Transcript
[00:00:08] Matthew DeVane, DO, FACC: Hi, I'm Doctor Matt DeVane.
[00:00:09] Carolyn Lacey, MD, FACC: And I'm Doctor Carolyn Lacey. We are cardiologists at John Muir Health and this is our podcast, Living Heart Smart.
[00:00:16] Matthew DeVane, DO, FACC: Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.
[00:00:24] Carolyn Lacey, MD, FACC: Thank you for listening and we hope you enjoy our show. Hi everybody, it's Carolyn Lacy. I'm here again with Matt Devane. We're at Living Heart Smart and we're going to continue our atrial fib journey today. We're going to talk about why atrial fibrillation happened to me. I have patients ask me this every day why is this happening to me. And they also follow that question up with what am I able to do to take care of my atrial fibrillation? We're here again with one of our partners. You met him in another atrial fib episode, Doctor Andy. Benn, he is like we talked about before, a native Chicagoan and would love to hear more about one of his favorite days at opening day of the Cubs Wrigley Stadium.
[00:01:15] Andrew Benn, MD: It is Wrigley Field, um, the only baseball park in the United States that matters. My first baseball game, I love it. My first baseball game was Opening Day, 1967 at Wrigley Field. I was with my dad. The Cubs beat the Phillies 4 to 2.
[00:01:30] Matthew DeVane, DO, FACC: And you probably remember.
[00:01:31] Matthew DeVane, DO, FACC: That's amazing. You were.
[00:01:32] Matthew DeVane, DO, FACC: Probably.
[00:01:33] Matthew DeVane, DO, FACC: Eight, I.
[00:01:34] Andrew Benn, MD: Was six. There you go in 1967 and loved the park. Great days I've had at Wrigley Field include when Mike Schmidt. Not a great day for the Cubs. Mike Schmidt, one of the few four home run games in baseball history, was at Wrigley Field. That was a really, really cold spring day. I can't remember the year exactly. I'm going to guesstimate 75 or 76. And of course, the greatest day in baseball history. I was not at the park because the park would have been Cleveland. Um, but that was November 2nd, 2016, when the 108 year drought was ended by the Cubs winning the World Series. Um, a great moment for me and for fans around the world.
[00:02:17] Matthew DeVane, DO, FACC: That's so awesome.
[00:02:18] Carolyn Lacey, MD, FACC: He hasn't stopped smiling since his first day at Wrigley Field, actually.
[00:02:22] Group: Absolutely. Well that's.
[00:02:23] Carolyn Lacey, MD, FACC: Great. Thank you for being here, Giants fan.
[00:02:25] Matthew DeVane, DO, FACC: I'm struggling right now, but I think the Cubs are having a good year. So far. No.
[00:02:28] Andrew Benn, MD: Cubs are seven and five currently. Like all Cub fans, we believe they'll finish the season officially 157 and five because.
[00:02:37] Carolyn Lacey, MD, FACC: That's right.
[00:02:38] Andrew Benn, MD: That Cub fans are the ultimate. You should be as positive about your atrial fibrillation as a Cub fan is about the Cubs.
[00:02:45] Group: Great, yes. Never, never.
[00:02:48] Andrew Benn, MD: Believe in anything but success. The good news is that's probably true for your atrial fibrillation. The bad news for me is probably not true for my cubs.
[00:02:55] Carolyn Lacey, MD, FACC: Probably not.
[00:02:56] Matthew DeVane, DO, FACC: Well, today we're going to talk about, as Carolyn mentioned, like patients want to know what can I do? How can I help. And before recently, I think a lot of us felt like there probably isn't a ton you could do. Of course, there's always some lifestyle changes and things, but the more data that we hear about AFib, the more that's coming in. We think there's a lot you can do to help yourself. And so we're going to cover a lot of that today. I think today I like to cover maybe the five big major takeaways that I hope our patients get from today. First and foremost is atrial fibrillation, as we talked about in another show, rarely lives by itself. It's usually has company like high blood pressure and other heart conditions that you'll need to manage and understand. That's really going to help you get through atrial fibrillation. Number two is atrial fibrillation. Treatment is a team effort. You've got things to do to make your heart better. And you're going to work closely with us, your cardiologist, to help get it better as well. And you're going to do fine. Remember, the atrial fibrillation is a chronic condition even if you're going in and out of it or even if it only happens once in a while to you, it's still chronic, and there are still things that we all have to do to manage it and to make your life great.
[00:04:04] Matthew DeVane, DO, FACC: We're going to talk a little bit in this episode about starting looking at the treatment for atrial fibrillation. We're going to have dedicated shows related to blood thinning and to ablations and to antiarrhythmic drugs. But today we're just going to start that overview of how you should start thinking and how cardiologists really are going to think about how we manage your AFib. And then it's just kind of a big picture overview from there of your treatment options to get you off on the right foot. So with that said, we're going to start out by talking about a lot of the risk factors that go along with atrial fibrillation. And Andy, Benn, if you could really just dig in there and how you're talking to your patients about how they should be thinking about what they can do when they're looking at their risk.
[00:04:45] Andrew Benn, MD: Absolutely. I think it breaks into two parts, Matt. One part is for the patient experiencing atrial fib. What can they examine in their own lifestyle that they can change to try to help reduce the burden of atrial fibrillation, how much atrial fibrillation they're having. And then upstream from that, there's also the question of what lifestyle factors. But cardiac risk factors come to the table to increase your risk of getting atrial fibrillation in the first place. So let's start downstream and we'll move upstream. So we'll start with people who already have atrial fib. Fascinating. Um survey study. Gosh it has to be 1520 years ago they asked people what sets off your atrial fib 1200 people plus about 1260. They surveyed people, all with demonstrated atrial fib. And they asked number one was alcohol. Number two was caffeine. And we'll talk about the vexing question of caffeine and atrial fib. Number three was exercise. And number four was stress. Um, things that physically stress them lack of sleep psychologic stress, etc.. As the data's rolled in over the last 20 years and even before in another way, we know that more alcohol equals more AFib. There have been studies done in recent years that have shown that if you take people who get atrial fib, who are drinking at least moderately, and you can get them to either go to zero or near zero alcohol consumption, you can greatly reduce their incidence of symptomatic atrial fib by at least 80%.
[00:06:13] Andrew Benn, MD: And that's been demonstrated in multiple studies and seems to be true. There's no calculus to give you, except that less alcohol equals less AFib. And that's clear. And as we age as the wiring in the heart, the thing that's demonstrating the atrial fib as it ages, it's clearly more sensitive to alcohol. Caffeine. A more complicated question if you look at caffeine. And you ask patients what sets off the rape? I just told you they'll give you the number two. But when you survey a population, when they look at large population studies, whether it's Framingham or the Women's Health Study, consistently, there's no correlation between caffeine and incidence of atrial fib. But in an observational study, the people who were feeling arrhythmias, atrial fib and otherwise who were consuming caffeine, they stopped drinking the caffeine because they knew it made them feel poorly. So that's why in a population, you may not pick up the association, but for any individual, it's worth asking. If I switch to half caf or I drink half caffeine, half decaf, or to decaf altogether, can I reduce my onset of atrial fib? That's a very legitimate question. Another factor that's been shown to impact patients who are already expressing atrial fib is body mass.
[00:07:32] Andrew Benn, MD: The Australians were the first, but not the only people to demonstrate it. To show that, say, a £20 weight loss could greatly impact the incidence of atrial fibrillation. That's so easy to say. It must have taken me only 15 seconds to say that on the radio. It's hard to do. We have some tools now that can help us, both pharmacologically, and there are some diets that have been very helpful to people, of course, in helping them reduce their weight. But it's a hard thing to ask of someone, but it's clearly been associated with reduced atrial fibrillation burden. Treating sleep apnea appears to reduce atrial fibrillation. But again, you can't study it because you can't take a bunch of people with sleep apnea and not treat half of them. That's unethical. So there is an impression that treating it reduces atrial fib. Certainly the mechanism of weight loss reducing atrial fib may pass through less sleep apnea because a great treatment for sleep apnea is, of course, weight loss. Um, exercise relieving a sedentary lifestyle may be helpful to atrial fibrillation. We know that very aggressive exercise. The people who do really high level, multi hour per day exercise do seem to have an increased incidence of atrial fibrillation. But for the normal exercise or that person getting a couple of hundred minutes a week, there does seem to be a negative correlation.
[00:08:56] Andrew Benn, MD: Meaning the more your regular with your exercise, the less you seem to get. Atrial fibrillation though we're not quite ready to say the reverse. Hey exercise and you'll get less AFib. For those of you listening to this podcast who may not have had AFib yourself or saying, hey, how can I avoid stepping in that bear trap? We look at the cardiac risk factors because so many cardiac conditions and the risk factors that lead to those conditions correlate with atrial fibrillation. Is your blood pressure well controlled? That's 120 over 70 right now by guidelines. If you're under 65, 130 over 80, over 65 and up. Is your diabetes well controlled? Controlling your lipids probably doesn't directly affect AFib, but it impacts your risk of vascular disease. And there certainly is a correlation with all forms of artery clogging vascular disease with atrial fibrillation. Dietary sodium important to watch as it pertains to blood pressure. Certainly important for the patient with a history of congestive heart failure and staying out of heart failure with some dietary discretion would be important for the atrial fib patient, who, as we said, is bringing something else typically to the party if that thing they're bringing is congestive heart failure. Matt, you know, we've mentioned a lot of risk factors today that are associated with atrial fibrillation, everything from smoking and lipids to diabetes and hypertension and a lot of preexisting cardiac conditions like vascular disease and congestive heart failure, as well as the other lifestyle things we talked about like weight, caffeine and alcohol.
[00:10:28] Andrew Benn, MD: And it's often not one thing in any one patient. It's often a package, and not every part of that package applies to you. You may be listening to this and you're not a diabetic. It doesn't apply to you, but you may be drinking half a pot of coffee a day. You may be having that third glass of wine. You're going to get more atrial fib. Um, it's really that simple. Now, there's some things we can't control. We know that as we age. We know that as we go through certain other procedures, such as open heart surgery. Both of those things are associated with atrial fibrillation, open heart surgery, and incidents of anywhere from a third to a half, depending on which study you'd like to quote me. And for aging, every year we age, the incidence of atrial fib rises. You touched on that at the very beginning of the last podcast. Incidents may be 2% of the population below the age of 65, but by the time you hit 80, it's 9% and it only goes up from there. We're an aging population. Why is that happening? If you really explore old, old medical literature from the early 1900s, a man from France named René René La Negra and a man from Chicago, a town that has my heart.
[00:11:37] Andrew Benn, MD: Maurice Lev from Michael Reese Hospital, where a young doctor, Benn, was born. They together did work to show that what was going on in patients who back then were very rare. This is the early 1900s. People didn't live that long. But for those rare patients who did and now they had Electrocardiograms, first described by Eindhoven in 1905, I believe they had these EKGs and they started to look at the hearts of those people postmortem, and they found that the wiring in those hearts had decayed and degenerated. And so for some of our aging patients, it may be the factors we described a minute ago, but it may also simply be that, like the wiring in a beautiful old mansion, the rest of the house is great. The muscle, the valves, the arteries that we talked about are still doing well, but the wiring is decaying and that decaying wiring is finding it harder and harder to organize. So we always think of age, but that's a risk factor we can't change. And other conditions as we talked about, like somebody going through open heart surgery. Should be ready. That atrial fib may be a part of that story.
[00:12:41] Matthew DeVane, DO, FACC: And even beyond open heart surgery, I mean, so many lots.
[00:12:44] Group: Of surgeries.
[00:12:45] Matthew DeVane, DO, FACC: We see in the hospital that we're consulted on came in for completely other reasons, right? Stress, pneumonia, an accident, a broken hip or whatever. And then they ultimately have atrial fibrillation. So those types of stresses, those types of surgeries predispose you to more episodes as well.
[00:13:02] Andrew Benn, MD: Being ill predisposes you acutely ill especially, it seems, respiratory illness, which we see of course, a little bit more of in the winter time, but we see it year round. I liken it to my patients this way when you're ill. The chemical that we've been literally evolutionized to make when we're sick is adrenaline and its sister, noradrenaline. Adrenaline is the same thing as epinephrine. What's in an EpiPen? And if every day I burst into your house and gave you a shot of epinephrine in your leg, and you started to have more arrhythmias, you'd say, well, gee, mom, I think the best thing to do would be tell Doctor Benn we're coming to my house and.
[00:13:38] Group: Leave me alone. Stop doing that.
[00:13:40] Andrew Benn, MD: Stop doing that. And yet, when you're sick, you are your own EpiPen, because that's how you evolve to survive. Before we had medicine. So when we're covering the hospital, any of the three of us and we see patients having atrial fib left and right because they're sick with something else, it's because their epinephrine, their adrenaline is off the charts.
[00:13:59] Matthew DeVane, DO, FACC: Well, I'm writing this down. When you are sick, you are your own EpiPen.
[00:14:02] Carolyn Lacey, MD, FACC: Yes, that one's great.
[00:14:04] Group: That's a keeper.
[00:14:04] Carolyn Lacey, MD, FACC: That's a definite.
[00:14:05] Group: Keeper. Okay.
[00:14:07] Matthew DeVane, DO, FACC: And so many patients though are asking, you know, when it comes to stress, it's so hard to quantify. I mean, everybody has their own stresses. It's just it's a difficult one. But again, if you throw that into the mix with other things that are going to lead to AFib, AFib is going to show its ugly head. At some point when.
[00:14:22] Andrew Benn, MD: You talk about psychologic stress, Matt. And it's a good thing to bring up a, we have to acknowledge that each of us reacts to different types of stresses differently, something some stresses energize us, stumps, some stresses beat us down, some stresses just plain stresses. And we feel that agitated feeling of stress. And that's going to be very individually dependent. But the same adrenaline we talked about when you're physically sick is the same adrenaline. You're released when you're psychologically stressed. And there's no question that when stress is building for you, you're going to have more arrhythmias. And that will include but not be limited to atrial fibrillation. So anything we do as a tool, whether it's Ayurvedic relaxation, breathing, yoga, tai chi, meditation, guided imagery, exercise, better sleep, less alcohol, things we do to treat our stress in healthy, productive ways is going to translate to less arrhythmia.
[00:15:19] Group: The.
[00:15:19] Matthew DeVane, DO, FACC: I would also get a lot of questions about are there dietary things that kick off atrial fibrillation?
[00:15:25] Andrew Benn, MD: I've had patients walk in the door and swear to me that every time they do a particular diet thing, it sets off their atrial fib. There are two dietary things that are really central, and that's the alcohol and caffeine. Acknowledging the caffeine is probably very individually determined, whereas alcohol seems to be a more universal phenomenon. As we discussed, there is a phenomenon and it is described and it has an acronym that I candidly cannot recall in which large meals set off atrial fibrillation in certain people. And it has to do with gastric distension, literally pushing up on th e diaphragm. So you have both a physical stimulation of the atria and also stimulation of the vagus nerve, which can sometimes set that off. So those are the dietary things I think of in my patients with atrial fib.
[00:16:17] Matthew DeVane, DO, FACC: Huge meals equals.
[00:16:18] Group: Bad I.
[00:16:19] Andrew Benn, MD: Generally we're meant evolutionarily again to eat small frequent meals.
[00:16:23] Matthew DeVane, DO, FACC: I like it I like it. Okay. Well we've covered I think most or all of the cardiac risk factors that go along with atrial fib and beyond cardiac risk factors. Right. So lifestyle and other health issues that are going to help lead to atrial fibrillation episodes I think we nailed it.
[00:16:42] Group: I think so too.
[00:16:43] Carolyn Lacey, MD, FACC: Okay. And Matt, you know, it's one of those things that as you've heard in our hypertension our hypertension episode, as you've you have heard in our lipids episode, there's a lot of things that people can do, and they're all very similar things to take care of your heart, eat healthy, exercise, get good rest, manage your stress, all of those things. Those are things that no matter what, they're always going to be good for our hearts.
[00:17:10] Andrew Benn, MD: And they're going to translate, I think, Caroline, to compounded Bennefits. Meaning if you watch your dietary sodium, well, that doesn't have a direct effect on your likelihood of AFib. It has a direct effect on your blood pressure, keeping your dietary sodium to a couple of grams a day or less translates to better blood pressure. And that's going to translate to less congestive heart failure. That's going to translate to less AFib. So a lot of the things we seem to do for one reason, like a bank account receiving compounded interest, it builds on itself in a very useful way.
[00:17:42] Group: Perfect.
[00:17:43] Carolyn Lacey, MD, FACC: I like that description a lot.
[00:17:45] Matthew DeVane, DO, FACC: Okay. So those are the things that our patients are going to be working on. And now we're going to move the pendulum over to what cardiologists are thinking about when it comes to the treatment of atrial fibrillation. So in this we're going to dive into other episodes where we're going to go deep on really the treatments. But let's start here with the big picture, Andy, Benn, of how you think about the patients coming in there in atrial fibrillation, their heart rate's 120. They feeling okay? How do we tackle treatment from that standpoint going.
[00:18:14] Group: Big picture wise.
[00:18:16] Andrew Benn, MD: A great question. Back to the concept I gave during the last podcast and want to restate, because I would hope if you're listening to this podcast and you're helping yourself or a loved one or a friend get through working with their atrial fibrillation, they should ask their caregiver the same four questions that I hope their caregivers are asking themselves. Question one was, how did we get here? What's going on with the patient's heart? What's going on with other elements of their health that produce the atrial fib? We've touched on that already. That was question one. The other three questions are how do I slow it down? How do I get them out and keep them out of atrial fibrillation? And most importantly, perhaps because it's the most dangerous thing associated with atrial fibrillation, how do I reduce that risk of stroke? As we approach those first two questions that I just brought up a moment ago, slowing down the atrial fib and keeping you out and getting you out of atrial fib. Let me give you a little bit of a framework with the acknowledgement that future episodes on AFib with this podcast are going to dive much deeper into those for slowing down the atrial fib. We've really got a choice of three medications. We've got a group of medications called the beta blockers. We've got the calcium channel blockers specifically just diltiazem and verapamil. And then we've got digoxin, which 2000 years old is still having to prove itself.
[00:19:41] Andrew Benn, MD: But it has a definite role in the treatment of rate control. We have other solutions when we just can't get the rate under rate control. Let's leave that for the future. Podcast. When somebody comes in in atrial fibrillation, uh, symptomatic or not, we may want to get them out of atrial fibrillation to get them out. We're typically going to bring them to the hospital. We're going to have anesthesia, put them in sleep for a moment. We're going to give them a shock with the paddles, just like you see on TV. And then we're going to put them back in normal rhythm. And the question will then become, how do we maintain that normal rhythm? If we think, well, maybe it was caused because you had those five cocktails at the Christmas party and there's a clear precipitant we may leave you alone. On the other hand, if we think, wow, given your other risk factors, your age, this is likely to recur. We're going to have options. We'll have medications. We call those antiarrhythmic drugs because they're opposite of arrhythmias. They're trying to keep the rhythm normal. And then we have a procedure called ablation. And that's going to be covered really well down the line in future podcasts. All those things are important, but nothing is really quite as important as preventing the strokes associated with atrial fibrillation. And we're going to touch on that on the next episode.
[00:20:58] Carolyn Lacey, MD, FACC: I think we've had a great discussion about things that we really all can do to help prevent us all from having atrial fibrillation in the future, and making sure you're taking care of yourself, treating your your other conditions, your blood pressure and sleep apnea, those sort of things, having a heart healthy lifestyle where you're eating well and you're watching your alcohol intake and really trying to get good rest. Andy, you told us in an earlier episode that you had had atrial fibrillation before. Can you tell us about your experience?
[00:21:31] Andrew Benn, MD: I can, it was the day before Thanksgiving 2010. I had the day off, so it's already starting. Great.
[00:21:38] Group: Went down my.
[00:21:39] Andrew Benn, MD: College age daughter was in town and in fact she may have been in from New York. She had just graduated, so she was of legal drinking age. We went out to a restaurant in Walnut Creek. Locally. We each had a glass of wine with lunch. I never had wine during the day. It makes me too sleepy. But we did. It was the day before Thanksgiving, so all the stores were set up for Christmas shopping. But of course it's the day before Thanksgiving. No one's there, no one's in the stores. I'm the chef at home. I had dinner all teed up, ready to go, so I really didn't need to run home and cook so well. We needed a change for the parking meters, because we were going to do a little Christmas shopping when we were the only people in the stores. So we went to Pete's Coffee, had a nice extra cup of strong coffee. So already I've loaded myself up with more alcohol than usual because I'm normally zero alcohol in the daytime. I'm working and then I have a little extra caffeine. Um, then. When we got done with our shopping, I headed to the health club and did a very intense isometric workout. I was doing a lot of CrossFit workouts back then. There has been an association of intense isometric workouts with spells of atrial fib, and I put myself into atrial fib and work out that I will describe gently as above my pay grade. But to my credit, because I am a stubborn mule, I finished the workout.
[00:23:04] Andrew Benn, MD: I recognize that I was still in atrial fibrillation. Also in dense denial, I drove myself to the emergency room, which I am not advocating on this podcast, but I did. I was breathing fine. I just felt like my heart was jumping around like there was a trout farm in my chest. And I walked into the emergency room and they all said to me, Doctor Benn, you're not on call. What are you doing here? And I said, I'm an atrial fibrillation, to which repeatedly they would go, shut up, take my pulse and go, you're an atrial fibrillation. I'm like, I told you, the high adrenaline, which we talked about as it relates to illness, my adrenaline was sky high because that workout was just so hard for me, and there was no way medicines were going to get me out. So my partner Chris came in, he cardioverted me, and, uh, I've not had atrial fibrillation since. Um, so what I think I illustrate there is dehydration, high isometric exercise, maybe above my pay grade. It's a really strain in the system. Alcohol? Not a lot, but more than zero, which is my normal daytime consumption and more caffeine than I was used to a normal one cup a day guy. Then I was suddenly a couple extra shots of Pete's, and so I was kind of setting myself up on a how to manual on how to put myself in atrial fibrillation.
[00:24:17] Carolyn Lacey, MD, FACC: You did a great job on setting yourself up for.
[00:24:20] Group: You went all, you went all.
[00:24:22] Carolyn Lacey, MD, FACC: You went all out on that one. Go big or go home. There you.
[00:24:25] Group: Go. All right. That was thank you for sharing that.
[00:24:27] Matthew DeVane, DO, FACC: Thank you so much for sharing that information and for all the good information for our patients. And we look forward to having you back for more episodes. Thank you, Doctor Benn.
[00:24:37] Andrew Benn, MD: You're most welcome.
[00:24:41] Matthew DeVane, DO, FACC: This is Doctor Matt DeVane and on behalf of my co-host, Doctor Carolyn Lacey and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.
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