Chapters Transcript Video Afib - Rate vs Rhythm Control and Anticoagulation Options Back to Symposium Click Here to View Presentation Deck A Little bit of background. I've been doing EP for about 12 years, um, and before that I did primary care. Um, I actually did a stint in the National Health Service Corps, so I know you guys are the true rock stars and heroes, so thank you. Um, so I tried to tailor a little bit to that, um, for my speaking today. Um, I'm a speaker and educator for BioSense-Webster. That's the only thing I have to disclose, um, so Div gave a good brief overview, but again I did as well, um. You know, as we all know, it's, uh, AFib is an irregularly irregular rhythm. It's coming from the left atrium. So I thought this was like a really good picture of the pulmonary veins. So this is where the Afib is originating from. So when we're talking about that sort of thing, just keeping an eye, you know, thinking in the back of our head that the left atrium is where we're going. The big thing, and I can't say this enough to patients, there is no cure for AFib. We will not cure you. I'm going to be best friends with you. We will never let you go, OK? Um, we will treat you for a long time. So, um, you know, I'd like people to understand that, um, AFib, uh, affects approximately 30 million people globally, um, and it's a diagnosis of advanced age too, so. Um, you know, like I said, symptoms, they vary. I have some patients who come in and they say, July 3rd at 7:00 a.m. I went into AFib. They know exactly. Then there's other people who show up and they're in like in an atypical flutter going 150, and I'm like, hey, how are you feeling? And they're like, oh, fine, I'm great, you know. So everybody is different, right? So the main symptoms though, dyspnea on exertion and fatigue. These are the number, like number 1 and 2 things that people tell me. And some of those can be so mild that they don't even realize they're feeling it until after they get back in normal rhythm. So a lot of people will come in and they'll, they're in AFib and they're like, hey, I feel great. And I'm like, hey, I beg you, let me just put you back in normal rhythm. And then if you tell me you still feel great, cool, I'll, I'll believe you, but just let me, give me a shot, you know. So, but a lot of different symptoms, a lot of people feel the palpitations, chest pain, tightness, um, dizziness, that sort of thing are the most common things we see. The other big things I think as, you know, PCPs and other primary care providers, um, you know, the screening and treatment of sleep apnea is massive. um, so almost every single one of our patients gets a sleep study. The only time I will say no is if they're like, hey, I'm never gonna wear this mask, so I don't care if I have it. And I'm like, OK, cool. Let's not waste some money then. Um, but that is, you know, I can treat AFib all day long, but if you have untreated sleep apnea, it's gonna keep coming back. So, um, aggressive BP control and weight loss. So we're talking about that a little bit later today, but weight loss is a big thing. Obesity is, you know, um, a growing epidemic, and it's causing a lot of AFib problems. So the big things, you know, sustained atrial fibrillation causes rapid electrical remodeling, and it makes normal rhythm restoration challenging over time. That's a really fancy way of saying, you got to get him back in normal rhythm real quick, OK? The longer you're in AFib, the harder it is for us to treat. So, patients who come in and they're like, I've been in AFib for 2 years, I'm like, awesome, this is going to be so easy and so fun. Um, you know, if left uncontrolled, it can lead to a significant decrease in quality of life, uh, leads to heart failure, um, increased stroke risk, um, so it, and even, not even with systolic heart failure, it can just be acute volume overload. Their EF doesn't have to be 10% to feel the volume overload. So those are things to keep in mind. So the big things, um, so one of the big topics I want to talk about is there's two ways to treat AFib, break it down. You either rate control them or you do rhythm control. That's all you've got to ask yourself, OK? Rhythm control is a little bit more in-depth rate control. I never use this. Like, I don't want to rate control anyone. I'm EP. I want to get you. I don't like AFib. I want you to be in normal rhythm. I will say, I mean, there are some patients who are truly a good rate control patient, but there are not many. I will be honest with you. So, um, I, I think that if we can just keep that in the back of our head, that rate control really isn't the answer. Um, that's the take-home message from my whole speech here. Um, the only patients that I think are appropriate, um, if they're completely asymptomatic, their EF is normal and they could be anticoagulated properly. Um, so you can use beta blockers, calcium channel blockers. We'll throw some dig in there as a last ditch effort sometimes. Um, and amiodarone, again, kind of a Hail Mary. Um, but again, if we're unable to rate control, we will do a pacemaker AV node ablation. So some medicines that we use, I kind of put some classes down here for you. Um, the big things I did want to kind of note because I get a lot of questions about this, we get a lot of consults in the hospital. Um, for these types of things, calcium channel blockers, really confusing, right? Some affect the AV nodes, some don't. So amlodipine, love it, great blood pressure drug, but it does nothing to control heart rates, OK? Um, nifedipine, same thing. We love diltiazem, um, unless their EF is less than 30, 35, um, verapamil. Mill, um, those are the ones that we like to use too. This, I put a note in there about clonidine because I think this is like a silent bradycardia causing drug that no one kind of remembers. Again, we get consulted all the time for bradycardia and the patient's on like a ton of clonidine, and I'm like, hey man, that's probably your answer. Um, so keeping that in the back of your head. Not that people use that that much anymore, but, um. So the big drugs that we use, I kind of put them in there, not that we expect you guys to know this stuff, but in case you're seeing patients that are on these drugs, don't be scared, right? That's our whole take home message. We don't really like to use drugs. I mean, I would prefer to never prescribe a medication ever again if I could help it, um, but sometimes we have to. Um, so flecainide and propafenone, this is a 1C agent. These are my favorite drugs. I use flecainide all the time. Love it. Um, it blocks the sodium channels in the heart. It doesn't have high toxicity, i.e., you can put 25 year olds on this and they can stay on it long term. OK? So that's a really good thing. Um, can't use with coronary disease patients. You have to monitor the renal function, so it gets a little bit tough. The next one, the, this is, um, ranterone, AKA Multaq. Not super effective. I'm going to be really honest with you. It has a little bit of properties of amio, so it causes the same issues with it, um, and it's got a lot of GI side effects and it's really expensive, so we don't use it a lot, but it's there. Stronger agents, Tikosyn, another one of my faves, if people want to be on it. The big thing with this, as again, PCPs, this drug interacts with everything. Like, don't put people, like if you go home with from the urgent care on the Z-Pak and Zofran, wow, huge QT prolonging agents. OK, please don't do that. Um, so, you know, that's the big thing. Uh, if you guys are seeing people on Tikosyn, um, it's really, really well tolerated. The bad news is you have to come hang out with me for 3 days in the hospital, um, when we first load this drug. So not a lot of people like to do that. Um, also AO, man, we in EP, we love AMO, and you guys hate us putting people on AMO. I get it. You got to check TSH, LFTs, pulmonary function tests, yearly eye exams. I get it. I don't like it either. Um, so, uh, but, you know, it just, it helps so many things, all the rhythms, um, and it's really the strongest drug we have. You can use it in heart failure, you can use it in kidney failure. So it's our gem. Sotalol is, you know, basically just a really fancy beta blocker. Um, it has to be in higher doses to be effective for rhythms. So if someone comes in and sotalol 40 BID, that's not an EP drug, that's a beta blocker. You might as well give them metoprolol at that point. Um, but it's also, again, you have to come into the hospital for a couple of days to hang out with me. People don't like to do that and you can't use it in heart failure. Whomp womp. So, rhythm control cardioversion. So this is another misdemeanor. I have patients all the time who say, hey, I had a cardioversion, but my AFib came back. Yeah, I know, um, it's a band-aid to the problem. We'll put you in normal rhythm, but it does nothing to prevent the rhythm from coming back. So people will go right back into AFib, not surprising. Um, it's a, it's a procedure that we do very frequently. We do a lot of cardioversions. Um, we try to do them electively unless they're hemodynamically unstable. That's not my favorite patient, but it happens. Um, and you just have to watch for, you know, sinus arrest afterwards, rare, rarely, but it does happen every now and then that we've to put a pacemaker in post, uh, cardioversion. It's not how I want my day to go, but sometimes that does happen. Um, so we do that a lot, um. If you take nothing else home from this entire lecture, just know that everyone in AFib should have an ablation. Almost everyone should just get an ablation. So it is the gold standard of treatment. Um, it's, uh, we've got all sorts of new technology. EP people are geeks. Like they are coming out with new stuff all the time. Even when I started 12 years ago, AFib ablations took 4 to 6 hours. Now they're like taking 1 hour and a half, you know, it's crazy what we can do. Um, so I thought this was a really cool picture, just how we gain access into the heart, you know, to, you know, a couple, we make a couple of incisions down here, put a catheter up into the right side of the heart, cross over the muscle here and go over to that left atrium that we talked about, um. So here's some cool pictures again kind of geeking out um this new stuff here this PFA has changed the game for us. It has made ablation so much shorter and much more safer um so this is some new technology that Centera's, um, had on board now for a couple of years. This other one's like a cool voltage map. I just thought it was a cool picture, but I don't know you guys probably don't care, um. Post-op care, you know, this 90 to 95% of patients go home the same day. You can't do heavy lifting for about a week afterwards, but other than that, we have people doing desk jobs 48 hours later. Um, so this is in and out. Um, so I did wanna kind of note that that this is a lot less, um, intense than it used to be. Um, obviously not everyone's an, uh, you know, an anesthesia candidate. This is done under general anesthesia. So, um, that's the biggest risk that we have, you know, and who can get this ablation and not, um, you can have some growing complications, obviously, we can injure something when we're inside the heart. We could cause bleeding. Um, it's, it's very rare for us to have complications. I think our percentage is less than 1 to 2% of people have any sort of complications, so. Um, but a lot of it is, uh, much more minimal these days, especially with being under general, a lot less time. Um, there's, um, a lot of different things that we look at afterwards, um, as far as, you know, long term things, uh, pulmonary vein stenosis, not as very common anymore. Um, again, they are exposed to some radiation. Um, we do actually create a little PFO when we're doing this procedure. Most of the time it closes up on its own. Sometimes it does require closure later on. So, those are things just to keep in mind. So again, this is not a cure for AFib. So I warn patients all the time, I, especially young patients, you're probably gonna have at least a 2nd ablation in your lifetime. Um, so again, we're going to be friends for a long time. Um, some people require several of these ablations. They don't need to be in AFib. I actually prefer if they're not for the procedure. Um, the, again, the less time you're in AFib, the easier our job is. And not everyone's an ablation candidate, um, but we sure do try and make them an ablation candidate, don't we? Um, so, you know, um, some people will say that if you've been in Afib too long, the left atrium just gets so remodeled and so enlarged that some people are like, hey man, we're not gonna keep you in normal rhythm, we're not gonna put you through the risk. Obviously if you have ongoing infections, if you have thrombus, um, that's, uh, a risk for us as well. So the other thing I thought was really good to talk about is anticoagulation. There's a couple of other little gems that I would love for you guys to take home. Um, so Chad's VAS score, I kind of put this down here so you guys had it. Again, I can calculate a CHA's VAsk in like 5 seconds, you know, but this is, this is what I do all day long, right? Um, I think it can get a little bit confusing. There is MD calc that you can use. So basically, the take-home message is, if it's 2 or less for men, you probably, or actually, they say less than 2, you probably don't have to be on blood thinner. For women, we are so lucky that that's a risk factor. However, there are some studies that show that maybe we're, it's not a risk factor, so we're plus or minus like 2 or 3, needing anticoagulation. So medication options. I'm really showing my age here, but back when I was in school, we didn't even have DOA. OK, so I'm, I'm really telling you my age. Um, these have been around since like what, 2010 or so. Um, this is the best option. Um, they used to be called NA back then too. Um, now it's DAC. I don't know why they keep changing it. Um, my favorite is probably Eliquis or Apixaban. Um, it's a 5 mg twice a day dosing. So this is my other parole to take home. You have to meet 2 out of 3 criteria to be on a reduced dose. As a family practice provider, please do not reduce their dose unless they meet 2 out of the 3 criteria. At that point, if you're reducing the dose, there's actually no benefit. You're just putting them at higher risk for bleeding and you're not actually giving them the stroke risk benefit. I get it. There are people of advanced age. There are people who just like their skin's thin or they're not quite 60 kg, they're like, you know, 80, and they just want to be on a lower dose. Don't do it. Don't say yes. Say no. Just, just do it for me, OK? So the problem is. is when they go back into AFib, they're not properly anticoagulated and they can't do anything. Um, so it makes it a little bit difficult. So if creatinine is over 1.5, age is over 80, and weight is less than 60 kg, again, 2 out of 3 have to be met to reduce the dose to 2.5 BID. The other one a lot of people like to use is Xarelto. Um, I like it because it's once a day dosing. Um, you do need to take this with a considerable amount of calories. Um, And it is also renally dosed, so you have to calculate creatinine clearance is another MD calc that I love. Um, so that one's a little bit tough if they have renal dysfunction. Um, less common is, um, the OG, um, Pradaxa, and, uh, Savasa. Not a lot of people use those, but they are options. Um, if someone says that it's, you know, too expensive, I have them look into every single one of the options before switching them. Um, the pros, obviously there's a steady state. They're not affected by diet, and there's better efficacy with this and a very much lower bleeding risk profile than Coumadin. Obviously the big, the big con is cost. We all hear this. I mean, I can't tell you every single patient tells me how expensive it is. Um, I've been really recommending alternative pharmacies. I couldn't actually write this down here, but like I've been having patients send their scripts to Canada and had a lot of great luck with that. Um, I heard the Mark Cuban, uh, pharmacies are really working. They don't have Dox yet on there, but they're, I think it's coming. They have a lot of great heart failure drugs, so that's awesome. Obviously, and then the alternative is Coumadin. I do not like this. I hate Coumadin. Um, I just think it's so labile. It's not actually effective. It's so diet, um, dependent that it, it makes it very, very hard to use, but it is, um, an option, especially for our valvular patients. Um, so some big trials that I wanted to kind of mention just because you guys are gonna start seeing this, you're gonna start seeing us take people off anticoagulation, and so I want you to understand why we're doing it. There's a couple of recent trials that have come out in the last like 6 months, the Alone AF trial, um. So this is post ablation. Again, another reason why everyone should get an ablation, um, patients at least one year without AFib post ablation can safely DC their oral anticoagulation if they are low to intermediate risk. So this is great. It just kind of reconfirms that patients who are in that like mild to moderate CHAD score, if they've had an ablation, they haven't had any AFib for a while, we feel pretty solid that they can come off blood thinner, which is amazing. Um, if they're high risk, you still need to have a healthy discussion, and this is, I mean, I discussed this so much. I feel like we could have an anticoagulation clinic. Um, this is something that I, I really, really ask patients to talk with their PCP, so you guys hear this too. You know them better than I do. Um, you're assessing their fall risk, you know, and everything else that goes along with taking a blood thinner. So this is something that I really strongly encourage. The, um, ocean AFib trial is similar, basically it was a study with Xarelto, um. With a Chaz Vask of 1 to 3, again, saying the similar thing that if you've had an ablation, Afib free, you can probably just switch to aspirin. Both of these trials have really changed how we've, you know, kind of managed people afterwards. And again another thing why we're pushing for ablations. The other thing that patients ask me all the time is how much Afib do you have to have to put you in increased stroke risk? And the answer is. I don't know. I mean, there's some studies that show 6 minutes of AFib increases your stroke risk. Other studies show up to 6 hours. So like Doctor Patel was saying, you know, wearing these, you know, monitors, wearing smartwatches, everything, that's really kind of changed stuff for us. Obviously people who need NSAIDs, that sort of thing, that's, um, uh, something, you know, that we have to consider. So I just put this slide in real quick because again, pre-op considerations just with blood thinners, we are asked to do so many pre-ops because of blood thinners. Um, so we don't bridge anymore unless, you know, there's certain high-risk patients, valvular, that sort of thing. We will always say 48 hours pre-op, stop the blood thinner. If the surgeon wants to do longer than that, that's on them. But they paid a lot of money for these studies and they've said 48 hours, it should be out of their system. Um, the high stroke risk, like Doctor Patel said, is going in and out of AFib and 30 days post cardioversion. Um, for ablations, we can't interrupt blood thinner for 90 days. Um, so we will not clear them, um, to hold blood thinners after that. Last, not least is Watchmen. Oh, man, Watchmens are amazing, right? They've really changed the name, uh, or the game here. So, um, it's a little device. The way I describe it to people is again, that left atrium, that's our gem, right? It's got this little out pouching on the side. I like to call it a cave. So essentially this watchman goes in there and it shuts off the entrance to the cave. So that 90% of those blood clots that have formed in that cave can't come out into the bloodstream. However, that means 10% risk is still there. There's a 10% chance that you could still have blood clots. So they did this whole trial. It's called the closure trial. And the thing I liked about this one is that it's non-industry based. How hard is it to find a trial that's non-industry based, by the way? Um, but it failed to prove that the left atrial appendage closure devices were as effective as DAX. So. What does that mean? That if they can still take a blood thinner, they should. OK. So a lot of people just want to come off because they wanna, um, and so the recommendation is still like, hey, man, you've got to have a reason to get the watchman or the amulet. I'm not, you know, whatever, whichever one you want to do. Um, but there still needs to be a medical reason why you cannot take blood thinners. Um, and so that was a big trial for us recently as well. They also have to have a CHAD score of at least 3, OK? And that's insurance purposes. The studies were actually done on a CHADS of 2. However, Medicare does not care and only wants a CHAD score of 3 or higher. So that's something to keep in the back of your head when you're referring people to us for the Watchman, um. So just keeping that there. And that's all I have with, oh, man, 10 seconds remaining. OK Published June 30, 2026 Created by Related Presenters Carrie Ziemer, PA-C
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