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Atrial Fibrillation (transcript)
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ANNOUNCER: Behind every heartbeat is a story we can learn from. As we have for over 80 years, Blue Cross and Blue Shield companies are working to use the knowledge we gain from our members to better the health of not just those we insure but all Americans. Some call it responsibility. We call it a privilege. "Second Opinion" is funded by Blue Cross Blue Shield.

 

NARRATOR: "Second Opinion" is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.

 

[ Applause ]

 

DR. PETER SALGO: Welcome to "Second Opinion," where each week medical experts discuss real-life cases. I'm your host, Dr. Peter Salgo, and I want to thank all of you in our live studio audience for being here. Want to thank you at home for watching, too. Our experts today are Dr. Sam Asirvatham, electrophysiologist at the Mayo Clinic, Dr. Sam Sears, psychologist from East Carolina University, and Dr. Lou Papa, primary care physician from the University of Rochester Medical Center. And now I'd like you to meet our special guest, Joel Dittman. He's going to share his personal story.

 

JOEL: I have led a very healthy, active lifestyle, and every once in a while, I would feel something strange going on with my heart where it would feel like it was, like, fluttering, like it was gonna jump out of My chest. It wouldn't last very long, maybe half hour to an hour, until one time I was away on a snowboarding trip, and it happened for pretty much the whole weekend where every night my heart was just racing like crazy, but I just assumed it was 'cause I was snowboarding all day and drinking and not getting enough sleep. And so it went away by the time I went home from the weekend. And it continued to happen where I would feel just my heart was fluttering. And so then it happened once when I was probably just turned 30, right around my 30, 31. And I felt like I was having a heart attack 'cause my heart was just racing like crazy, and I was home, so I decided I'd go to the emergency room and have them tell me what was wrong. By the time I got in there, my heart was back to normal. My blood pressure was normal. My heart rate -- Everything was normal. They couldn't see anything wrong with my heart.

 

DR. PETER SALGO: That's got to be frustrating. It's like you take your car to the shop because it's got a grinding noise going on.

 

JOEL: Right.

 

DR. PETER SALGO: And when you get there, it sounds great. [ Laughs ] What did you think?

 

JOEL: I didn't know what to think. It was very strange, and I couldn't figure out what the problem was, and that was the scariest part -- not knowing if it was gonna come back or how long it would last.

 

DR. PETER SALGO: Lou, he's in your office, and you know that he went to the emergency room and they said, "Nothing on the cardiogram."

 

DR. LOU PAPA: Right.

 

DR. PETER SALGO: So what are you doing? What are you thinking?

 

DR. LOU PAPA: It's a very common complaint -- palpitations or fluttering of the chest. And it could be something completely benign. It could be related to anxiety. It can be intrinsic to the heart, either a problem with blood flow to the heart that's causing that sensation or an electrical problem in the heart. And a lot of it is kind of like being able to catch it when they're having the symptoms, 'cause just because they don't see it at the time doesn't mean that it's not happening.

 

DR. PETER SALGO: Great. So, Joel, with a normal cardiogram in the E.R., you go to see your doctor. What did your doctor say to you?

 

JOEL: He said next time I experience it, get right in there as quick as I could so they could catch it when it happened.

 

DR. PETER SALGO: And did you?

 

JOEL: I did.

 

DR. PETER SALGO: And did they?

 

JOEL: They caught it.

 

DR. PETER SALGO: And they told you what?

 

JOEL: I had atrial fibrillation.

 

DR. PETER SALGO: Atrial fibrillation, also known as a-fib.

 

JOEL: A-fib.

 

DR. PETER SALGO: What is a-fib?

 

DR. ASIRVATHAM: Well, a-fib is a condition where the upper part of the heart beats abnormally fast rather than the normal controlling center for the heart. It's the most common cause of palpitations worldwide.

 

DR. PETER SALGO: Okay, so just for our viewers' benefit, it's that upper part of the heart that actually paces the entire heart.

 

DR. ASIRVATHAM: Yes.

 

DR. PETER SALGO: And it's supposed to be a nice, regular rhythm. And when it turns into a can of worms, it's not. So you brought some slides to sort of give us a graphic idea about a-fib.

 

DR. ASIRVATHAM: Yeah, this is a picture of the heart. The lower part is the important pumping chamber of the heart. That's what we really need to send blood to the whole body. But it's a spot in the upper chamber that's like the controller of the heartbeat.

 

DR. PETER SALGO: That upper part where the curlicue arrows are.

 

DR. ASIRVATHAM: Yes. And it should only be one of those spots that tells the heart when to beat. But in atrial fibrillation, it's hundreds of different spots but all in the upper chamber that don't listen to each other or listen to the normal controller that makes the heart beat fast and beat irregularly. Now, for years, decades, we thought that atrial fibrillation is gonna be a disease of the heart, the atrium. But one of the great medical breakthroughs happened about 15 years ago that showed that the real cause of atrial fibrillation is a neighbor of the heart, something that lives nearby. And what you see around this normal heart, all those different tubes are veins that drain into the heart, and behind them will be the nerves that control those veins.

 

DR. PETER SALGO: So that's a picture of a heart.

 

DR. ASIRVATHAM: Yes.

 

DR. PETER SALGO: And all those hollow things are the veins. And around those veins are the nerves you're talking about that we really don't see here.

 

DR. ASIRVATHAM: That's exactly right. This understanding that there is a cause or trigger for atrial fibrillation is a little bit like the spark that starts the fire.

DR. PETER SALGO: Okay.

 

DR. ASIRVATHAM: And that spark is what we try to extinguish with therapy.

 

DR. PETER SALGO: All right, but here's the key question. It's nice to have a heart that beats regularly, at a normal speed. A-fib, that doesn't happen. So, what?

 

DR. LOU PAPA: So, part of the problem is there's a couple of things with atrial fibrillation. Some people can have it and actually not feel palpitations at all. There's times I pick it up in the office by accident. The problem is when the heart has that irregular shaking, non-contracting state. Sometimes patients can feel exhausted. They need that extra boost from that contraction. But the bigger concern is that slowing down can sometimes form a clot, and they know that patients that have atrial fibrillation have a high risk of clot. The biggest concern is clot to the brain, causing strokes or TIAs.

 

DR. PETER SALGO: Right. So, in one sense, if you have a-fib, even if the heart's output is okay, there's all that clot in there just waiting to travel north to various important places, like your brain. That can't be easy to live with psychologically, Sam.

 

DR. SEARS: Absolutely. And he got taught to pay a lot of attention to his body. In fact, they told him, "Hey, make sure you catch it next time and run to the E.R.” It creates kind of a crisis mentality and constantly looking for a problem.

 

DR. PETER SALGO: Okay, so how do we treat it? If we don't like it, we want to get rid of it, take a pill, do what?

 

DR. ASIRVATHAM: Well, the first step is education. And thousands of times, I've seen a patient's face just turn, like a curtain of anxiety goes away when you just say that this is not a life-threatening condition. It's more of a condition than a disease, and it's appropriately managed by seeing what each individual patient's risk is and what their individual symptoms are.

 

DR. PETER SALGO: Okay, but all comers now, everybody, what are the classes of treatments? What are you looking to do for a-fib?

 

DR. ASIRVATHAM:The main reason for treatment is symptoms, like what Joel has, and we first think about medicines that can slow the heart rate. So while the atrial fibrillation is there, patients can go ahead and do what they like to do. If that doesn't work, we think of stronger medicines that keeps the heart in rhythm or procedures, like ablation or pacemakers, when young patients especially have symptoms that affect their quality of life.

 

DR. PETER SALGO: Now, that's what you're doing for the heart. And I heard you say that you want to slow down the heart rate even though its upper portions are still fibrillating. But that doesn't end the risk of clot, so how do you get it to clot?

 

DR. ASIRVATHAM: Well, the clot and atrial fibrillation, they tend to go together. One doesn't necessarily cause the other. I sometimes tell patients, it's a little bit like gray hair and wrinkled skin, that they tend to go together. But if you color the hair, the wrinkles don't go away.  [ Laughter ] So it is extremely important for patients to understand that whenever they get a-fib, they shouldn't think, "Oh, I'm gonna get a stroke," 'cause a lot of people have atrial fibrillation and have very low stroke risk. We have to risk stratify by looking at the company it keeps. The older the patient, the more heart disease they have, the more the risk of stroke.

 

DR. PETER SALGO: Sam, you talked about changing the rhythm. In other words, I suppose it's better to be not in atrial fibrillation than in atrial fibrillation. How do you make the heart beat regularly?

 

DR. ASIRVATHAM: Well, I should say while we suppose that it's better to be in a normal rhythm, study after study after study has shown that there's nothing intrinsically better about normal rhythm than atrial fibrillation. So it's only the patients who feel it and who are symptomatic that then we think about medicines that can change the rhythm back to normal.

 

DR. PETER SALGO: Okay.

 

DR. ASIRVATHAM: Sometimes an electric shock, defibrillation, can be done to change it back to normal rhythm, but to keep it in normal rhythm usually takes some medication.

 

DR. PETER SALGO: Joel, what did you decide to do? You were 30 when all this was going on?

 

JOEL: Early 30s. And the way it was explained to me is it was like hiccups. They come and go. Nobody knows what causes them. And sometimes they last a long time, sometimes last 5, 10 minutes. And the treatments were suggested to me, which was the medication or the ablation. And at that time, I didn't have it that often, so I just figured I would live with it and deal with it.

 

DR. PETER SALGO: Then what happened over time?

 

JOEL: Over time, it started to become more and more consistent.

 

DR. PETER SALGO: Okay.

 

JOEL: It got to the point where it was almost every day. More days than not, I would have a-fib. From 8:00, 9:00 in the morning it would start, and it wouldn't end until I woke up the next day.

 

DR. PETER SALGO: Was there anything you were doing that you could trace and say, "Gee, that provokes it"?

 

JOEL: I've tried. I eliminated caffeine, I eliminated alcohol. I tried to eliminate stress.

 

DR. PETER SALGO: [ Chuckles ]

 

JOEL: I think stress is the only thing I couldn't really control.

 

DR. PETER SALGO: No, I mean, you had a-fib. Sam, here's somebody walking around with an irregular heartbeat. It keeps coming back. Somewhere there's at least a small worry of stroke. Good luck with stress, huh?

 

DR. SEARS: Yeah, absolutely. Most patients say stress is their most common trigger, even though we've always had a hard time linking it in research.

 

JOEL: I think that has to be my trigger.

 

DR. PETER SALGO: Did you start any medicine at all that you stayed on?

 

JOEL: I did. Once I decided I needed to do something about it, the first was cardioversion, but I went in for a cardioversion, and while I was waiting, I was out of a-fib.

 

DR. PETER SALGO: There it goes again. It comes and it goes.

 

JOEL: They took everything off me, and then I said, "You know what? I'm in a-fib now" after I was ready to leave the hospital. And they said, "Well, obviously you go in and out on your own. There's no sense in shocking you into a normal rhythm when you go in and out all the time."

 

DR. PETER SALGO: But it kept happening.

 

JOEL: It did.

 

DR. PETER SALGO: And it kept happening more and more if I heard you right.

 

JOEL: Right. I tried the medication, was the next step.

 

DR. PETER SALGO: Okay.

 

JOEL: And --

 

DR. PETER SALGO: How did that make you feel?

 

JOEL: It made me feel like I had a governor on me. Like, it felt like a cloud, like, controlling my heartbeat. I still had the a-fib. It just felt -- I felt – I didn't feel well.

 

DR. PETER SALGO: So, yeah, Lou.

 

DR. LOU PAPA: I think it's important also when you have somebody that's going in and out of a-fib like  that when you think about from primary care, there's other things that can cause a-fib that can be reversible or can be important to know about, especially in somebody who doesn't have a lot of risk of heart disease. Certain thyroid conditions can cause atrial fibrillation that if you pick it up, you can treat it. And pulmonary emboli can cause atrial fibrillation.

 

DR. PETER SALGO: Those are blood clots going to your lung, and those can be really dangerous, so we want to know about them.

 

DR. LOU PAPA: So it's very important to explain. And I think from a primary care point of view that I think is important to stress, and Sam spoke of this, is addressing the risk for stroke is very important from the primary care doctor's point of view. Those other things that Sam's talking about is very important to address first to make sure the patient's not at risk for stroke. And the rest of it is, yes, the quality of life aspect.

 

DR. PETER SALGO: And with that, we're gonna pause, because in every episode, "Second Opinion" looks for game changers, medical innovations that are making a difference. In atrial fibrillation, the WATCHMAN is having quite an impact.

 

 

DR. HUANG: When atrial fibrillation happens, the contraction or the beating of the upper chambers become very inefficient. There's always a danger that blood can pool, and when blood pools, blood can clot. And if that lodges in the brain, people can suffer a stroke. People with atrial fibrillation, almost all of them will need to be taking blood thinner medicines to help prevent blood clots. However, some people can have intolerances to these medicines. By far, most of the clots occur around this left atrial appendage, which is an out pouch right outside the left atrium. And in that appendage, because it is an out pouch, blood tends to pool. Until recently, we have this device that's now become available where we can actually implant this device into the vulnerable area in the heart where blood clots happen most frequently, and we can reduce the incidents and the risks of stroke substantially. The device is intended to be delivered where it's gonna be able to block off the blood flow into that out pouch in the left atrium or the left upper chamber of the heart. The device will be permanent. It will stay with the patient the whole time. We do want it to be permanent because patients will continue to be at risk for these blood clots for the rest of their lives.

 

 

DR. PETER SALGO: We're back with Joel Dittman. Joel, you had atrial fibrillation. You had it for quite a while, but it was becoming more and more bothersome. So, you went to your cardiologist, I guess, who said, "Take some medicine." And I got a little whiff of this in the first part of our show. You didn't like the medicine.

 

JOEL: No, I was not a fan, the way it made me feel.

 

DR. PETER SALGO: Why?

 

JOEL: It just slowed me -- It made me feel like I had, like, an umbrella in my heart, where it was like a governor almost, and it didn't feel right.

 

DR. PETER SALGO: So you talked to your cardiologist. You say, "I don't like the drugs." What else is there, and what did he tell you?

 

JOEL: He told me the catheter ablation was the next option.

 

DR. PETER SALGO: Okay, catheter ablation.

 

JOEL: Right.

 

DR. PETER SALGO: That's your job. Tell me about that.

 

 

DR. ASIRVATHAM: Yeah, so --

 

DR. PETER SALGO: We've got another slide.

 

DR. ASIRVATHAM: We can show that in this picture here. For decades, what we thought as atrial fibrillation is like a house on fire. The whole atrium is beating abnormally, and you pretty much can't do anything other than change the house. But what was found is when you had a video camera in the heart, the fire always started in one of two or three places, like a faulty switch, and if you could fix that, you could make most of the atrial fibrillation go away. And where that faulty switch is is where you see this catheter.

 

DR. PETER SALGO: That blue thing, the blue line.

 

DR. ASIRVATHAM: The blue thing with a steel-like tip. It's touching the pulmonary vein, the vein that drains blood from the lung back to the heart. About 70% of the atrial fibrillation, that's the faulty

switch. Now, the way we like to treat that is to just burn the faulty switch. And, in fact, it's for fear of instilling fear in patients with the word "burning," we invented another word called "ablation."

 

[ Laughter ]

 

DR. ASIRVATHAM: And what this ablation would like to do is to actually kill the abnormal tissue. But we can't quite do that because there can be scar tissue that narrows the vein. So what we do is actually do the ablation at the orifice or where the vein joins the heart. It's like creating a roadblock so the bad cells aren't able to create atrial fibrillation even though they are still living.

 

DR. PETER SALGO: So, here you are. You have this "ablation."

 

JOEL: Right.

 

DR.PETER SALGO: Did you know that it was burning?

 

JOEL: They made it sound like it wasn't that big of a deal.

 

DR. PETER SALGO: To them.

 

JOEL: They do it all the time.

 

DR. LOU PAPA: Little heartburn.

 

JOEL: If it was gonna solve my problem, I was okay with it. I mean, I didn't want to be on medication for the rest of my life, and this sounded like a permanent solution to the problem.

 

DR. PETER SALGO: Sam, what does that do to you psychologically?

 

DR. SEARS: Well, I think the big challenge for atrial fibrillation is it draws your attention, your mindfulness, to your heartbeat, and you then choose to sort of disengage from activities out of fear of elevating your heart rate and therefore creating even more attention to your heartbeat. And so this cycle of attention, emotion, and activity starts off, and you start declining activities, mood drops, and ultimately all your attentions is, "Am I in? Am I out of atrial fibrillation?" It's a mind game.

 

DR. PETER SALGO: Okay, into the hospital you go.

 

DR. LOU PAPA: Well, I think it's important that, as Sam pointed out, he's a gentleman who's at lower risk for stroke.

 

DR. PETER SALGO: Okay.

 

DR. LOU PAPA: So it's mostly symptom driven. And as a primary care doctor, one of the things that I worry about with some of these ablation procedures, are you gonna also be able to lower the risk of stroke without having to be on blood thinners? So it's very different depending on the population. Look, it's a young, healthy man who has a low risk for stroke, where we're really symptom driven. It's a very different conversation with older patients.

 

DR. PETER SALGO: Okay, so there's the risk balance, right? And you're going in, and you're all ready for this ablation. How did that go?

 

JOEL: Went fine. It was a long procedure.

 

DR. PETER SALGO: Okay.

 

JOEL: They said I had very large veins. It took awhile to burn all the way around them.

 

DR. PETER SALGO: You were put on drugs to keep your heartbeat stabilized afterwards for a while.

 

JOEL: Yeah, because they say the longer you go after without having an a-fib episode, the more success rate you have.

 

DR. PETER SALGO: And then what happened? How long did it -- Did it work, first of all?

 

JOEL: It worked, but I still had occasional bouts of a-fib, and then I went into another pretty long a-fib that was a couple days. I called the doctor. They brought me in, and they did a cardioversion to get me out of it.

 

DR. PETER SALGO: Okay, so they shocked your heart.

 

JOEL: Right.

 

DR. PETER SALGO: What's going on here? I thought this ablation is great.

 

DR. ASIRVATHAM: Yeah, so that's, I think, the most important part of educating a patient. It's not just risk and benefit about the procedure, but managing expectations. Ablation is not a cure for atrial fibrillation. It's a controlled strategy that helps people have more symptom-free lives. So there will always be some atrial fibrillation. And, in fact, sometimes it can be worse soon after a procedure, and that's why your doctors would have used that medication for a while. But the majority of patients will have less symptoms. But to date, we don't believe that ablation is a cure for atrial fibrillation.

 

DR. PETER SALGO: So, Joel, you had the ablation. Then your atrial fibrillation came back. You had cardioversion. Your heart was shocked twice.

 

JOEL: Yeah.

 

DR. PETER SALGO: Any more problems?

 

JOEL: I was good for a few years, and then just recently it started again right around Christmastime. And this one was different. It didn't stop. It was --

 

DR. PETER SALGO: That's important.

 

JOEL: ...a different arrhythmia.

 

DR. PETER SALGO: Important. I think something you said -- Christmastime. Sam, what's holiday heart?

 

DR. SEARS: Well, holiday heart's an idea that perhaps a little bit more drinking, a little bit more festivities, a change in lifestyle very acutely that probably has some physiologic and psychologic consequences.

 

DR. ASIRVATHAM: I don't think this was probably related to stress. What you're describing where it becomes persistent like this is probably an atrial flutter that comes from having scars in the heart.

 

JOEL: Okay.

 

DR. ASIRVATHAM: Sometimes from ablation. And sometimes it's just like a close cousin of atrial fibrillation, that people who get one tend to get this, as well. This does have a curable type of ablation. But unlike atrial fibrillation, ablation for this arrhythmia flutter can permanently eliminate it.

 

DR. PETER SALGO: How accurate is he, Joel?

 

JOEL: He's very accurate, 'cause I had a second ablation, and it cured the flutter.

 

DR. PETER SALGO: So, have we reached the promised land, Sam? What do we have to look forward to going into the future?

 

DR. ASIRVATHAM: Well, since atrial fibrillation is a little bit like gray hair -- we live long enough, we get it -- we don't think we can cure it. We learn a lot from the few people who never get atrial fibrillation, and these are folks who have had a heart transplant. And what's happened at the heart transplant for the first few years is the nerves are no longer getting to the heart. So since that's a model to work on, new procedures and diagnostic tools have tried to look at, is it the nerves? Is this really an epilepsy of the heart? And I have a slide here that shows exactly what we're up against.

 

DR. PETER SALGO: Oh, it's real simple. Really simple stuff.

 

 [ Laughter ]

 

DR. ASIRVATHAM: This hairy ball-like thing are all the myriad nerves that constitute the small brain of the heart. This is what really keeps the heart in tune, and this, when it goes different, because of genes, because of athleticism, the lack of exercise, extremes in life, then this is what probably gives rise to the ability for the heart to fibrillate. The key is the relay station. We have thousands of nerves, but when they get to the heart, they have discreet relay stations called ganglia, and these ganglia can be reached with catheters, but not the ones like you had going through the vein, but ones that we slip under the

breastbone to try to find them, record their signals, and modulate them, maybe burn, maybe just modulate so they don't quite do the kind of work they're doing in patients with atrial fibrillation.

 

DR. PETER SALGO: Lou, 21st century medicine. When you were in medical school, you ever think you'd be talking like this?

 

DR. LOU PAPA: No, I mean, even when I was in medical school, we really didn't even know a-fib was causing strokes, so it's a huge advance with all these different -- and not to mention the new drugs for blood thinners that are out there. There's a lot of things that we can do for patients that have a-fib.

 

DR. PETER SALGO: Sam, it sounds like people might calm down a little bit.

 

DR. SEARS: They might very well. That's our hope. I think comprehensive care, like we've talked about with teams like we have here on the stage, can help with these patients.

 

DR. ASIRVATHAM: I'd just like to add that to control the nerves, there are also some very low-tech solutions like meditation or yoga that these same nerves can be modulated but without a procedure.

 

DR. PETER SALGO: I hate to say this, but I'm going to. Sam, it's the mind-body connection.

 

DR. SEARS: That it is.

 

DR. PETER SALGO: I've heard that from you before.

 

DR. SEARS: Yeah.

 

DR. PETER SALGO: But here we have it from an electrophysiologist, too. We're beginning to converge, aren't we? It's interesting. Well, Joel, I want to thank you for joining us today. And, panel, all of you, I want you to know that I thank you, too. Want to thank our audience out there, as well. Now, to end the show, here's Joel's advice to anyone who may be dealing with atrial fibrillation.

 

JOEL: So, my advice for anyone who has a-fib, has been diagnosed with a-fib, is to have a good relationship with your doctor. Discuss the different options. There's living with it, there's medication, and then there's ablation. Find out what fits you best, what your lifestyle is, how much it affects your day-to-day activities, and go from there. If it happens, I just rest. If it doesn't happen, I go about my normal daily activity and try to live as healthy as I can and eat as healthy as I can and limit my number of drinks to two so that hopefully I don't get it anymore.

 

DR. PETER SALGO: I want to thank all of you in our live studio audience for being here today. I'd also like to thank you at home for watching. Remember, you can get more second opinions and patient stories on our website at secondopinion-TV.org. And you can continue this conversation on Facebook and Twitter, where we're live every day with health news. I'm Dr. Peter Salgo, and I'll see you next time for another "Second Opinion."

 

 [ Applause ]

 

ANNOUNCER: Behind every heartbeat is a story we can learn from. As we have for over 80 years, Blue Cross and Blue Shield companies are working to use the knowledge we gain from our members to better the health of not just those we insure but all Americans. Some call it responsibility. We call it a privilege. "Second Opinion" is funded by Blue Cross Blue Shield.

 

NARRATOR: "Second Opinion" is produced in conjunction with UR Medicine, part of University of Rochester Medical Center, Rochester, New York.