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:
0:17
Hello, I'm Dr. Michael Koren here with another episode of Two Docs Talk A-Fibrillation on our MedEvidence platform. I'm delighted to be speaking with my friend and colleague, Dr. Neil Sanghvi, who is the medical director of heart rhythm services at Flagler Hospital here in Northeast Florida. W e're excited to have this conversation. We've been having a really informative and fun conversation. So thanks, Neil, for this. And we end our last section by talking about a hypothetical person who we both know, by the way, a guy in his 50s who was discovered to have atrial fibrillation during a soccer match when he missed a penalty kick, at great consternation amongst all of his teammates. But in fact, he had a good excuse. He had an irregular heart rhythm on the soccer field and fortunately it settled down there for a little bit, but then ultimately, I evaluated him and sent him over to you. So tell me what your analysis of this type of person might look like in general, and then we'll sort of dig into some specifics about the care of people like him.
Dr. Neil Sanghvi:
1:22
Sure, Yeah, absolutely. You know, it's unfortunate, it happened on the soccer field and it cost the team a game. So I'm sorry about that.
Dr. Michael Koren:
1:30
I'm still a little upset, I must admit he was too.
Dr. Neil Sanghvi:
1:35
Yeah, no. So this is the patient, right, he's noticing, he's in physical high stress level and he says my heart's beating wrong, right? And then, it's not constant. So you know, the first question is, what situations causes this to happen? So we kind of try to get to that underlying understanding of triggers. And then the most important thing for me is I have to see it. I have to see it to know what's going on. And so typically what we'll use is some form of a wearable monitor which records the rhythm of the heart, so that way I can actually see what the heart is doing when the patient is having the symptom that they're having.
Dr. Neil Sanghvi:
2:11
And the type of monitor will vary based on the frequency of the symptom. And so patients may have heard of things called Holtres, which are somewhat shorter term monitors, anywhere from 24 hours to like a week. And then they have other long term monitors, which are called event monitors, which you can wear upwards up to a month. And what's nice about these monitors these days is that historically these monitors had a lot of wires and it would be fairly burdensome to wear, But nowadays we have these little patches or stickers that come on board.
Dr. Neil Sanghvi:
2:39
They just stick it on themselves. They can wear it all the time. Many of them are actually even water resistant, so you can shower with it, and it has the ability for the patient to push a button or somehow indicate to us that, hey, i'm in the middle of a symptom, and I can pay special attention to that period of time to see what is the heart doing when the patient is having their symptom. The other benefit is that the monitors also have the capability of recording arrhythmias or irregular heartbeats that are of significance even when the patient's not pushing the button. Say you're asleep, and so that will be a tool I would use to try to determine what is going on when the patient is feeling what they're feeling.
Dr. Michael Koren:
3:14
Yeah, and that's really, really important is making the diagnosis, and especially in these cases where it happens, it stops happening and people are having a hard time to describe exactly what it is they're experiencing. Sometimes the symptoms are vague. And also, you know, I'm a little bit of a historian and one of the trivial facts is that most people don't know where the term halter comes from. It's actually the name of the doctor who first prescribed this kind of concept Dr. Halter.
Dr. Neil Sanghvi:
3:44
You know, you've just taught me something today, thank you.
Dr. Michael Koren:
3:48
You ever think about that? No.
Dr. Neil Sanghvi:
3:50
I did not. I actually thought of it like almost like a harness halter and walked away with that.
Dr. Michael Koren:
3:56
But I just learned something new. We'll do fact check on that, but I'm pretty sure that's correct. So that's a little trivia question, Trivia answer, I should say. Okay, so let's get back to the guy who I played soccer with, so you do this analysis. Lo and behold, you find out that he is having some episodes of atrial fibrillation in different circumstances. What are the next steps? All right.
Dr. Neil Sanghvi:
4:22
Well, you know, we've diagnosed him with AFib. We figured out a trigger, which tends to be exercise in this individual, And so the next conversation is all right, how do we deal with this? Well, I'm not taking him away from exercise and I'm not taking him off the soccer field because you'd kill me and he would be upset. So we need to figure out ways to manage this and suppress the arrhythmia. And so, you know, assuming he doesn't have anything reversible, so we go back to that earlier conversation of electrolytes, thyroid, all that kind of stuff, to make sure all of that's in balance. We've taken away anything that could be addressed simply, and now it's activity and adrenaline that's triggering it. So then we have the discussion. You know, how do you want to manage this?
Dr. Neil Sanghvi:
5:04
There are obviously chronic medicines that he could take that could try to suppress the trigger and prevent the episodes from happening. The downside, though he's a young guy, otherwise healthy, and, you know, would be committed to lifelong medications. Or we talk about that ablation that he and I talked about before, to try to deal with the symptoms. But the other side of this, Mike, is stroke. Right? I mean, you and I kind of haven't really touched on that. So besides symptoms? AFib is the number one cause of strokes due to clots in patients over the age of 65 and a common culprit of strokes in patients who come in with unidentified reasons for stroke when they show up to the hospital.
Narrator:
5:41
Dr. Michael Koren: So I've got to manage that.
Dr. Neil Sanghvi:
5:43
Huge point right, and so this patient who now has atrial fibrillation. We have the symptom side that we can address, but I got to manage the stroke side. And that management will vary based on the patient. And really it's based on risk factors and there's several things that we look at. We look at the patient's age. Whether they have high blood pressure or not, irrespective of whether it's well controlled or not, just the mere fact that they've developed high blood pressure, whether they're diabetic, what's the heart function is right? Is it weak? Not weak that kind of thing?
Dr. Neil Sanghvi:
6:13
Have they ever had a stroke or stroke-like event before? Do they have other vascular disease? Do they have a diagnosis of coronary disease or some sort of blockages in their legs or something like that? These risk factors culminate into something called a CHADS Vascular that we use to stratify patients to determine who are the patients at the highest risk for stroke from AFib versus those who are low risk. Low risk we don't necessarily need to worry about things like blood thinners. H igh risk that's when we're talking about those things that patients have read about in the past or seen commercials about Warfarin or Coomidin that we've all heard about Alakuis, zirelto, cvesa there's a number of them out there that we have to talk about.
Dr. Michael Koren:
6:49
Yeah, and we use the term NOACS for that as novel anti-coagulants. Yeah, so that's a really important point. So when I was serving as Chief Resident at New York Hospital in internal medicine, i used to quote data at that time this is a little while ago, of course that stated that if you had atrial fibrillation versus not having atrial fibrillation, your risk of a stroke went up six-fold. And if you had atrial fibrillation with valvular heart disease compared to somebody without atrial fibrillation and valvular heart disease, your stroke risk goes up 20-fold. Are those still pretty accurate numbers?
Dr. Neil Sanghvi:
7:24
Yeah, yeah, we haven't changed the risk profile at all in that regard, so you're absolutely right. A five to six-fold increase in risk of stroke just simply taking two patients one with the diagnosis A-fib and one doesn't and then if you put concomitant diseases on top of that valve disease, cardiomyopathy, history of having a prior stroke-like event and those numbers skyrocket. So the concern levels are very high when it comes to this, and so generally, what we say is that when we estimate your risk of stroke, if it's greater than 3% per year, using some of those risk factors that I just described, that's a patient who really should be contemplating anticoagulation, whether it be through one of the novel agents that you just described Warfarin, which is something that we don't often turn to as much these days, but certainly still on the table as a tool or some other alternative thromboembolic or stroke-preventing technology that's out there.
Dr. Michael Koren:
8:24
Yeah, so another little trivia question. Warfarin, as we all know, was originally developed as rat poison, and I don't know if you're familiar with this, but the W-A-R in Warfarin stands for Wisconsin Agricultural Research, because it was originally developed as a product to deal with rat issues on farms. That's a bit of history.
Dr. Neil Sanghvi:
8:46
I do know and I'm just gonna piggyback just to get how it came about. You probably know this as well as a farmer. It was a farmer who was sitting there and his cattle was bleeding out and hemorrhaging because they were feeding right, and so he brings the cattle to the university and they were like, what is going on? Why am I a cattle guy? Amazing story. And yep, rat poison is exactly how it started off and unfortunately, some of my patients are like do not give me the rat poison.
Dr. Michael Koren:
9:14
Yeah, and the other crazy trivia question is that President Eisenhower was treated with Warfarin extensively after his heart attack and that was really the main treatment they had back in the 1950s.
Dr. Neil Sanghvi:
9:27
That's right, that's exactly right, actually in secret. They did not want the public to know. That's right.
Dr. Michael Koren:
9:33
Exactly, yeah. So interesting little tidbits, all right. So getting back to our soccer playing buddy, so you're gonna put them on a blood thinner, you know. Can you mention the CHAD Vaskor? I gave you a bit of a sense. Let's say, his blood pressure jumps up and down a little bit.
Dr. Neil Sanghvi:
9:50
You know we're thinking in somebody like this, fortunately for him, he's still in the low-risk profile because he's young, otherwise healthy, heart, strong, and the blood pressure may be a contributor. But he's on a low-risk profile and so for him the hazards of the blood thinner are going to be far greater than the benefits that is offering. So we're able to safely avoid blood thinning in his specific case, though it's not without accepting a little bit of risk, right, but the numbers are small. We're talking about one and a half, two percent risk, and so that's something that we converse about and saying are you comfortable with that? And he says yes, we're good. If he says no, we need to think of an alternative, because I worry about a soccer player being on a blood thinner, playing in a high-contact sport.
Dr. Michael Koren:
10:37
Understood. Yeah, and that's an interesting part of the management, which we'll get to in a second. But just exploring this anticoagulation issue just a little bit more. One of the controversies is that when you newly diagnose somebody, some people would argue and I have to admit that I fall into this category that I want to anticoagulate while I do the exploration of what one's risk is and how do you manage that practically?
Dr. Neil Sanghvi:
11:02
Yeah, no, i don't think that's unreasonable. I mean, fortunately, most of the time, you know, it's colleagues like you actually that make my job a little bit easier because you've done the first steps for me. You know, you've gone through the discovery phase. But if they're showing up to my door and I don't know what's going on, it depends again on them. If they're exceptionally young, because, as I mentioned I have 30-year-olds that show up right and they're young and they have zero risk factors whatsoever and they're lonely, what we call. They're called loan a Fit. They're considered very low risk. That's a patient.
Dr. Neil Sanghvi:
11:33
I feel very comfortable being off the blood thinner and saying we're gonna go through this discovery phase but we're low risk. Everybody else, you're absolutely right, we will. We may even use transient blood thinner for a short period of time while we're just stratifying the risk. And then, once we've identified where they fall on the platform, then we'll have a informed conversation to say here are the numbers, what are you comfortable with? And I just describe it as it's a set of scales right? And there's risks and benefits in both. The blood thinner is very powerful and helping prevent strokes, elevate your risk of bleeding, though, right, not being on them elevated risk of stroke, but you're not bleeding as much, and so we're just trying to find which balance that we can strike, and in some patients the blood thinner makes sense, others it doesn't.
Dr. Michael Koren:
12:13
Okay so let's go back to our hypothetical soccer player who ruins our entire season by missing a PK and you're talking about whether or not you would do an actual procedure on him, an ablation procedure, and whether or not you would use a watchman, or what would make you decide to use that, given the fact that in a coagulation, in a contact sport, may not be so compatible.
Dr. Neil Sanghvi:
12:40
Absolutely. So let's talk about the way I like to talk about A- fib is symptoms and stroke risk, and we separate the two. How do I get them asymptomatic, how do I make them feel better so he can perform wherever he's looking to perform? A nd for this patient, right, we had of we would have a very strong conversation about ablation, mainly because it's as I mentioned previously. It's the most effective tool I have in my War chest of treatment options for a fit. It also offers the least complexity on needing to be on meds lifelong for a young guy, and so I would certainly mention all of the options. B ut I think ablation would be something that I would be pushing him towards and saying, hey, this may be the best for you, you know, because in otherwise healthy heart the outcomes are quite high, right, I mean, I mentioned 70, 75%. But these young hearts where patients have what we call paroxysmal, A- fib, that's that coming and going of the symptoms not being stuck in them, they have upwards of 85% success with ablation. So that would be the way I would handle the symptoms, stroke wise for him. If he's low risk, we may not want anything, okay, and just say this is, we're fine, we don't need to do anything at all. We'll deal with the symptoms and we don't need anything else. But let's just say this guy happens to be diabetic as well, a healthy diabetic, but and so now he's at elevated risk of stroke because the diabetes plays a role, the blood pressure, as you mentioned, plays a role, and even though I do an ablation, I can't guarantee cure. So just because you get an ablation doesn't mean your risk of stroke goes away, okay, so I have to still protect him. And now he's a soccer player. Or let's take another patient, just as an example. Let's take the patient who's just not stable, much older patient who falls a lot. Right, these patients, they need protection.
Dr. Neil Sanghvi:
14:22
And so this watchman that you described, which is a device that was devised by Boston Scientific, or there's others that are on the market, but they fall into a category called left atrial appendage closure devices or LAACs. These are devices or plugs that get placed into the heart And what they're meant to do is there's a pouch called the left atrial appendage, in the left upper chamber of the heart, which tends to be the source of the stroke, the clot that forms when patients are in the A-fib. So when we talked about the heart quivering. Blood doesn't move well. Well, blood has a property of wanting to clot when it's still, and it sits in this pouch more times than not. 90% of clots that develop in A-fib sit in the or found in, this pouch. So if we plug this pouch off, close it off through a very minimally invasive procedure, we're able to seal off the pouch, we can reduce the risk of stroke equivalent to as if you were on a bloodbath, and so that would be an ideal solution for this patient, because that procedure 45 minute procedure, risk of complication 1% or less and success rate greater than 95% And so that would be an ideal procedure for this type of patient or any high-risk patient.
Dr. Neil Sanghvi:
15:28
And those high-risk patients are your sports athletes or vocations that are high-risk for bleeding. I'll tell you. I just put one in a patient. She's a glass worker, she's an artist who works with glass, cuts herself all the time, and she was on a blood thinner and she would just bleed like there was no tomorrow. That's a patient we would consider the watchman on The fall patient that I talked about, or patients who are prone to hemorrhage because they have ulcers and will have bleeding. So we need to those are those scales. And the scales are such that the bleeding risk on the blood thinner is so high that it makes sense to look for an alternative.
Dr. Michael Koren:
16:01
Sure, so the left atrial appendageal closure devices are a great example of recent technology that's been highly studied in clinical trials, and in our next segment I'm gonna explore more clinical trial information with you and also what the future holds for people diagnosed with A-fibrillation. Perfect.
Narrator:
16:21
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