Atrial Fibrillation SOC: An Electrophysiologist Review [2022]

Atrial fibrillation (also called Afib) is an interesting disease. I would say it's probably the most complicated cardiovascular disease. That probably stands in line with atherosclerosis, right? So when you really talk about atherosclerosis, a lot of work has been done in this space for decades.

Secondary prevention, primary prevention, tertiary prevention, and genetic melio risk factors are all factoring into the equation. Similarly, the exact same risk factors that you really talk about at risk are also potential contributors, for the most part, for the atrial population as well.

And it is not a case where it just comes and goes away once you try to tackle it one time or two times. It is a systemic disease that is driven by underlying risk factors.

Atrial fibrillation (also called Afib) is a lifestyle and genetic condition that must be constantly modified and worked on in order for us to truly master atrial fibrillation (Afib). And really, to get anything meaningful in terms of success and control is a concern in treatment.

So rhythm disorder affects anywhere from five to six million people in the United States right now. I think it is equally important. With a significant burden on quality of life, stroke, congestive heart failure, and increasing tendency towards dementia, I think it is equally important. By all measures, this is probably the most important cardiovascular condition that we are dealing with now as part of atherosclerosis.

Please Review The Current Standard Of Care For Atrial Fibrillation (Afib)?

When you talk about atrial fibrillation (also called Afib), right? So there are three fundamental things that we take into consideration. People are obviously protected from the risk of strokes, since atrial fibrillation (Afib) (irregular heartbeat or heart beats) is a thrombogenic situation that contributes a lot more to both ischemic and embolic strokes.

So oral anticoagulation (treatment) based on the risk factor profile and arrhythmia burden is an important facet of it. So you have a plethora of oral coags that are available for treatment. And then the next important part is that for those patients that have very rapid ventricular rates or heart rates, how do you really slow down the heart so that it doesn't impact or minimize the impact on cardiovascular physiology?

Cardiac emptying, ejection fraction, and all those are important when you are considering a patients treatment. This is where medications like beta blockers, calcium channel blockers, and the ACS come into play.

And then you talk about rhythm control, which is where restoring the sinus rhythm means suppressing atrial fibrillation (also called Afib) and allowing the sinus node to take over or take control back and restoring the rhythm with the help of a drug.

Or rate frequency, cryoablation, or catheter ablation in general, is something to think about. So there are three fundamental tens. The first is the rate control anticoagulation strategy with AV nodal blockers for stroke prevention. And rhythm control, either with an antilithic drug and or catheter ablation, first line, second line, depending on whatever you have access to, I think would be the three important things to think about.

How Do Electrophysiologists Diagnose And Find The Right Treatment For Atrial Fibrillation (Afib (Heart)) Patients?

So, it's a hand and glove experience, right? Our general cardiology colleagues see a lot of the disease. They're the purveyors of general cardiovascular care and treatment. Electrophysiologists are more focused on arrhythmia care. As a result, it is critical for both the general cardiology and electrophysiology teams in a given setting to collaborate closely.

Depending on who sees the patient first, the other team needs to get involved in this patients treatment. For example, imagine a scenario. My general cardiology colleagues see a patient with atrial fibrillation (also called Afib) (irregular heartbeat). They have done everything that they needed to do, like getting the patient on an anticoagulant treatment and making sure that their ventricular rates are properly controlled with the right doses of blockers.

They've already initiated a drug, but then they're also simultaneously thinking about how do we expedite this patient's care so that we can actually decrease the burden of arrhythmia and the complications of arrhythmia that come out of it, because the old school thinking that somehow if you put a patient on an analytical drug, you really don't need to do anything else, has really gone away, right?

Atrial fibrillation (Afib) is a chronic condition, and it is not a question of if a patient is going to fail an analytical drug treatment. It's a question of when a patient is going to fail a drug treatment. So when you know that you are inevitably going to fail, which is the analytical drug that you're going to use, then what's the point of actually waiting until the drug fails? So you really need to have a strategy in place while I'm going to use this antarctic drug as a bridge to temporize the situation. and get my patient back into normal rhythm so that they don't have to pay the price of not being in rhythm. But I'm also making a choice that would help my patient to really fix this arrhythmia in a more definitive, curative fashion, which is where the catheter ablation comes into place for treatment.

It's wonderful to see that a large number of our general cardiology colleagues are thinking along these lines right away. They use the acute bridge with their antilithic drug treatment to get them temporarily stabilized. And then send them over for a catheter ablation to an electrophysiologist, but for the conversations at least about catheter ablation and really getting these (af) patients taken care of so that they don't have to be on antilithic drugs the rest of their life, so that they don't have to be on anticoagulation the rest of their life.

And also, discussing strategies like left rachel appendage occlusion and left rachel appendage management really becomes an important piece and parcel, on the other hand. I get to see a patient with atrial fibrillation (also called Afib) (irregular heartbeat) first, right? Then I consider, okay, I know I can get them rhythm control catheter ablation.

But then my patient has all these risk factors that need to be appropriately managed. They have really uncontrolled hypertension. They have dyslipidemia that needs to be addressed. They have diabetes, they have congestive heart failure. All of these things are not in my area of expertise. My general cardiology colleagues have a lot more expertise in taking care of these things. And so a tight conducive collaborative effort between the cardiologists  and  That, I believe this is critical in truly managing conditions such as atrial fibrillation, which is truly a team sport rather than an individual one.

What Are The Most Common Symptoms of Atrial Fibrillation (Afib)?

It's a symptom is an interesting question, right? So I would say about 80% of (af) patients have symptoms of some form, or most of them are driven by rapid heart rates. That is, you feel palpitations because your heart is racing so fast. People recognize it immediately and then try to seek help.

And then, in some cases, it's just shots of breath, fatigue, being tired all the time. These are a little bit subtle. Symptoms frequently lead to a significant pedal because PE patients do not recognize the symptoms of heart failure or fatigue that they are experiencing.

But they don't feel a rapid heart rate, and the only symptom they have is fatigue. Most of the people, they are of an age where they think, "I'm just getting old and that's the reason why I'm not able to do what I'm able to do." That's the reason why a lot of these (af)patients don't seek help right away.

And these are the people that I really worry about quite a bit. And these are the (af) patients that often end up in the hospital with a really bad episode of heart failure, right? Because they have not sought any clinical help until they're really broken down, right? Until their hearts really gave up to the point where they said, "I can't take this anymore and I'm developing congestive heart failure."

Or somebody is presented with a stroke. It's unfortunate. A large number of (af) patients that present with a stroke are the ones that have atrial fibrillation (also called Afib) (irregular heartbeat), which is relatively silent. That means, I have mild symptoms or no symptoms. The only thing they notice is the first presentation of stroke, which I think is a terrible thing.

And then you have scenarios where people have really readjusted their lifestyle to things, right? Human beings are very adaptable. If you think about it, We stop doing things that we're not able to do, and you slowly kind of decline. And this is a group of people that we need to be. Be extra careful about asking them pointed questions, especially if they have a higher risk profile and a family history of atrial fibrillation (Afib) (irregular heartbeat).

We have got to be asking them very specific questions. One particular symptom that I find extremely helpful is what I call "the climb botany." So there are (af) patients that say, "Gosh, I really don't have any symptoms from my AFib (irregular heartbeat)." But I get into trouble when I try to climb a staircase. This is very important because climbing stairs is a physical exercise that really tests your cardiac endurance in many ways.

So it's actually an important test in heart failure patients. It's an important test in coronary artery disease. And it's also a very important test even for atrial fibrillation (also called Afib) (irregular heartbeat(af)) patients who otherwise say that they don't have any effect. Now, this is how I uncover symptoms in a lot of my patients by asking one question about dyspnea upon climbing a staircase.

What Can Help Patients Get Early An Diagnosis Of Atrial Fibrillation (Afib)?

When you think of care equity, right? If you are fortunate enough to live in a major city with access to numerous medical care institutions with well-developed programs where you can seek help right away, your story is very different from that of patients who live in inner cities, rural areas, or other areas where access to care is significantly different.

So when you really take the patient into consideration and really talk about health equity, we have got to think about how we can educate our patients better, right? How do we empower them with the knowledge that they really need so that they can make better informed choices about their therapy? If you really look at interventions or definitive therapies offered in medicine, the socialness of health really plays an important role in this, right?

So if you are a woman, if you are a person of color, if you are from a lower socioeconomic status, if you are from the inner city, if you are a rural patient, your ability to seek a particular definitive curative therapy is many times lower than somebody who doesn't fit that profile. And it is becoming very well established in many aspects of medicine.

That also includes cardiology, and that also includes access to ablation. So, as doctors, what can we do to shift the paradigm? What can we do as hospitals, healthcare institutions, or professional societies like the Cardiology Society, or ACC, or others, as a society in general? What can we do? To address and mitigate these inequalities that tend to be inherent to what we do on a day-to-day basis, right?

Access to care is an important facet of that. We educate our patients really well, whether it is social media, whether it is at the primary care physician's office, whether it is in the cardiologist's office, or whether it is special months like the AFI awareness month, like September, where you really launch a mass campaign and really work with the social media giants like Google on Twitter, someday on Instagram, and on Facebook to really make education an important piece of what we do.

And then there is something that you can do to change the paradigm of health inequity, which is how do you really tweak little things in workflow, right? Hundreds of patients, thousands of patients that come through the emergency rooms or primary care physician's offices. And these patients don't have access to care once they leave that emergency room or they don't know what to do once they leave that emergency room.

And this is where the ER to EP concept that we developed and worked upon as a pilot project really fits in very nicely in eliminating some of those health inequity related factors by leveling the playing field and taking away the hurdles and barriers to care in a significant fashion. Any opportunity that you have, if you as a patient come into a medical healthcare delivery system and you have a diagnosis of atrial fibrillation (also called Afib) (irregular heartbeat or heart beats), how can we facilitate that patient's care and really put them through rapid transit so that they get into the hands of a neurophysiologist for definitive care and get help right away, rather than going through the roundabout process of having to make an appointment with a primary care physician.

And then the primary care physician has to refer this patient to a cardiologist, and the cardiologist then has to refer the patient to an electrophysiologist, which typically consumes anywhere between nine to 12 months of that patient's process flow. While we are We are trying different medications and trying to figure out what works and what doesn't work while we are exploring these options.

So how do we really eliminate these barriers and then provide straight, easier access to definitive care by putting them in the hands of the electrophysiologist when you have an opportunity to do that? So that's exactly where the emergency room meets electrophysiology as a concept and really makes a huge impact on patient care, right?

We spend millions of dollars inventing new catheters and new energy ablations and different things to really change the needle with a very small game. But when you look at the process flow, you can eliminate a lot of these inequities in care and improve access to care by streamlining the process with a very simple order.

So Lira Pure Electrophysiology services and eliminate the barriers. The moment they step into the ER or into a private care physician's office, how can you get them into the hands of an electrophysiologist who can see them and provide them with definitive care? That's essentially a winner. And we have very clearly shown that in our study.

What Is The Future For Atrial Fibrillation (Afib) Clinical Trials?

I think there are trials that we are working on multiple fronts. There are clinical trials that we're looking at a molecular level, whether you're talking about the new antilithic drugs or gene therapies for those patients who are genetically prone. Or you talk about newer forms of energy and new forms of catheters.

Pulsed field ablation is an exciting area that is really at the forefront right now. There are probably about 15 to 20 companies that have some form of pulsed field ablation technology or other that they're working on. And then you have therapies in the left atrial appendage management for stroke mitigation.

And then you have the whole area of risk factor modification. This is an area where the medical establishment has historically lagged behind, particularly in the Western world, particularly the United States. We haven't really done a good job with the primary prevention or secondary prevention, of really tackling the risk factors, whether it is exercise, obesity, or obstructed sleep apnea, and really getting aggressive with it and really creating a comprehensive Therapeutic opportunities, I think, are the next area. There's a lot of work that's coming out. And then, right, you have the whole social perspective of what we have done with ERPP, right?

I think removing barriers to access to care is an important facet that has to be worked upon. So it's actually wonderful to see that you have clinical work or research that's going on from a micro-molecular level all the way up to workflow processes and things like that. There are various people that are working on these concepts and a lot more exciting work that I think is going to come through.

Final Thoughts On Atrial Fibrillation (Afib)

I say atrial fibrillation (Afib) (irregular heartbeat or heart beats) is a chronic disease. We have great morbidity and mortality, and we really need to work together, and rather than worry about the territoriality of who's in charge of what, it doesn't really matter who sees this patient first. Isn't early intervention preferable to late intervention?

Thinking about the old at the age of a stitch in time saves nine. The longer we wait to get patients back into rhythm, the more difficult it is to care for these patients in the future, and the cost is quite high. He was working together as a team, keeping the patients in. At the heart and front and center of what we do, I think this is the most important thing for us to do.

What Led You To Study Electrophysiology and Atrial Fibrillation (Afib)?

I was always fascinated by medicine. I was probably inspired by my family doctor back in India. This guy literally saved my life from malaria, which was about to kill me. Right? Talk about dying from the most preventable causes of things in life, right? And that really was, I would say, a propelling factor in my personal desire and journey towards becoming a doctor.

And I was always fascinated by the intricacies of the human heart and just the critical nature of what cardiology meant. So, in medical school, there were many mentors who were inspiring cardiologists who clearly provided me with mentorship and inspiration. And then, during my implementation years, I always imagined myself as a plumber and an interventional cardiologist.

But then I changed my mind in my very first clinical rotation in cardiology as a cardiology fellow. I was given the opportunity to rotate through EP very early in my very second month. And the mentors there that I met were just incredible. And this was right around the time when radiofrequency ablation for atrial fibrillation (also called Afib) was really coming to the forefront in a big way.

At my very first AHA (American Heart Association) meeting in 2002, there was this massive meeting of the minds in a large lecture hall, with some of the space's thought leaders at the time discussing how they could actually curate atrial fibrillation (Afib), right? Leave it alone, just control it, atrial fibrillation (Afib) (irregular heartbeat or heart beats). I think that was a very fascinating experience to really see as the pulmonary veins get isolated, the atrial fibrillation (Afib) terminates, and then you have fibrillating pulmonary veins with normal sinus rhythm in the atrium of the heart. That's a very fascinating experience.

And that was a day I thought, oh gosh. I really need to be one of those docs that are sitting on this podium. and really be able to be part of this journey of understanding, innovating, and fixing atrial fibrillation (Afib). And that's my journey.

Dhanunjaya Lakkireddy, MD - About The Author, Credentials, and Affiliations

Dr. Dhanunjaya Lakkireddy is the medical director of the Kansas City Heart Rhythm Institute at HCA Midwest Health. Dr. Lakkireddy performs the sinus node sparing hybrid ablation technique to cure symptomatic, drug-resistant inappropriate sinus tachycardia (IST).

He specializes in electrophysiology, complex arrhythmia management (atrial fibrillation (Afib) (irregular heartbeat or heart beats), atrial flutter, ventricular tachycardia, supraventricular tachycardia), heart ablation, left atrial appendage closure; ablation, pacemaker and other device implantation and management, cardiac resynchronization therapy & pulmonary artery pressure sensors in heart failure, premature ventricular contractions, syncope, adult congenital and inherited heart disease. He's a leader in electrophysiological research and instruction and a university professor. Dr. Lakkireddy earned the Professional Leader of the Year award from the Asian Chamber of Commerce, the Prevention Magazine Integrative Medicine Award, and the Ingram's Heroes in Health Care Award. His honors mostly recognize his clinical research. He still leads clinical studies and investigations internationally. His electrophysiological research has appeared in 350 journals. Dr. Lakkireddy is also editor-in-chief of Journal of Atrial Fibrillation (Afib) and deputy editor of Journal of Interventional Electrophysiology. He reviews for more than 30 scientific journals, including the American Heart Journal, American Journal of Cardiology, Clinical Cardiology, Heart Rhythm Journal, and Journal of Interventional Cardiac Electrophysiology. Kansas ACP Governor. He's active in cardiology groups. He chairs the ACC Electrophysiology Council and is on the HRS Program Committee. He speaks in national and international heart conferences. Dr. Lakkireddy works for HCA Midwest Health in Kansas City, Missouri, and Overland Park, Kansas.

Men vs. Women - What’s the Difference?

It's possible that you feel that men and women have an equivalent amount of cardiac awareness. However, the findings of the research point to the fact that this is not the case.

What are the symptoms of a sudden cardiac arrest? Are they distinct from heart attacks?

The primary symptom of a sudden cardiac arrest is the sudden loss of consciousness with an absence of breathing or pulse. Some patients have heart attacks before or during their sudden cardiac arrest. As such, heart attacks—blocked arteries of the heart—are a common cause for sudden death. A person suffering from a heart attack can have chest pain; weakness; discomfort in the jaw, neck, or back; and shortness of breath. A heart attack can trigger an electrical malfunction that leads to cardiac arrest. Demetri Yannopoulos, MD from the University of Minnesota Medical School and M Health Fairview

In the United States, heart disease is the top cause of death for women of all ages, ethnicities, and sizes. However, women and men experience heart disease differently at times. Diet and exercise go a long way toward preventing heart disease and reducing its progression if the patient already has it.

STEP-HFpEF Phase 3 Clinical Trial

This study will examine how heart failure impacts the participants' daily lives. The study will also examine the weight change of the individuals from the beginning to the conclusion. The purpose of this study is to assess the effects of Semaglutide (a novel medication) on heart failure symptoms and body weight between persons taking semaglutide and those taking a placebo. The participants will either get semaglutide or a placebo; their treatment will be determined by chance. Once each week, participants will need to receive an injection. A tiny needle is used to inject the study medication into a skin fold in the abdomen, thigh, or upper arm.

During the course of the study, participants will have conversations with the research team about healthy lifestyle choices, such as healthy eating and physical activity.

The duration of the trial is approximately 59 weeks. Participants will receive eleven clinic visits and one phone conversation with the doctor conducting the study. Women who are pregnant, breastfeeding, or plan to become pregnant during the study period are ineligible to participate.

What Is CAD And Who Is At Risk?

Anyone can develop CAD. It begins when fats, cholesterol, and other substances gather along the walls of your arteries. This process is called atherosclerosis. It's typically no cause for concern. However, too much buildup can lead to a blockage, obstructing blood flow. There are a number of risk factors, common red flags, that can contribute to this and ultimately lead to coronary artery disease. First, getting older can mean more damaged and narrowed arteries. Second, men are generally at a greater risk. But the risk for women increases after menopause. Existing health conditions matter, too. High blood pressure can thicken your arteries, narrowing your blood flow. High cholesterol levels can increase the rate of plaque buildup. Diabetes is also associated with higher risk, as is being overweight. Your lifestyle plays a large role as well. Physical inactivity, long periods of unrelieved stress in your life, an unhealthy diet and smoking can all increase your risk. And finally, family history. If a close relative was diagnosed at an early age with heart disease, you're at a greater risk. All these factors together can paint a picture of your risk for developing CAD. Stephen Kopecky, MD, Cardiovascular Disease, Mayo Clinic

Echocardiographic Assessment of Pulmonary Transit Time Following Exercise Phase 4 Clinical Trial

Echocardiography can be used to evaluate the quantity of fluid in a patient's circulatory system, which can affect the diagnosis and treatment of certain types of heart failure. In certain people, the amount of fluid is normal at rest but may increase during physical activity. Therefore, heart failure cannot be identified until after physical activity. 

Currently, fluid measurement is an invasive procedure. Without requiring an invasive procedure, we have proved that echocardiography can estimate fluid in the pulmonary circulation during rest. Now, we want to investigate if a similar assessment can be made after physical activity. In the event of success, certain kinds of heart failure may require fewer catheterizations. 

Echocardiography can be used to evaluate the quantity of fluid in a patient's circulatory system, which can affect the diagnosis and treatment of certain types of heart failure. In certain people, the amount of fluid is normal at rest but may increase during physical activity. Therefore, heart failure cannot be identified until after physical activity. Currently, fluid measurement is an invasive procedure. 

Without requiring an invasive procedure, we have proved that echocardiography can estimate fluid in the pulmonary circulation during rest. Now, we want to investigate if a similar assessment can be made after physical activity. In the event of success, certain kinds of heart failure may require fewer catheterizations.

GUARD-AF Phase 4 Clinical Trial

The purpose of this research is to determine whether or not a detection intervention for atrial fibrillation (AF) or atrial flutter (AFL) in people who are at least 70 years old and have not previously been diagnosed with either condition can reduce the person-years incidence rate of stroke in comparison to standard therapy (no AF detection intervention).

Screening for atrial fibrillation (AF) is desirable due to the fact that AF alone increases the risk of ischemic stroke, that this risk is usually reversible with long-term oral anticoagulation treatment (OAT), and that many patients who have AF go unreported and untreated. Atrial fibrillation (AF) screenings that have been conducted more recently have not led to a discernible increase in the number of individuals who are identified as having AF. In trials of longer-term screening, there has been an increase in the number of patients diagnosed with atrial fibrillation, particularly paroxysmal atrial fibrillation. However, as of yet, there has been no clinical research that has demonstrated that screening for atrial fibrillation reduces the risk of stroke. Screening for atrial fibrillation is encouraged to varying degrees, depending on the clinical practice standards that are being followed.

GUARD-AF is the largest randomized trial for AF screening that uses a patch-based continuous electrocardiographic monitor for a longer period of time. The findings will provide valuable information on the yield of patch-based AF screening, the "load" of AF detected (percent time in AF, longest episode), and physicians' OAC recommendations in relation to AF burden. The stroke and bleed results from GUARD-AF will be included in pooled trial analyses of AF screening, informing future research and guidelines.

Women Found To Be At Higher Risk For Heart Failure And Heart Attack Death Than Men

Identifying when and how women may be at higher risk for heart failure after a heart attack can help providers develop more effective approaches for prevention." “Better adherence to reducing cholesterol, controlling high blood pressure, getting more exercise, eating a healthy diet and stopping smoking, combined with recognition of these problems earlier in life would save thousands of lives of women — and men.” Justin A. Ezekowitz, M.B.B.Ch., M.Sc., is a cardiologist and co-director of the Canadian VIGOUR Centre at the University of Alberta in Edmonton, Alberta, Canada

In conclusion, the research suggests that women are more susceptible to heart failure and heart attack than men. However, regardless of the gender of their patients, doctors should have conversations with them to ensure that their patients are aware of the risks and the factors that can cause this. As time goes on and these studies continue, we will have access to more facts, allowing us to make more informed decisions.

References

1. ClinicalTrials.gov - Phase 3 - Research Study to Investigate How Well Semaglutide Works in People Living With Heart Failure and Obesity (STEP-HFpEF). ClinicalTrials.gov, September 22, 2022

2. ClinicalTrials.gov - Exercise Pulmonary Transit Time. ClinicalTrials.gov,  July 12, 2022

3. ClinicalTrials.gov - Abbreviate or FAST Breast MRI for Supplemental Breast Cancer Screening for Black Women at Average Risk and Dense Breasts. ClinicalTrials.gov, July 13, 2022

4. University of Minnesota - Talking cardiac awareness with U of M. University of Minnesota News

5. Mayo Clinic - Heart disease. MayoClinic, no date of publication

6. American Heart Association - Women found to be at higher risk for heart failure and heart attack death than men. American Heart Association, November 30, 2020