Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr Michael Koren.
Dr. Michael Koren:
0:16
Hello, my name is Dr. Michael Koren and I'm delighted to host another episode of Two Docs Talk, which is a series that we've been doing here on the MedEvidence platform. And, as you know, MedEvidence is our platform to try to present medical information in a unique and creative way. And we're really excited about this Two Docs Talk series, because I think people get a lot of insight to see how two very qualified physicians talk about a subject matter. And we can all learn based on the way we analyze these things, the way we take the data that is out there and the clinical trial results that are out there and then turn it into practical advice for the people who we see in the office each day and our family and friends as well. So I'm extremely delighted to have Dr. Neil Sanghvi with me today.
Dr. Michael Koren:
1:11
Neil and I are actually clinical partners, so we've known each other for many years. And Neil is a tremendous resource and a fabulous clinician. You know I refer a lot of patients I'm a general cardiologist and I refer a lot of patients to Neil as an electrophysiologist. And I've only got stunningly positive reports from all my patients. So thank you, Neil, for that. That's actually the most important thing, but he's also very well accomplished and we do share a credential, which is that we both had cardiology training at Cornell, New York Hospital, which I guess was that Presbyterian. By the time you got there, It was not quite at that stage when I was there.
Dr. Michael Koren:
1:46
But we share that commonality, so we have that part of our fellowship as well. So thank you for joining us. Neil, thank you for being part of the MedEvidence platform, thank you for participating in Two Doc's talk. We're going to talk today about atrial fibrillation, or AFib, and AFib is out there. It's a very common problem, so maybe you can set the stage a little bit by just giving us a little bit of the epidemiological background about AFib.
Dr. Neil Sanghvi:
2:13
Absolutely, Mike. Thank you so much for having me. I really look forward to our conversation today. It's a pleasure to be able to talk to you and your audience. Yeah, AFib is a trendy word. Unfortunately, it's the most common heart rhythm problem in the world. We have, I would say, somewhere between five to seven million Americans that suffer from atrial fibrillation these days, and it's projected that in the next 20 years, that could balloon up to about 15 million people. So it's something that most people out there have probably heard about. Either they themselves suffer from it or they may have a family member that suffers from it. So let's talk a little bit about it.
Dr. Neil Sanghvi:
2:53
AFib. Right, Mike, you and I we deal with patients all the time that come in and we end up having to give them this diagnosis of atrial fibrillation. And they come in with various symptoms, but physically, what's actually happening with their heart, so they understand what's happening is that they have four chambers in their heart, as you know two on the top, two on the bottom, And typically these chambers beat in sync, So the top beats and the bottom beats in a one to one fashion, and that's a normal rhythm.
Dr. Michael Koren:
3:21
Right, and just for clarification atria, the atria or atrium, is the top and the ventricles the bottom. Perfect, yep, exactly right, and so it's like I get that right, it's been a little while since I reviewed that.
Dr. Neil Sanghvi:
3:35
You know, we got to go back to those basics all the time, Mike.
Dr. Michael Koren:
3:39
Yeah, everything is so specialized that you probably have to send it to somebody who's an atrium person or a ventricular person.
Dr. Neil Sanghvi:
3:45
So true, you know medicine's gotten so complex these days. You know, it's your expertise and lipid management. I'm turning to that, you're turning to me for a little rhythm issues and we're all trying to play it out a little sandbox.
Dr. Michael Koren:
3:57
Absolutely, we're being facetious, of course, but I guess thank you for the explanation.
Dr. Neil Sanghvi:
4:03
So the upper chambers, as you mentioned, the atrium they begin to fibrillate, they try to quiver And it's that quiver that creates the atrial fibrillation. That's the description, and it's that quiver that then translates to symptoms and other associated problems that can occur. And this, you know, this quiver can occur at any stage in life. Quite frankly, I've had teenagers that have come to me with atrial fibrillation all the way up to adulthood, it is something that can affect many patients in different stages in their lives. T hough commonly, you and I, would be seeing patients much older in their spectrum of age as they present to us.
Dr. Michael Koren:
4:43
Absolutely. Explain to folks what causes atrial fibrillation, and what factors.
Dr. Neil Sanghvi:
4:51
So you know, it's one of the curses we probably face as having the opportunity to live a little bit longer than we used to. So age is a contributor, for sure. As we get older, the risk of developing atrial fibrillation goes up. But in addition to that, it's a lot of other things that we're suffering from high blood pressure, obesity, sleep apnea, heart disease. So having had a coronary heart attack or some sort of heart attack, having a valve problem are all major contributors to atrial fibrillation. There's even a genetic predisposition in certain instances, but that's an area that's really really well-defined been yet.
Dr. Michael Koren:
5:32
So okay, so, just the the perspective, there are certain things you kind of hear as storylines. So and I'll let you comment on each of these things. So, for example, somebody that's had high blood pressure for many, many years, we often tell them that it's a major risk factor for atrial fibrillation. So maybe you can explain how that happens. But we also have people that drink a lot of alcohol and then have some problem with arrhythmia off atrial fibrillation. So maybe you can touch base on it as well. And we also see people who are having some severe nutritional problems that can end up having some arrhythmia, commonly atrial fibrillation. So just help people understand that quickly, those different types of scenarios.
Dr. Neil Sanghvi:
6:15
Yeah, sure, so the hypertensive patients, by far probably the most common patient we have, the patient whose blood pressure isn't controlled, and they call it the silent killer for a reason, and it's because of this constant stress on the heart. The way I like to tell patients or describe it to patients is to imagine that you're constantly putting pressure on a car engine. It's not able to get its output out because there's some restriction in some tube somewhere along the way. Well, at some point in time, that engine is going to say enough . I enough can't handle this anymore. And then, you go into fibrillation as a consequence, along with other problems that may develop.
Dr. Neil Sanghvi:
6:50
Similarly, alcohol has a direct impact on actually the properties of the heart in several ways. One, it can be a toxin to the heart and that toxicity can cause the heart to weaken, and that weakness can then lead towards arrhythmias, including atrial fibrillation. And another avenue is that it has properties on how the heart actually electrically discharges and recharges. So too much alcohol or a heavy ingestion of alcohol in a short period of time can actually impact how the heart is activating and discharging itself and lead towards a situation where an atrial fibrillation event can be triggered. By extension, there are also other pressure points. You can have aphid because you've just had surgery done and the release of stress hormones can trigger an episode of atrial fibrillation, as you and I have probably seen as well.
Dr. Michael Koren:
7:44
The treatment of high blood pressure with diuretics that can lower your potassium and magnesium could be another factor.
Dr. Neil Sanghvi:
7:49
Absolutely. So, the electrolytes as you were talking about sometimes these, electrolytes the potassium, magnesium, sometimes calcium they are involved in the actual physical electrical processes of the heart of helping the heart discharge and recharge. And it's this discharge-recharge aspect of the heart, of the heartbeat, that lends towards aphid being triggered. So you have a disruption in how this is done properly and you can have atrial fibrillation occur.
Dr. Michael Koren:
8:12
So getting into the alcohol issue just a little bit more, we used to have something called holiday heart syndrome. Do we still use that term or do we have a better term now?
Dr. Neil Sanghvi:
8:22
No, it's still applicable, though it's not just the holidays anymore, is it?
Dr. Michael Koren:
8:27
Oh yeah, well, there you go, any day heart syndrome. That's exactly right. It's a good time. Any drinking day heart syndrome. That's exactly right. So help people understand it a little bit. So is it your person that goes home and has a martini with his or her spouse? Is that person at risk? Or is it the person that drinks 14 beers with their friends watching a football game on Saturday, or some combination thereof?
Dr. Neil Sanghvi:
8:54
Yeah, no, you know, that's a great question. A lot of patients ask well, what's an appropriate amount? And you know, what we believe is that it's really the quantity that's ingested in a short period of time. That's sort of shocked the system. And so it's that person who's binging, you know, and who has a binge event of some form, and the quantity may vary for different people. For some, it may be just three beverages and for others, it may be 10. But the point is that it's a high quantity for that person in a short period of time, which could be that trigger because it's system is not used to that level of alcohol. It gets inundated with it and next you know it is kicking off.
Dr. Michael Koren:
9:29
And to explore some of these things a little bit more. We talked about high blood pressure and certainly, I've had an interest in how blood pressure affects the heart size and function over time. So is that a necessary part of the process of hypertension leading to atrial fibrillation? Walk us through any data that we may have to look at structural changes in the heart, particularly related to blood pressure and how that puts you at risk for A F ib.
Dr. Neil Sanghvi:
9:53
Yeah, I think it's a contributor. Obviously, there are patients who don't have hypertension but suffer from atrial fibrillation. But as it pertains to hypertension itself, there's a variety of different physiologic changes that occur to the heart and anatomically. We know that the heart can develop something called diastolic dysfunction as a consequence of hypertension, meaning that the relaxing ability of the heart diminishes. Well, you have a stiff heart. It's not emptying. It's well building up pressure, and that pressure backs up because that ventricle, which is that bottom chamber that we talked about earlier, is attached to that atrium which is right above it. And it can back up the pressure into that atrium.
Dr. Neil Sanghvi:
10:30
Now that atrium is starting to stretch and that atrium stretches, it has a tendency to have misfires occur and then those misfires cause atrial fibrillation to happen. So there is definitely an anatomic and physiologic consequence of hypertension that's untreated, the thickening of the heart muscle, the lack of relaxation of the heart muscle is a strong driver of atrial fibrillation. And then, on the other end, severe hypertension, uncheck can lead to a stretching and weakening of the heart muscle, which is a whole different problem, which also again leads to pressure in the heart, atrial fibrillation, and then consequences of congestive heart failure and such that we've talked about in the past.
Dr. Michael Koren:
11:07
Well, thank you for that great explanation. So one of the things that patients and friends and family ask me all the time is how would I know if I'm in atrial fibrillation? See, if you want to comment on that a little bit, that is probably helpful for the audience.
Dr. Neil Sanghvi:
11:20
You Know, Mike, we're living in a cool age right now. So historically, it was simply the symptoms, right, and the most common symptom is the sensation of a fluttering in the chest or what's described as a palpitation or an irregularity or a feeling of something quivering. That's common words. But what you and I have seen is there are a lot of patients who don't have that symptom. But what they do have, they'll sometimes say all of a sudden, I'm getting short of breath with activities that just didn't get me short of breath. I'm all of a sudden drained and fatigued when I otherwise wasn't, and it's an abrupt change. But what's really cool in today's day in age is the fact that we have these wearables right, this Apple Watch right, and I was a naysayer, I wasn't sure if these wearables were going to be very powerful in predicting A F ib.
Dr. Neil Sanghvi:
12:10
I've had a number of patients come in and saying I'm feeling off and my watch is telling me that I got a problem. And I'll get a tracing and lo and behold, it's not 100%, but it's fairly predictive, and so patients have been discovering A Fib more frequently because of some of these wearables, smart watches and such as well.
Dr. Michael Koren:
12:26
Yeah, we're going to talk a lot more about that. Right now we're doing clinical trials using technologies to determine if people are having arrhythmias, and we're working with a company, for example, right now that's very interested in the concept of taking people that come into the hospital with strange symptoms either they passed out or they had a little TIA transient ischemic attack and some neurological problem. And we're not sure exactly what's going on and then giving them these wearable devices that contract their heart rhythm over a course of time and get other insights from their heart to see whether or not we can figure out what the heck's going on. So we're going to jump into those issues in our next part of this series of Two Docs Talk Atrial Fibrillation.
