Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENORE 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 very, very delighted to be talking with my colleague and friend, Dr. Neil Sanghvi, in another episode of Two Docs Talk, which is a series that we're doing for our MedEvidence platform. Neil and I had a fabulous discussion in our first segment, talking about what the heck atrial fibrillation is and ways of diagnosing it, and for this segment, we're going to jump into really how to start treating it. Dr. Neil Sanghvi is the medical director of Rhythm Services at Flagler Hospital here in Northeast Florida. He's the one that's really when it comes to coming up with policies and gearing other people toward the best ways of identifying and treating arrhythmias. Neil's the guy in our town. So thanks for that service, Neil and let's jump into a discussion about the ways that we treat atrial fibrillation.
Dr. Neil Sanghvi:
1:10
Sounds great. Thank you for having me, Mike. I really appreciate it.
Dr. Michael Koren:
1:13
So okay, we make the diagnosis of atrial fibrillation. Tell us what the next steps are and how we think about it as cardiologists. I n terms of what the appropriate level of intervention may be, depending on what we're finding in the clinical scenario.
Dr. Neil Sanghvi:
1:29
Yeah. W hat we try to dive into are potential trigger points or contributors that allowed the patient to develop atrial fibrillation. You know we talked about hypertension, we've talked about electrolyte imbalances, and so we try to tackle these in individual formats. So, first and foremost, basic lab work right, let's make sure that you're not deficient in magnesium or potassium or that your thyroid is overactive or hyperactive because that could potentially lend towards atrial fibrillation and correcting those simple deficiencies or overactivity through diet and or supplements or medical therapy if the thyroid happens to be hyperactive. That'd probably be the first, very first step.
Dr. Neil Sanghvi:
2:13
Then the more difficult journey begins because most of the time, these patients are suffering from a multitude of problems high blood pressure, obesity, sleep apnea, as we talked about before. And these are lifestyle changes that individually need to be tackled and are not easy to tackle but often yield a lot of reward if we do tackle. And that's involving things like losing weight and aerobic activity. What do we talk about? I think you know, Mike, I think you've told me before, you've told your patients what Thirty minutes a day, five days a week at a minimum, right? That's what we're looking for, and so you know that's what we're pushing.
Dr. Neil Sanghvi:
2:50
That's right. Yeah, right, we admit, that this is easier said than done, but the rewards probably outweigh any of the medicines that we can provide. And so, weight loss management, sleep apnea, managing and monitoring high blood pressure and trying to treat it. W hether it be through a combination of weight loss, diet alterations, right. And then there's dash diet in the past, right, dietary approach to stopping hypertension, and it's, you know, as crazy as it is. What we put into our bodies impacts us, and so if we could change what we put in, that would help, right?
Dr. Michael Koren:
3:22
So in your scope of clinical experience, is there a big percentage that can come in, get diagnosed with a brief episode of A fibrillation and then just change the lifestyle, be it alcohol reduction or treating their sleep apnea or the things and then be fine.
Dr. Neil Sanghvi:
3:38
You know, amazingly, the ones who are successful? The answer is yes. Yeah, there's a number of trials that have been done, both in the US and Europe, actually looking at this very question and saying if we have a very rigorous approach to diet and exercise, can have a meaningful impact. W hether it's completely getting rid of A-fib rillation altogether or to the point where it's not a bother right. And they've shown clearly that that is a powerful tool. The biggest challenge is us being successful at it. Right, the amount of lifestyle change required is a dedication, but the rewards are tremendous. And so any therapy I offer has to be based on that.
Dr. Michael Koren:
4:19
So and, let's get a little more specific. Let's say somebody comes in, and you find out that they overindulge in alcohol. They're not a complete drunk, but it's not unusual for them to drink two, six packs of beer on the weekends. And they notice they're getting some palpitations and other things the next day or maybe later in the day, and they behave themselves and they stick to a very, very strict regimen of one glass of red wine within or every day and that's it. So rate that person.
Dr. Neil Sanghvi:
4:50
Yeah, again, it's very difficult. Unfortunately, I don't have a test that exists to say that this is your trigger, so I can only advise them to say these are the potential contributors. And if it turns out that in this individual, there's a sensitivity to alcohol, which often there is. I've seen tremendous success in just simply changing alcohol intake. I'll take another example just to piggyback off that. In the Starbucks world that we live in right, we live in these worlds where a coffee serving which used to be this, and I saw you pick up your mug right there- Yeah, it's water.
Dr. Michael Koren:
5:19
Yeah, it's water. It's turning to this. It's turning to this right. Unlike Johnny Carson, there's nothing alcoholic in there.
Dr. Neil Sanghvi:
5:27
There are no two carbon molecules.
Dr. Michael Koren:
5:29
I swear to it.
Dr. Neil Sanghvi:
5:30
Okay, very good. So you know, oftentimes I'll ask a patient. I was like, how much coffee do you drink? They'll say a cup. I was like, tell me how big that cup is. And it turns out it's this guy (showing large cup). There you go, so and so that's not a single serving of caffeine, right? And so a successive caffeine can be a trigger as well.
Dr. Michael Koren:
5:45
Yeah, yeah, okay, perfect, and we're still engaging in lifestyle there as well. Okay, so run us down the spectrum of different levels of intensity in terms of the treatment of atrial fibrillation.
Dr. Neil Sanghvi:
5:56
Yeah, so we talked of lifestyle. That's foundational, you know it's the hardest goal, but it's the foundation of anything that we build on. So the patients, who are doing a good job, are trying to do their best, but yet we're still having episodes of atrial fibrillation. Then we'll move toward things that are pharmacologic. So there's a classification of medicines known as beta blockers and there's another class called calcium channel blockers. They come under common names metoprolol, an d verapamil, these are meds that are meant to try to have an impact on the electrical properties of the heart in a mild way, and sometimes we'll be successful in suppressing these triggers that are triggering atrial fibrillation.
Dr. Neil Sanghvi:
6:37
So, to backtrack just for a moment, A-fib has to be triggered in many instances, and that trigger is a series of misfires in the heart that initiate it. So we're trying to suppress the triggers, and it's through lifestyle changes that we just talked about, or some of these meds that try to suppress the triggers. So that would be the next strategy. Now, the success rate in these meds varies from patient to patient. Okay, but they're not the most powerful meds and oftentimes, they may not be successful in suppressing the trigger, but what they can do is help make the symptoms less evident to the patient. So many times, patients here, they feel the irregularity, they feel the racing, and the meds will help calm that. So it's not so debilitating, and so the botoprolos and the dothylatisans can help in that regard.
Dr. Michael Koren:
7:22
Let me explore that with you a little bit more. And I think that this speaks to physicians who may be really focused on underlying triggers, versus physicians that are just kind of checking boxes when they make their decisions about what meds to use. So in my experience and obviously as a general cardiologist, I treat atrial fibrillation. One of the tricky parts is to understand the triggers and then to pick the therapies that are most likely to offset that effect. So, for example, if somebody may be a driving executive and we think that adrenaline surges are causing atrial fibrillation, maybe a beta block is a good choice. If you have perhaps an African-American female that has high blood pressure, maybe a calcium channel block would be better because that will reduce blood pressure to a greater degree in an African-American patient compared to a beta blocker, and that might be a good choice. So targeting your therapy to the specific circumstance of the patient is such an important part of what we do as cardiologists.
Dr. Neil Sanghvi:
8:24
I wholeheartedly agree. I think we are not all built the same and each of us we do require some tailored therapy, and there's definitely tailoring that goes along with ethnic background, personal circumstance, physical circumstance, situational right. So the history becomes such a big part of this. When do you have your AFib episodes? Some will say it occurs while I sleep. Well, those are triggered by a vagal response, a nerve that's in the body, And so you're now trying to treat vagally mediated atrial fibrillation, and there's certain therapies for that. There's the executive, as you described, which are adrenaline or exercise-induced AFib, and so those are adrenaline-induced, and so I agree, there are tailored therapies, for sure, and I try to dissect the patient a little bit to understand which may be a specific trigger to decide which medicine may be effective.
Dr. Michael Koren:
9:18
Okay, so let's jump from that class to the more stronger anteroid mix.
Dr. Neil Sanghvi:
9:22
Yeah. So the anteroid mix is a second tier of therapy that I will turn to when our basic therapies are ineffective. Now, these are drugs that are designed to specifically manipulate the electrical properties of the heart. Okay, the channels that actually help the heart beat are what they're manipulating, and they come into a different set of categories. W e choose agents based on specific patient criteria. So, for example, certain anteroid drugs can be used safely in all patients, some patients who have severe coronary disease, blockages in their heart arteries, weakness in the heart muscle.
Dr. Neil Sanghvi:
10:01
We can't turn to certain meds because they've been shown to be more harmful than good. But their effectiveness as a whole, in aggregate, tends to be about 50%. Okay, so 50% of patients that get put on these meds will see medical benefit right and have suppression of their atrial fibrillation because the direct therapy is now suppressing the misfires that are allowing this A-50 trigger. That's not 50% lifelong, it's 50% for, you know, certain durations. Unfortunately, there are patients who've been put on these meds works for a while and then the body adapts. And so all of a sudden they're breaking through the medication. There's others where we use a certain med but because this time goes on, the patient may develop another ailment, which then makes that med prohibitive. So we have to come off and go to something else. Unfortunately, the best odds are 50-50, you know, and those aren't great, right? I mean those aren't great, but that's the best that we have in medical therapy.
Dr. Neil Sanghvi:
10:54
I'll turn to an agent, droneterone, also known as Motak. It's the last agent that came onto the market for atrial fibrillation. There was hope in the medical community that it was going to be this panacea. It was going to be this powerful medicine that was going to help us manage atrial fibrillation, be very effective, without any toxicities, and unfortunately it ended up becoming one of the weakest ones that's out there on the market. It's power, it works for patients in the right patient, but it doesn't work for everybody, and so we just haven't made headway in this anti-arhythmic drug therapy. But drugs do make effect in patients. We try them in certain patients, but they do come with some side effects, like any medicine would, and so we balance them.
Dr. Michael Koren:
11:34
Yeah, motak's an interesting product. A s you bring up Droneterone, we did a lot of research. I personally did a lot of research with that over the years and the thought process it was a safer anti-arhythmic because it really worked just in the atria rather than the ventricle. But, as you point out, we get the data, it turns out maybe not to be the best anti-arhythmic agent and probably something that we don't use nearly as much as we thought we might use. So, moving from drugs to devices, I know you do a lot of that work, so it sounds like that's become more a common approach for a lot of patients with AFibylation.
Dr. Neil Sanghvi:
12:03
Yeah, so anybody who looks up A Fib, they're going to see the term Obylation come across, and so it's a minimally invasive technique where we take catheters through veins in the legs to attempt to eliminate misfire and tissue. So conceptually, anatomically, you and I have talked about this atrial fibrillation comes from the upper chamber, the atrium of the heart, and what we've learned through years of research is that the source of the misfire, the trigger, oftentimes comes from structures known as pulmonary veins. And these are vessels that drain blood from the lungs. As they empty the oxidated blood from the lungs back into the heart ambriologically, these vessels actually form for the heart itself. As they stretch out from the heart, they pull along some conducting tissue. But the problem is that the cuff of conducting tissue ends up being not as well regulated as the rest of the heart is, and as a result, misfires will trigger.
Dr. Neil Sanghvi:
13:01
So what catheter ablation is is a technique, and we can do it with either heating the tissue or supercooling the tissue, but effectively we're destroying that cuff of tissue, and by doing that we're not impacting the overall function of the heart in any way. So patients really worry am I kind of hurting regular heart muscle? The answer is no. All we're doing is taking away that cuff and by doing so we suppress in many patients the misfire. The success rate 70 to 75% in patients who otherwise have a healthy heart in preventing atrial fibrillation. So much more powerful than the medications that exist out there, but not 100%. I wish it was, but it's not there.
Dr. Michael Koren:
13:38
So interesting and so impressive, and the technology just gets better and better. As I understand the data, the success rates have improved dramatically over the last decade or two.
Dr. Neil Sanghvi:
13:48
Absolutely, the key here was the heart, as the rest of the body wants to heal itself, and I just mentioned that I'm trying to actually cause a scar. I'm trying to destroy tissue, and so the tools we had weren't as effective. So we would get some inflammation and what we thought was destruction, but over time it would re-heal, and then the problem comes back again. The way I like to explain it to patients is I'm trying to build a wall, and if a door develops in the wall because something heals, it's very difficult for misfires to come through. The tools we have now are much more powerful than before. The success rates are going up, I said 70, 75%. And in the right patient it could be even upwards of 85%. And the procedure is not very taxing, so that's why it's become much more favorable for patients to turn to inablation versus other therapies that exist that we talked about. So let's go from very high tech, which is really, really cool, to low tech.
Dr. Michael Koren:
14:38
How about supplements? A lot of people think that there are different types of supplements. A lot of people think that there are different supplements that can work for A fibrillation.
Dr. Neil Sanghvi:
14:48
That's much more challenging, right? I think the electrolyte supplements magnesium, potassium there's been some role in helping A fibrillation. In that regard, there aren't any other major supplements that I've come across. I mean, Fischwell has been mentioned as a possible tool, you know, variable success. To me where the supplements come into play is that there isn't much harm in going on them, you know, assuming you don't have any major kidney issues or liver issues, and so it's a compliment to that lifestyle change that we were earlier addressing. The challenge with AFib, as you and I know it's not one thing often that's the trigger. It's a multitude of things that come in constellation.
Dr. Michael Koren:
15:32
So maybe for a limited population there can be some role, but maybe not something you should put too much hope in.
Dr. Michael Koren:
15:39
Alright, so let's get to a clinical case. This is a hypothetical. It's a completely hypothetical, but I played soccer for a number of years and periodically people would come up to me knowing that I was a cardiologist and a soccer player, mostly a defenseman. But we had this one occasion where somebody missed a PK, a penalty kick. And they were, I think, coming up with an excuse that they were having some palpitations that seemed to have distracted them from their goal of scoring a goal and winning the game for our team. But nonetheless, I took the person at their word and noticed that he did have an irregular heartbeat that led to my evaluation that showed that this person in fact had paroxysmal A Fibrillation. So, with this person in mind, who, let's say, he's in his fifties, hypothetically. I'm very curious in our next segment to see how you would manage that person. And hopefully get that person back to the soccer field and actually scoring goals when they were asked to take a PK. Sounds like a good plan.
Narrator:
16:44
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