More than Just a Heartbeat: The Truth about Atrial Fibrillation (AFib)

This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Welcome to the show. I am Deborah Howell, and today we'll try to get to the real truth about atrial fibrillation, or AFib. Our guest today is Dr. Nikhil Warrier, an electrophysiologist with the MemorialCare Heart and Vascular Institute at Orange Coast Medical Center. Welcome, Dr. Warrier.

Nikhil Warrier, MD: Good morning, Deborah. Thank you so much for having me this morning.

Deborah Howell (Host): It's our pleasure. All right, the basics. What is atrial fibrillation, please?

Nikhil Warrier, MD: Well, atrial fibrillation, or AFib, is the most common cardiac arrhythmia, particularly once the person reaches the age of 65 years. It represents a major cause of mortality and morbidity, mainly related to stroke and heart failure. During AFib, the heart's two upper chambers, the atria, they beat chaotically, irregularly, and very, very fast, anywhere between 300 to 600 beats per minute. with loss of synchrony or coordination with the lower chambers, the ventricles.

Deborah Howell (Host): And what are some of the possible causes of AFib?

Nikhil Warrier, MD: Well, the risk for developing AFib increases with age. High blood pressure accounts for about 20% of AFib cases. Additional risk factors or causes also include family history of AFib, obesity, smoking, heavy alcohol or caffeine use, stress due to surgery or other illness, diabetes, heart failure, and other forms of structural heart disease, such as coronary disease or valvular heart disease.

Deborah Howell (Host): Roughly how many people in the United States have AFib?

Nikhil Warrier, MD: Well, the estimates of prevalence of AFib in the United States range from about 2.7 million to 6 million. According to the CDC, approximately 2% of people younger than 65 years old have AFib, while about 9% of people ages 65 and older have it. At the age of 80 years, the lifetime risk of developing AFib is quite substantial with a rate of about 22%. And as our population ages, AFib is predicted to affect almost 12 million people in the United States by the year 2050. Basically, this is a growing epidemic.

Deborah Howell (Host): Absolutely. And who, again, is most at risk for atrial fibrillation?

Nikhil Warrier, MD: Well, I know we had previously addressed the risk factors that included age, family history, obesity, and smoking. So let me talk a little bit about how to identify people who are at risk. So, identifying individuals is extremely important. There's stronger evidence that early detection and treatment of modifiable risk factors can reduce morbidity and mortality due to AFib. Our current guidelines advocate that all patients who present with symptoms of AFib should have their pulse checked for irregularities, as well as obtaining a 12-lead electrocardiogram. Prolonged rhythm monitoring may also be useful in patients with heart failure and post-stroke in order to enhance detection and reduce healthcare costs. Recent studies suggested that newer technologies such as modified blood pressure monitors and single-lead electrocardiograms may be more accurate in detecting AFib. In fact, wearable technologies rapidly advancing in this arena with the newest version of the Apple iWatch having an FDA-cleared heart monitor function with the electrocardiogram. This app was launched on the last Apple launch, and it was able to identify over 98% of patients who had AFib and over 99% of patients who had healthy hearts. However, these technologies are just not widely available, and therefore, they're used for population-wide screening initiatives is limited.

Deborah Howell (Host): Wow. Again, we touched on this earlier, but I want to get to it again. The common signs and symptoms of AFib are?

Nikhil Warrier, MD: Well, AFib symptoms often include heart palpitations, shortness of breath, and weakness. Other symptoms can include dizziness or lightheadedness, faintness or confusion, chest pain, and probably the most common symptom that we see from our patients related to AFib is fatigue. Although an irregular pulse may point to AFib, an EKG is still required to confirm the diagnosis. And sometimes a negative ECG just doesn't exclude the diagnosis of AFib since it may be paroxysmal or intermittent.

Deborah Howell (Host): Now the good part. What are the best treatment options for AFib?

Nikhil Warrier, MD: We tailor our treatment to each individual patient, and it usually depends on how long patients have had AFib, how bothersome their symptoms are, and what the underlying etiology or the cause of AFib is. Generally, the treatment goals for AFib are to address the risk of stroke, to prevent blood clots, with blood thinning medications to determine a rhythm or rate control strategy, which can be addressed with medications as well, and then healthy lifestyle changes to manage AFib risk factors, which includes screening at-risk patients for obstructive sleep apnea. The strategy basically depends on many factors, including whether there are other problems with the heart and if patients are able to take medications that can control the heart rhythm. And oftentimes, patients may require invasive treatment for management of their AFib and AFib-related symptoms as well.

Deborah Howell (Host): Okay. And going further, what type of new and advanced procedures are available for someone living with AFib and how do they work?

Nikhil Warrier, MD: Well, sometimes medications or cardioversion, which is an electrical shock to control AFib, just doesn't work. In those cases, we recommend an invasive procedure called catheter ablations. that creates a scar in the area of the heart that's causing the erratic or electrical signal. Approximately 95% of these signals or triggers originate from the pulmonary veins in the left atrium. And our ablation approach tries to address these triggers. In catheter ablation, we insert thin, long tubes through the veins in the leg and guide them into the heart. We use the electrodes at the catheter tips to apply radiofrequency energy to create scar that electrically isolates those pulmonary veins. Oftentimes, there may be additional scar tissue in the heart that could act as triggers, and we try to address these regions as well during our procedure. Another procedure called AV node ablation involves using the catheter to apply radiofrequency energy to disconnect the normal pathway that connects the upper and the lower chambers of the heart. And we usually reserve this procedure for patients in whom medications or other forms of catheter ablation don't work. And afterwards, we implant a permanent pacemaker to kind of pace the bottom chamber of the heart. And lastly, in patients who aren't able to take blood thinners due to excessive bleeding and who are at high risk for stroke, we perform a procedure called left atrial appendage closure, during which we implant a closure device into the small sac called left atrial appendage to minimize the risk of clot.

Deborah Howell (Host): It's just amazing how many treatments that we now have, as opposed to what used to happen 30 years ago.

Nikhil Warrier, MD: Absolutely, absolutely. I think there's a growing field in terms of what we're doing and what we're able to offer to our patients.

Deborah Howell (Host): Now, is a procedure always necessary to correct the heart rhythm, or can people live with AFib if they're monitored?

Nikhil Warrier, MD: Well, in AFib, the chaotic rhythm may cause blood to pool in the heart's upper chamber and form blood clots. So most of our strategy is to minimize the risk of blood clots. So procedures are not always necessary, but in patients who are extremely symptomatic, they prefer to maintain a normal rhythm, and that's the reason why we recommend invasive procedures.

Deborah Howell (Host): Sure. Now, since an irregular heart rhythm is sometimes unnoticeable, when is it most appropriate to see your physician to get checked for this condition?

Nikhil Warrier, MD: Well, there's an AFib risk assessment screening tool provided by the Heart Rhythm Society. It's an interactive tool designed to help individuals estimate their risk of AFib. Unfortunately, many people living with AFib have no symptoms and are unaware of their condition until they're actually suffering from complications which may often require urgent treatment. So unfortunately, in patients who are very symptomatic, it's easy to seek urgent treatment. However, oftentimes we're left with patients who are minimally symptomatic and who end up seeing us later on in the course of their illness.

Deborah Howell (Host): Are men or women more prone to getting AFib?

Nikhil Warrier, MD: Men are absolutely more prone to developing AFib. You know, it's been shown that there are higher risk for developing AFib. However, in terms of the risk of stroke, unfortunately, women are at higher risk. And that's actually a potential risk factor, additional risk factor, when we think about blood thinners and starting patients on blood thinners.

Deborah Howell (Host): Interesting. Now, if a patient is newly diagnosed, what are some of the important questions a patient should ask his or her physician?

Nikhil Warrier, MD: Well, the most important question should be, should I see a heart-rhythm specialist? Because I feel like we offer a service or, you know, we offer an expertise in terms of managing this arrhythmia that other physicians are probably not able to. Some additional questions that I hear from my patients are what kind of additional tests will I need? What's the most appropriate treatment? And, you know, what are the alternatives to the primary approach that's being suggested? And, you know, oftentimes they have other concomitant heart disease and, you know, they prefer having a management or therapy that's addressing all of their medical issues.

Deborah Howell (Host): And how long does a pacemaker last usually?

Nikhil Warrier, MD: Usually the newer pacemakers that are coming out, they last anywhere between 12 to 14 years. So, you know, the technology is rapidly evolving in terms of, you know, back in the day, it used to be much, much shorter and patients would require a lot more generator changes. But, you know, some of the newer devices that are coming out are lasting decades.

Deborah Howell (Host): And there's the thing about changing the battery in a pacemaker. Can you get us up to date on that?

Nikhil Warrier, MD: Sure, sure, sure. Usually when we get patients who come in who have devices that are nearing the end of, you know, or elective replacement, it's usually a same-day procedure. We make an incision at the site of the prior pacemaker. We extrapolate the old device out of the capsule. We essentially unscrew the device from the leads, put the brand new generator on, and then insert it back into the capsule. It's usually a same-day procedure. Patients usually go home within a couple of hours of our procedure, and they do fairly well.

Deborah Howell (Host): Sounds good. Is there anything else you want to say about AFib in particular this morning?

Nikhil Warrier, MD: No, I think, again, I think awareness is the most important thing in terms of atrial fibrillation And, you know, more and more literature is coming out saying that patients are not being adequately treated in terms of reducing their risk of stroke. So I think as long as we're creating awareness and people are aware of this, I think that's probably the most important thing that we can do.

Deborah Howell (Host): And prevention, you know, healthy lifestyle, everyone, right?

Nikhil Warrier, MD: Absolutely, 100%. That's what we aim to emphasize in all of our patients is that despite all the things that we have to offer, prevention and healthy lifestyle and screening for all these identifiable risk factors, they can help us manage the conditions so that they can live long and healthy lives.

Deborah Howell (Host): We want to thank you so much, Dr. Warrier, for coming on the show today. Really enjoyed having you with us.

Nikhil Warrier, MD: Thank you so much for having me.

Deborah Howell (Host): To learn more or to listen to a podcast of this show, go to MemorialCare.org. That's MemorialCare.org. That's all for this time. Thanks for listening and have yourself a terrific day.