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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. Welcome to another episode of Living Hart Smart. I'm here today with Matt and one of our special guests. He's one of our partners who's been in the area for 32 years. We're going to introduce him in a in a minute here. We're going to start talking today about atrial fibrillation. Start diving into this extremely huge topic.
[00:00:50] Matthew DeVane, DO, FACC: Yeah Carolyn I'm really excited about this. This is a a big part of what we do now. And a lot of our patients have a lot of questions. And really this will lend itself very nicely to us bringing together. And we've heard some great feedback from our patients. And so we appreciate that. I hope you guys keep listening and give us feedback. But atrial fibrillation is a topic you wanted to hear about. So we're going to dive deep into it. We're going to bring you probably do seven maybe eight episodes. We're going to bring in Electrophysiologist, general cardiologist and even a structural cardiologist to talk about some of the newer procedures. But we're going to start with the basics, because you got to know the basics before we get into a lot of the treatment and the nuances. So we're very excited and we're going to thank our partner for being here. Please introduce them now.
[00:01:35] Carolyn Lacey, MD, FACC: We're here today to talk to one of our partners, Doctor Andy Benn. He's been in the area in the East Bay area for 32 years at this point. But he's a native Chicagoan. He came out to Stanford to do his undergraduate degree and then went back to Chicago, University of Chicago to do internal to do medical school, internal medicine, cardiology training. He has great advice for his patients, and we're really happy that he's here with us today. Thanks for being here. Yeah.
[00:02:01] Matthew DeVane, DO, FACC: Welcome, Andy. Thank you for being here.
[00:02:03] Andrew Benn, MD: Thanks for having me.
[00:02:04] Matthew DeVane, DO, FACC: We're going to talk about AFib kind of this this episode. We're hoping to just do a big overview. So some of the takeaway points I was hoping that our patients could really take away from this 20, 25 minutes, whatever it's going to be is first and foremost a lot of reassurance. We want you to know that if you have AFib, you're going to be fine. You have to go through some testing and some follow ups and some visits, but we're going to take good care of you. It's a team effort. So first and foremost, reassurance. Secondly, we this episode you're going to learn about what atrial fibrillation is and how we're going to start dealing with it. We want you to recognize the symptoms of atrial fibrillation and what to do with those. We're going to talk about some of the common testing that we will do to help identify your atrial fibrillation and how your heart's doing. And then we also just want you to understand that you need to think about atrial fibrillation as a chronic condition. This thing is not going to just come and go. It's going to take some steps. It's going to take visits, and it's likely something that you're going to be living with and you'll do just fine with it. So with that being said, let's back up a little bit and maybe we talk about atrial fibrillation. Like everybody knows what that is. Why don't we just start with Doctor Ben if you could maybe just what is a normal rhythm versus let's say a generic term like arrhythmia, because people kind of know what that term means.
[00:03:21] Andrew Benn, MD: Absolutely. Good question. Matt. Um, if you're listening to this podcast, maybe you've had atrial fib. For the record, I've had it twice. Um, the. Relative of yours that has atrial fib may have sparked your interest, even if you haven't had it, or you've heard the term and wonder if it applies to you. It's sounds very generic. It sounds very non-specific because most of the people listening to this aren't cardiologists, I hope. And. So what we can do is try to understand it together and then understand the issues it raises and how we're going to deal with them. I think you summarized it really well, Matt. It's a condition we can live with. We can live as long and as well as other people. And hopefully in this first episode, I'm going to touch on the two things we do to take somebody with atrial fib and make sure they live as long, and as well as other people that are critical to understand. Arrhythmias to understand normal heart rhythms, to understand atrial fib. What I'd want everybody to do out there is get a piece of paper and draw me a valentine. Draw a picture of a heart on that Valentine. So you'll draw me the two upper humps of the heart. And then you'll come together at the bottom into a triangle.
[00:04:32] Matthew DeVane, DO, FACC: I'm drawing the picture in my brain.
[00:04:33] Andrew Benn, MD: Yes, you forgot me on Valentine's Day. So you're making up for it tonight? Uh, the upper humps are the atria. They're the chambers that receive blood back. The right atrium gets it from the veins, the left atrium gets it from the lungs and the triangle at the bottom of your heart. Picture. Those are the two pumps that do the pumping of the body. Or, excuse me, the pumping of the blood to the body if you're the left ventricle and to the lungs if you're the right ventricle. So when we talk about atrial fibrillation that's an arrhythmia. There are many kinds of arrhythmia. And the specific arrhythmia. Atrial fibrillation will go over in just a second. To understand arrhythmia, where the heart's out of rhythm, let's talk about what happens just for a second. When the heart's in rhythm. In that picture, you drew me of a heart. In the upper right corner is the conductor of the orchestra that conducts electricity from that upper right corner down to the tip of the heart. That's how normal rhythm proceeds. By starting at the top, the atrium squeeze first and the ventricles squeeze second, and they're synchronized. The rhythm of the heart can go out of rhythm in many, many different flavors. You can have extra beats. You can have pauses, you can have many different types of electrical short circuits. And they all get lumped under the heading of arrhythmia.
[00:05:57] Andrew Benn, MD: Why do we call them arrhythmias? Probably because it sounds more erudite than electrical short circuit. But really, that's all it means. Your heart's wandered away from perfectly normal electrical conduction. What happens in atrial fibrillation specifically, is that those upper chambers, the two humps in your picture, they no longer are squeezing, they're electrically quivering, and they're quivering at hundreds of times per minute. You say, well, when I go into atrial fibrillation, my heart rate's not in the hundreds. No, because your body is built with a resistor in the middle of that electrical system that slows the conduction from the top to the bottom. So when you go into atrial fibrillation, with the two atria quivering at hundreds of times per minute, your heart rate is likely more rapid. But it's not in the hundreds. It may be 150, 160. It may be slower, but that gate, the AV node, allows us to have a livable heart rate should we go into atrial fibrillation. So when you as a person having cardiac symptoms or a relative or someone you've heard of has cardiac symptoms and says, I feel my heart beating, it could be atrial fib, it could be any of another any of a number of arrhythmias that are occurring. We'll talk about how we're going to know if it is AFib in just a few moments. But atrial fib is a very specific arrhythmia characterized by no squeezing of the atrium, typically a rapid and irregular heartbeat, typically when people have atrial fibrillation, as I noted a minute ago, they may experience a rapid, irregular heartbeat.
[00:07:40] Andrew Benn, MD: They may not experience their heartbeat at all. They may simply notice, for example, that their heart's beating less efficiently so that things that didn't leave them short of breath are now leaving them short of breath. If their heart isn't pumping as efficiently, they may feel lightheaded. They may feel more fatigued because the heart is working less efficiently. When all four chambers are not contributing to the output, and only the two ventricles are contributing, many patients may be as many as a third. Don't experience any symptoms when they have atrial fibrillation. It's there, but they don't know it. And in fact, in a very important study done years ago, back when they used to call me young Doctor Ben. So somewhere in the Paleozoic era, they. Found that patients. Who say, I feel all of my atrial fibrillation when they monitored those patients, they feel 15% of the atrial fibrillation that they actually have. So they presume that all the atrial fibrillation felt is all the atrial fib. As we talk about atrial fibrillation further, over the next few episodes, we'll use a phrase called the atrial fibrillation burden. What that means is what percent of the time are you in atrial fibrillation? And as we think about the burden, we'll look at both how big that burden is and how long the episodes are, because that will be relevant to some of the decisions we make.
[00:09:02] Andrew Benn, MD: Some people get atrial fibrillation in short spells, some people get atrial fibrillation as occasional spells, but that's hard for them to get out of. We call the first type of patient that I spoke of paroxysmal atrial fibrillation, just meaning spells of atrial fibrillation. When it sticks around as it comes, we tend to call that persistent. And some people live their whole life in atrial fibrillation. And again, as was mentioned by Matt earlier in this podcast, they'll live as long and as well as other people, as long as you do two things. One, protect them from stroke. And to make sure that their atrial fibrillation rate is not out of control. And we'll touch on each of those. So when I see a patient with atrial fibrillation in my office, the first thing I want to reassure them is you can live long and well with this, but we've got to partner up. We can't ignore issues, but we've got to tackle them together. And when I see a patient with atrial fibrillation, there's always the same four issues. And those questions are number one why did I go into atrial fibrillation.
[00:10:11] Matthew DeVane, DO, FACC: Everybody wants to know why. Yep.
[00:10:13] Andrew Benn, MD: Number two how do I protect against stroke. And we'll talk about how atrial fibrillation and stroke tie together in a moment. Number three what can be done to keep me out of atrial fibrillation. If you're one of those patients who's having it and spells as opposed to chronically. And four how do we slow down the rate of my atrial fibrillation when I have it. Do I even need to do something to slow it down? Maybe it's naturally slow on its own. A lot of patients who come into the emergency room will feel fine with their atrial fibrillation even before they convert back to normal rhythm, as long as you slow the rate down. Typically, in an E.R., your monitors over your head, you can't see it. And patients will say, oh, did I come back to normal rhythm because I feel so much better? And you'll say, no, your atrial fibrillation rate simply slow down, perhaps from 160 when they walked in the emergency room to 80 beats a minute. And it really illustrates how for patients chronically, just taking control of their atrial fibrillation rate may eliminate a lot of those symptoms. I spoke of a couple of minutes ago.
[00:11:22] Matthew DeVane, DO, FACC: Andy, that was a fantastic beginning to this AFib story. I just want to take a pause here for one second and maybe summarize a couple of things that you said that are so important that our patients really need to remember. And the first thing is just symptoms. So most of you will have symptoms with AFib. And we call the main symptom really palpitations, which is you feeling your heart racing or skipping or jumping. And as Doctor Ben mentioned, that's not always atrial fibrillation. But many times atrial fib does cause that it may just cause breathlessness or shortness of breath or decreased, um, feeling of more breathlessness with your usual activities then you may feel or even just kind of fatigue. So symptoms can be not overwhelming. They can be subtle. So you need to be aware of those. And the other important thing that Doctor Ben mentioned was that up to 30% of you will have zero symptoms. And the first symptom therefore could be something bad like a stroke. So for many of you who feel good, make sure you're always going to your yearly physical exams, your PCP. Get that yearly EKG, because that may be the only way you know you have AFib, especially if you're above the age 60.
[00:12:32] Andrew Benn, MD: I think the the next thing to point out, Matt, after that very good recap, um, was how did we get to the impression of atrial fibrillation in any one patient?
[00:12:42] Matthew DeVane, DO, FACC: The patient. How do we make the diagnosis?
[00:12:44] Andrew Benn, MD: Yeah, exactly. Um, sometimes it may be an examination. Uh, a physician, nurse practitioner, or PA is examining you. Notices a pulse. That is what we call irregularly irregular. There's no pattern to the cadence. It's all over the place. Um, you may feel the same thing. You may feel a heart that's irregularly irregular, or you just experience it as palpitations, an irregularity of your heart. You may be wearing a watch that throws out a signal to you that says, I think you're an atrial fibrillation. At the end of the day, the common road that holds all those pathways together is the EKG. Um. You may. That practitioner who heard your heart being irregular may get an EKG. That person who wears the Apple Watch. That said, I think you're in a fib with the more modern Apple Watches or a competitor can activate the EKG function, and those cardiograms have a lot of fidelity. They can really give great information to a practitioner like me when the patient walks in the door to confirm the diagnosis.
[00:13:49] Matthew DeVane, DO, FACC: I've been amazed at the progression of the of the technology within the smartwatches, that they really are pretty darn good. They're picking up AFib all over the place.
[00:13:58] Andrew Benn, MD: They sure are. Yeah. And when someone comes in with AFib. Uh, whether that was found by another practitioner, felt by themselves. And somebody did a prolonged recording to see how much atrial fib they had, will still be left with two questions about their atrial fibrillation, specifically, are they in it all the time or sometimes if they were in it at their primary care doctor's office, does it come and go? They may feel it coming and going, but does it really come and go? And we'll also want to know, because we said this was very important in their long term management. What's the rate when they're in atrial fibrillation. Is it under reasonable. Control. So typically, all these avenues of getting an EKG lead to a pathway of what is often more prolonged recording what we called in my med school days, a Holter recording where you wore a box on your waist for a couple of days and it recorded all your beats, is giving way to more modern technologies, typically patch technologies from various companies that allow us to record for longer periods of time, bigger sampling. To answer those two questions how much AFib am I having? What's the rate when I'm in it? And of course, because it's recording all your beats, what other beats am I having? Right? Those recorders also offer the opportunity for the patient to notify us, reading those recordings as to when they're symptomatic, because what you may find in some patients is that their palpitations are not due to the AFib they're having, but rather due to some other rhythm. And that may shape your management of the patient.
[00:15:44] Matthew DeVane, DO, FACC: Yeah. The home monitoring that we have now, we just mail those to your house. You can wear them for a week or two weeks depending, and then mail it back to us and we can get all that very important information, um, very quickly, very efficiently. Yeah. It's pretty pretty cool.
[00:15:58] Andrew Benn, MD: Absolutely.
[00:15:59] Matthew DeVane, DO, FACC: Carol and I were just talking earlier about, um, how it's so interesting that people have a tough time understanding how they can have AFib come and go. What we call paroxysmal atrial fibrillation doesn't really make sense to a lot of people.
[00:16:13] Carolyn Lacey, MD, FACC: I don't I don't understand how does this come and go? I was in AFib, but now I'm not. It must be gone. I'm asked that routinely every day, actually.
[00:16:23] Andrew Benn, MD: You know, at some point to one of the earliest points made in this podcast, we shifted in medicine from acute illness over a short block of time. Think pneumonia. I have pneumonia. I took a week of antibiotics. It was there. It's done. We shifted in medicine from a focus on acute illness as the populations age to chronic illness. Atrial fib. The number one reason a cardiologist has been consulted in a hospital. It's almost 20 years running now. When they. Whoever calculates that stuff. But it doesn't surprise me.
[00:17:00] Matthew DeVane, DO, FACC: I knew it felt that way. I didn't know the data supported it.
[00:17:02] Andrew Benn, MD: There is data actually to support that. And uh, to chronic illness. That is Matt. So uh, spoke so well to which was we control illnesses, we help patients live long and well with them, but they don't go away. You still have to keep an eye on them. Congestive heart failure, hypertension, high cholesterol, artery disease, atrial fib are all cardiac illnesses that we manage but we don't cure like a pneumonia. So you're right. People do have this impression. And for some patients, some patients atrial fib is a one and done. If you look at the number of patients who have atrial fib, 5% of patients with atrial FIB have nothing else to explain their atrial fib. They have no other structural heart disease. And we'll touch on what that means in a bit. They don't carry the other risk factors for atrial fib, like hypertension or diabetes or sleep apnea smoking. They're just atrial fib because and we call those patients low atrial fib. And if you look at them longitudinally in large studies, population based studies, about half of those lone atrial fib cases will recur within the next few years and half will never recur again. So there is a small group of people where atrial fibrillation is one and done. But it's such a small exception. You're talking about half of a 5% that you really can't base your care on that. Um, at least not long term. Uh, short term if the patient doesn't have other risk factors and it was one and done, you may sit tight and not do too much more for that patient. Depends on what other demographics are present in that patient. What other conditions are present.
[00:18:47] Matthew DeVane, DO, FACC: It seems like the one and done thing is so is becoming smaller and smaller and smaller over time. And it's almost like what something called the holiday heart syndrome, where a young person may, you know, binged, binge drinking or, you know, first they drink caffeine for a week studying for finals, and they go out and binge after finals. And next thing you know, they're in AFib. So things like that do happen. But for the majority of people that we see in our daily lives as adult cardiologists, that fraction is really, really shrinking. It's almost AFib is holds hands with a lot of other cardiology issues.
[00:19:22] Andrew Benn, MD: It does. And what happened, Matt, was I think the lone atrial fib hasn't grown as a population. And you alluded to some of the things that make up that lone atrial fib population, the holiday heart syndrome, the caffeine abuser, um, whether it's transient or chronic, uh, but the other 95%, that population is growing. So what appears to be shrinking to you is probably a static population, while the other 95% are growing exponentially as the population ages and getting more and more delusional on that 5%.
[00:19:58] Matthew DeVane, DO, FACC: Good point. Yeah. I think right now they estimate the number of AFib cases in the US at around 2 million. And just and by 2030 they're saying it's going to be up to 12 million. So yeah that population continues to grow.
[00:20:13] Andrew Benn, MD: You're right. By the time you're 80. As data has said, being an atrial fib or having atrial fib is as common as being left handed. And as you pass 80 it goes to two and three x being left handed.
[00:20:24] Matthew DeVane, DO, FACC: So only left hander could throw out only data.
[00:20:28] Carolyn Lacey, MD, FACC: But I'm left handed and I didn't. What's the what's the rate of being.
[00:20:32] Matthew DeVane, DO, FACC: You're both left handed. Oh my God.
[00:20:33] Carolyn Lacey, MD, FACC: There's two of us in this room that are left handed.
[00:20:35] Andrew Benn, MD: A third of my med school class was left handed. We all fought over those left sided desks that were on the edge of the row. The rest of the. It was really weird. We looked like a cult that lined up on the left side of every aisle.
[00:20:48] Group: Oh my gosh, I believe that.
[00:20:50] Carolyn Lacey, MD, FACC: Yeah, I can see that. Yeah, because you need the space.
[00:20:53] Matthew DeVane, DO, FACC: Let's back out a left handedness, you two goons.
[00:20:55] Carolyn Lacey, MD, FACC: Andy I think that that was great, I really do. I think it's really important to just sort of remember that when we're diagnosing atrial fibrillation, we need an EKG. You have to have a 12 lead EKG to make that diagnosis. And that's going to lead to some more testing. And I think it's really important for people to understand that such a small amount of atrial fibrillation that we see is actually what we call the lone AFib. There's a lot of other company that atrial fibrillation keeps, like you talked about with just aging, hypertension, heart failure, coronary disease, those things. And so keeping that in mind as a chronic condition I think is really very, very important. I, I'd like to talk more about some of the testing that our patients can expect when we see patients with newly diagnosed AFib. This is the first time we've discovered it. What are some of the tests that you commonly are telling your patients you want to order?
[00:21:49] Andrew Benn, MD: Great question. The as I mentioned earlier, there are four issues when I see a patient with atrial fib. One is how did we get here? How did we get to atrial fibrillation, whether it be in spells or we're still in it. The first question I ask underneath that banner is, how's the rest of your heart? If you think about a heart the way an engineer would draw it, they would tell you it has four parts, but not the four chamber stuff we talked about earlier. They tell you it has four functioning parts. They tell you it has a timer. The timer drives the heart to go beat, beat beat. And when it does, it's telling a muscle to go pump, pump, pump. Because all the heart is is a fuel pump. The fuel is called blood and the heart pumps it to the whole body, including itself. When it does, there are doors that open and close to let blood flow be one directional, a good idea, and not too directional a bad idea. Those doors are called valves. Why do we call them valves? It sounds more expensive than doors. When the heart pumps, it pumps into a big supply hose called the aorta. The aorta is like a water main on your street. It gives off a branch to every house.
[00:22:55] Andrew Benn, MD: The aorta gives up branches to every organ to deliver their blood supply. The first branches come right off the base of the aorta, back around the heart. The heart saying, hey, I'm taking my supply first because if I don't get mine, you don't get yours. So when we look at the rest of the heart, what we mean is you're an atrial fib. That's your timer story. But how are your muscle, how the valves, how the arteries? If you're 35 years old and have no cardiac risk factors, we may not take your arteries as a high risk factor. Part of that's going to be based on your own medical history and what you're bringing to the case of atrial fibrillation. We're always going to want to check out the heart muscle and the heart valves. And almost always that's going to be with an ultrasound of the heart. We call that an echocardiogram. But it's just an ultrasound, literally the same machine that they use to look at babies when moms are pregnant. We might do some stress testing because, as Carolyn mentioned just a moment ago, one of the associated conditions with atrial FIB is coronary artery disease. And if you're in an age group where that's common or you carry risk factors that are common for artery disease, such as high blood pressure or diabetes, smoking, high cholesterol, we're going to be suspicious that there may be artery disease there.
[00:24:10] Andrew Benn, MD: So some form of stress testing and there's many to choose from for the doctor and an ultrasound of the heart or how we're going to look at your heart. Structurally, we already mentioned that we would likely do some electrical testing, like the patch that Matt spoke to, because we want to understand that atrial fibrillation burden. We want to understand the rate of the atrial fib. What else are we going to look at? Couple things. One, we're going to want to check your thyroid function tests. It took four days for them to figure out that President George H.W. Bush was hypothyroid when he went into atrial fibrillation in 1991, probably because the medical student was finally able to speak and said, maybe we should send thyroid function tests. But that's why he went into atrial fib. Same reason Dan Quayle was your president for 20 minutes when he got cardioverted. Yes, that is true, doctor DeVane. They swore Dan Quayle in sedated the president. And when he woke up, they swore him back in nice. A little bit of presidential history there on this podcast.
[00:25:10] Group: That's pretty cool.
[00:25:11] Andrew Benn, MD: So. We'll certainly check the thyroids. Also, there's an interesting association between sleep apnea and atrial fibrillation. You can never do a study to look. If treating sleep apnea makes atrial fibrillation go away because you can't not treat somebody's condition, who has it? But what is known is this one. If you have sleep apnea, you're three times more likely to get atrial fibrillation than other people your age and with other medical conditions you have. And number two, if you show up with atrial fibrillation and I do a sleep study on you, you're three times more likely to have sleep apnea than other people your age who don't have atrial fibrillation. If. And remember this for when we do the atrial fibrillation ablation episode. If you treat somebody sleep apnea versus if you don't, the likelihood that an atrial fibrillation will be successful in the long term improves forex if you treat their sleep apnea. So a tidbit from the kind of deep bowels of the medical literature that's important to remember. That's something you can do as a listener. If ultimately you come to atrial fibrillation ablation to help yourself to make the procedure more successful. Coming back to that notion that was brought up at the very beginning of this podcast by Doctor DeVane, which is this is a team approach. You get your paddle in the water, we get our paddles in the water, and we succeed together. So summarizing, testing, you can expect echocardiogram. Very possibly a stress test. Thyroid function tests. Probably a sleep study resume.
[00:26:51] Carolyn Lacey, MD, FACC: We've had some really great information that we just started scratching the surface with atrial fibrillation. And I think when we when we start thinking about atrial fibrillation, I think what we all want our patients to know is that. This is going to be okay. This is a livable condition, even if it is a chronic condition. People live normal lives with atrial fibrillation. It does take a little bit of testing up front, but there you're going to be okay. Like Matt had said originally at the beginning. And it really is a matter of starting to think about, like Doctor Ben said, about paddling together with your cardiologists, about how we're going to treat this, the things that you can do, the things that we can do. We're going to touch on that in further episodes. Andy, thank you so much for being with us. I. Wish that in the office we would have time, like we do here, to just talk about atrial fibrillation in the way you do. So I hope that this is really helpful. I'm going to steal some things. I want you to know that. But I'm just really grateful to hear how you talk to your patients.
[00:27:59] Matthew DeVane, DO, FACC: And we're thankful for sure and look forward to having you on more episodes. 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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