications versus an ablation strategy, the outcomes in terms of negative outcomes were actually quite similar. And that’s a revelation because a lot of patients associate taking a pill with being something that is safe to do and a cardiac procedure as being something that is more risky when the reality is that they’re equivalent. And the reason is that the ablation procedure has now been established and is actually quite safe.
The difference, though, is that the outcomes using an ablation strategy are far better than they are compared to using medications. And so whenever possible, I think that’s a better way to go.
Eric J. Rashba, MD, MHCM, FACC, FHRS
All right. And then can you talk briefly about stroke prevention as well?
11:35 Stroke Prevention
Ibrahim Almasry, MD, FHRS, FACC
In general, the management of atrial fibrillation takes two parallel but important tracks. One is addressing the rhythm itself, but the second is aimed at trying to reduce the risk of stroke. And the only way that’s been shown to do that effectively is by using either an anticoagulant-type medication, and there are many new ones that are now available on the market, or in patients who can’t use a blood thinner, there’s an alternative which is a left atrial appendage closure procedure, which basically closes that left atrial appendage area within the heart, which is the area where most of the clots form, about 90 percent.
So either of those options are important in reducing the risk of stroke. There’s a strong emphasis within the guidelines recently at reducing the overall risk of atrial fibrillation and the progression of atrial fibrillation. And we believe that that will also reduce the risk of stroke. So as Dr. Fan had mentioned, watching things like high blood pressure, diabetes, weight, obstructive sleep apnea, all of those things help reduce your overall atrial fibrillation burden, and that will also reduce your overall risk of stroke.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Just a brief mention, we are participating in a study here that’s active now called React AF, where we’re comparing continuous blood thinners in patients with atrial fibrillation with intermittent blood thinners based on an Apple Watch algorithm that detects AFib.
If we detect it, the patient gets a blood thinner for a month and then goes back off it. So it’s kind of guided by the Apple Watch. So that’s as part of a study, but may reduce the overall exposure to blood thinners in the future if the study pans out.
All right. Well, thank you, Dr. Almasry, for sharing the latest in diagnosis and treatment of atrial fibrillation. And next, we’ll be joined by Dr. Abhijeet Singh, who’ll be talking to us about lifestyle strategies and how patients can actually change their lifestyle to help reduce the amount of atrial fibrillation that they experience.
14:00 Lifestyle Interventions
Welcome back, and Dr. Singh, welcome to the program.
Abhijeet Singh, MD, FHRS
Thank you, Dr. Rashba, thank you for having me. My name is Abhijeet Singh. I’m one of the clinical cardiac electrophysiologists at Stony Brook. And thank you for having me here today.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Dr. Singh, can you tell us about some of the lifestyle interventions that patients can do to reduce the risk of complications from atrial fibrillation?
Abhijeet Singh, MD, FHRS
Atrial fibrillation is such a common heart rhythm problem that we know what works and what doesn’t work. And I think there’s so much data and research, as far as atrial fibrillation goes, that we know what lifestyle interventions to advise our patients. In fact, in our recent guidelines that came out in the end of 2023, beginning of 24, it’s very prescriptive of what lifestyle interventions we tell our patients.
Earlier we used to say “exercise, eat less and have a good day.” But now we actually tell them there is data that you need to exercise about 30 minutes a day, so that’s 210 minutes a week and it has to be moderate exercise, so you get your heart rate going.
As far as weight loss goes, we have prescriptive evidence that if you lose 10 percent of your body weight and keep it down, it reduces the amount of AFib you have. It reduces the symptoms that you have from AFib and reduces the AFib burden. So these are things that are prescriptive now and not just “lose weight and exercise.”
15:22 Caffeine and AFib
Now, a common question we get is “Can I drink caffeine if I have AFib?” And in our guidelines recently, they said actually caffeine has not been shown to be a trigger AFib.
I mean, obviously doing excess of anything is bad, but at least as far as we know, caffeine has not been shown to be a trigger for you AFib in our studies.
And then the next question comes, is alcohol okay? There is no safe limit of drinking alcohol, but if you do drink alcohol, the recommendation is to drink three or less drinks in a week, roughly, and not all at once.
As far as sleep apnea goes, there has been a clear correlation between the amount of obstructive sleep apnea that you have and the amount of AFib. Although studies lately have been conflicting about whether treating sleep apnea is going to reduce your AFib, but we do know there is a correlation between the two. If this is a causation, I’m not sure.
Patients come in saying, “I have AFib and also sleep apnea.” So if I treat the sleep apnea, is the issue going to go away? And the answer is – that’s part of the story. I think it will get better, but it will completely go away. It’s hard to say.
16:35 Smoking and AFib
Eric J. Rashba, MD, MHCM, FACC, FHRS
And one of the surprising things I saw in the guidelines was the influence of smoking. I mean, we all know that smoking is bad, but it’s actually been related to AFib. So we have to counsel our patients about smoking cessation also.
Abhijeet Singh, MD, FHRS
Absolutely, I agree completely. And as Dr. Fan mentioned before, treatment of high blood pressure and diabetes goes a long way for management of atrial fibrillation as well.
16:55 Important Things to Know
Eric J. Rashba, MD, MHCM, FACC, FHRS
Yeah. Okay. And Dr. Singh, what are the most important things that people should know if they have AFib?
Abhijeet Singh, MD, FHRS
So that’s a really good question. When patients come to us thinking they have atrial fibrillation and they read about it, what I do want to tell you is at Stony Brook Heart Institute, we see a lot of patients who have atrial fibrillation and no two patients with atrial fibrillation are the same.
So you have to basically know that we can guide you through the process of this atrial fibrillation. We will tell you the lifestyle modifications that you need to make so that the AFib doesn’t progress. We will inform you of the things that you can do to reduce the symptoms of AFib. And then we offer you medications and we talk about procedures like ablation, and we speak about giving you medications to reduce the risk of having a stroke from atrial fibrillation.
So the three pillars of management of atrial fibrillation are basically symptom control, lifestyle modification and stroke prevention. So we help you get through the journey with this atrial fibrillation.
18:00 When to go to the ED
Eric J. Rashba, MD, MHCM, FACC, FHRS
So a lot of times patients wonder, you know, what needs immediate attention? When should I go to the emergency room? How can they help decide, you know, whether they can just call the office or whether they need to go to the emergency room right away?
Abhijeet Singh, MD, FHRS
Yeah, this is a discussion I have with my patients at almost every visit now. Again, different patients have atrial fibrillation that’s different. If you know that you have atrial fibrillation and you know your symptoms, and you have a recurrence of atrial fibrillation, and you can measure your heart rate somehow and you’re not having any additional symptoms, like you don’t feel dizzy, you don’t feel like you’re going to faint, you’re not having chest pain, then most of the times you can stay at home.
You can give us a call and we can guide you through the process so that you don’t have to rush to the emergency room every time you come in. As long as you’re taking a blood thinner, you’re protected from a stroke, and as long as you’re taking medications that control your heart rate and the symptoms are not too bad, you don’t have to come to a doctor’s visit immediately for management.
Most of the time, when the effort is starting during the initial stages of atrial fibrillation, the heart is going to go back into normal rhythm by itself. We don’t have to do any interventions. So these are some of the things that we discuss during patient visits at the end.
Eric J. Rashba, MD, MHCM, FACC, FHRS
If someone’s very uncomfortable or very short of breath, that’s different. But most of the time, we can manage this in the office or give telephone guidance.
19:25 What to Look for When Seeking Care
Alright, Dr. Fan, can you summarize for us, if you’re diagnosed with AFib, what should patients be looking for when they’re seeking care?
Roger Fan, MD, FACC, FHRS
Sure. Well, as Dr. Singh and Dr. Almasry and I have been talking about today, AFib is a complex disease process that will present differently in different patients, so the care has to be individualized.
Importantly, you want to find a doctor that’s well experienced and has that expertise in taking care of AFib. Also find a doctor that takes the time to evaluate you carefully, listen to your goals and concerns and offer you treatment options to treat this because each treatment plan is going to be tailored for you.
Also, you want to find a center that has all the resources available and all the latest technology for treating atrial fibrillation, as it’s a rapidly evolving field. And also you want to find a center that’s involved in research, advancing the field and developing new techniques and treating AFib. And I think you’ll find all of that at the Heart Rhythm Center, Stony Brook. All of us are very experienced and involved in all of these aspects of atrial fibrillation.
Eric J. Rashba, MD, MHCM, FACC, FHRS
Now, could you speak a little bit about the influence of ablation volume of procedures that people do, how does that influence how well they go?
Roger Fan, MD, FACC, FHRS
Definitely. It makes sense: The more of these that you do, the better you are at it. So you want to find a practitioner who does this on a routine basis. And, you know, we’re one of the highest volume centers at Stony Brook, and you’ll find all of that at Stony Brook Heart Rhythm Center.
21:00 Closing Remarks
Eric J. Rashba, MD, MHCM, FACC, FHRS
Thank you to each of our panelists, Dr. Fan, Dr. Almasry and Dr. Singh. If you have any of the symptoms that we talked about today, don’t delay your care. There’s so much that can be done today in terms of prevention and treatment strategies. And our heart rhythm team is here to help. Thank you for joining us today and be well.
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