Chapters Transcript Video Atrial Fibrillation: Modern Day Treatment Dr Hedley discusses the treatment practices and emerging technologies for atrial fibrillation. Um, but yeah, let's talk about Afib in the modern day treatment. Um, let's see. All right, so you know, briefly, everyone knows that there's sort of, you know, three arms of treatment rate, um, control, rhythm control, and stroke prevention. I'm not gonna belabor this point too much. Probably the single most um annoying and problematic thing that ever happened to electrophysiology was the affirmed trial. OK, so this is where that old doctrine of there is no difference between rate and rhythm control came from. And so now we have years and years and years of people saying, you know what, it doesn't really matter what we do so long as your heart rate's under control, you know, the clinical trials would suggest there's no difference between rate and rhythm control, and we have gotten ourselves into an enormous amount of trouble um with this approach, um. The reason for that is we weren't really using ablation very heavy back then we were only using antiarrhythmics that that study is also just highly, highly flawed in terms of the way it was designed, but think of it this way, we only have but a few antiarrhythmic medications, OK? This is literally all of them that we use to treat atrial fibrillation, and I would make the argument that dronearone, which is our most recent one. Is actually just a waste of a medicine. I mean, it has the sort of downsides of being both expensive and ineffective, so I'm not sure why it's ever used, to be perfectly honest. And if you take that into account, that means that it's been over a quarter century since the last time a useful medicine has been made. And so when we're saying, OK, do these medicines do a good job, you know, uh, versus rate control, the answer was kind of no it did not, um, so it's not surprising. Before we jump into all of how we move forward from that trial, um, I want to spend some time on something that probably everyone who's ever worked with me now gets nauseous any time they, you know, I bring it up because they've heard it so many times, but it's taking a very good look at the left atrium and what atrial fibrillation does to the left atrium. OK, so here is, you know, an apical 4 chamber view, um, and here's the left atrium and this is what a normal left atrium looks like, you know, it is normal size, it is not stretched out, um, and we would presume that the tissue in the left atrium is highly, you know, healthy and normal. Over time, as the heart spends more and more and more time in atrial fibrillation, it slowly but very surely begins to dilate, and the nice normal healthy tissue that's there gets slowly and gradually replaced by scar tissue. So you get dilation that you can see here, you get even more dilation with greater time and then you get massive, massive dilation which you see with people who've been in Afib for, you know, decades and, and probably also have some valvular disease as well. So, um, one really nice summary that I I've kind of used for a long time is I say that left atrial size is to atrial fibrillation as the hemoglobin A1C is to diabetes, and by that I mean that someone can walk into the hospital or clinic and have a normal blood glucose, right? But if their A1C is 15, they have diabetes, right? There is no ifs ands or buts about it, you can clearly show it. So when you see somebody and you're you're under the impression that they have brand new atrial fibrillation and this is their first episode, but their left atrium looks like a you know pictures I just showed you, it is just simply not new, right? I don't care what anyone says, so pay close attention to it. Here's me making a map right before an atrial fibrillation ablation. Um, I use a mapping catheter. I go around the left atrium and I kind of lay out what the left atrium looks like. And for reference, red means either electrically inert like out here in the four pulmonary veins. They shouldn't be active and so they're red, that's normal. Purple means stone cold normal tissue and then red anywhere else means scar tissue. So if you look at this, this is the left atrium, it's got a lot of healthy tissue but a lot of abnormal tissue as well. So let me give you an example of a different one. This is an even more dilated left atrium that's been in afib even longer. Now there's not much purple anymore. There's not much healthy tissue. There's little islands of healthy tissue, but it's a tremendous amount of scar tissue and also the heart's just, you know, the, the, the atrium's just dilated more, OK? This has a couple of different issues. It affects our ablations greatly. And more than that, take for example this map here, OK, you can see how there's this stripe of scar tissue along the posterior wall. Not only does it complicate the ablations and make them both more difficult and less effective, but it actually can give rise to new rhythms in and of itself. So here's an atypical atrial flutter just spinning around this scar tissue, and these things become very, very difficult to treat as you guys know if you try to treat atrial flutter and get heart rate control, it's very difficult. All of this is just because it was let go too long and scar tissue has formed, OK? So pain. This, uh, I put this in here just for reference. This is typical atrial flutter, so this is right atrial flutter where it's spinning around the the tricuspid annulus and we just take that one little line of ablation down there that you see um to get rid of it, but that's that's typical flutter and then you have an enormous number of atypical flutters like the, the video I just showed you before. Alright, so what, what are we doing now? What is the modern day approach? We began to see newer updated and better designed trials that began to show, you know what, actually rate and rhythm control are not identical. There is a benefit to rhythm control and specifically early rhythm control. The first of these is the East AFET 4 trial which showed this big long composite outcome of, you know, better, um, death, stroke, hospitalization, heart failure, and whatnot. So that was where the the tide began to change and then literally every study after that has now begun to confirm or even strengthen these um assumptions, um, so we began to say OK well we're not going to use medicines you know and say try a drug, try another drug, try yet another drug, and if they all fail well then guess what, at that point, finally we'll offer you an atrial fibrillation ablation we started to say, you know what, you've got afib, let's go, let's go do an ablation. Early first line treatment, does that do better? And yes, it absolutely does and does it outperform anti rhythmic therapy? Yes, it absolutely does. So ablation at this point has been demonstrated conclusively to do a better job of both keeping you in normal rhythm and preventing further recurrences of atrial fibrillation than any of our drugs, OK, um, so that was seen in the early AF trial, the stop AF first trial. Um, and so they also not only stop you from having kind of, uh, more recurrence of atrial fibrillation, but they also do a better job of preventing you from progressing to persistent atrial fibrillation. Once you go from paroxysmal come and go atrial fibrillation to just stuck in it persistent atrial fibrillation, your outlook changes wildly, so we have to get to people early on. One of the most, you know, um, important papers here showed us that the timing of this matters, OK? So if you don't get to atrial fibrillation in the 1st 36 months of diagnosis, the success drops off precipitously after that, and I liked the way they summarized this, they said. There is no lower limit to this. So basically, the shorter the better and the longer the more irrelevant. So really do not waste any time getting to atrial fibrillation and treating it. So you might say, OK, well these are sort of soft end points, right? We're we're sort of preventing Afib and whatnot, but you're not talking about hard outcomes the way that we normally do in cardiology with kind of, you know, OK, are we preventing death? Well, it, it turns out yes we are specifically when you start talking about heart failure patients. So if you have concomitant heart failure and atrial fibrillation, then atrial fibrillation ablation is now demonstrated to reduce mortality. And surprisingly I think surprisingly even to electrophysiologists this was also true of people with end stage heart failure so um we we are probably in the past saying that people are a little too sick to undergo ablation. Or it isn't gonna help them and in reality we probably missed a lot of opportunities there. So for heart failure patients, this is why you see us nowadays waste no time. I will bump stable patients to get heart failure patients in to do ablation because now it is actually mortality benefit. This is now reflected in the guidelines, they're saying, look, first line therapy is, is now atrial fibrillation ablation, so this is widely accepted at this point. And so one of the reasons for all of this is if you look at an ablation in the in the recent past, you know, it was always a very safe procedure um and you know we recently got to the point where it was about 1.5 to 22 hour long procedure. You go home same day and the success rates are high, um. The overall complication rate, I kind of quote this to people every day when I'm talking to them about ablation. I say the risk of any major negative outcome is under a single percent. That means you have a greater than 99% chance of having nothing bad happen to you, and this is sort of the breakdown. So if you look. These these percentages, the the higher one's 45%, 27%, that just means percent of the complications, but the actual rate at which they occur 0.08%, 0.3%, 0.07%. These are very, very low complication rates, and this is for recent past. This is not current, OK, so. This is what a radio frequency ablation looked like in the past. Here's a nice paroxysmal atrial fibrillation type atrium where it's tons of healthy tissue. All you have to do is encircle the veins to wall off the veins, and that's it. Then you get the much more dilated, much more scarred up. It takes a lot more ablation to try to get them to stay in sinus rhythm, and with more ablation comes more risk. But nowadays we have what's called pulsed field ablation, and I'll spend a minute explaining what pulsed field ablation is and why it has made a big difference. So instead of freezing the tissue like cryoablation or burning the tissue like radio frequency ablation, now we are basically just delivering electrical shocks, so to speak, to the tissue. And what that does is it it induces what's called electroporation. The cell membranes form pores, the cellular contents are extruded, and the basically the the the cells undergo programmed cell death. So we're delivering voltage to the tissue. We can deliver as much voltage as we want. We can deliver voltage over as much time as we want with with with different. Polarities, different numbers of applications, alternating types and so what we've essentially done is, and this is done through early trials is we have found out that if you actually deliver it in exactly the right way, it's a bit like finding this precise harmony such that it actually only touches the heart tissue, OK, and that becomes very important from a safety standpoint. I've already sort of explained that it causes electroporation and that's how the cell death happens, but what what the result is now is that the standard atrial fibrillation ablation probably takes something in the 50 minute range now, which is unbelievable because even just 5 to 10 years ago some of these took 4 to 6 hours, you know, so it's it's, it's absolutely absurd. Again, it same day discharge, the efficacy is at least as good, if not much better. Most of us believe it to be substantially better, which will probably play out with ongoing clinical trials. And if you look back at those complications, even though they were already low, they continue to be exceedingly low, and two of the more dreaded ones, the atrioesophageal fistula, which is often fatal, or permanent renic nerve palsy, which is absolutely disabling because you know you've basically um. Uh, you know, paralyzed half the diaphragm and they suffer from recalcitrant shortness of breath the rest of their life because we have finally tuned the delivery of this ablation and it only affects heart tissue, it doesn't touch the esophagus and it doesn't touch the phrenic. So you've actually wiped some of the already rare complications off the map. It's worth spending a few minutes as to who does not benefit from ablation, so I would argue that people who are morbidly obese are not going to benefit and in fact that has absolutely played out in the literature that they do not enjoy long term success um from from ablation. I I didn't put it in here and I and I should have, it was an oversight, but going along with morbid obesity, I would also argue that. You know, severe untreated sleep apnea also I would argue is going to highly, highly um uh impede your success from an ablation standpoint. So if I have a patient who's morbidly obese or has severe sleep apnea, I'll basically tell them I'm willing to do. The ablation, I need you to lose weight, I need you to treat this with urgency. I need you to see a bariatric clinic or a nutritionist or get on, you know, one of the imaglotide or one of these medicines, um, and I, and I absolutely insist that they see sleep medicine for um for sleep apnea. In terms of other things, OK, so specifically very advanced lung disease, um, the, the severe lung disease is just very pro arrhythmic, um, from an atrial standpoint, and if you've got end stage lung disease, not only are you a perioperative, you know, high risk, but you're unlikely to succeed long time and so we're gonna think long and hard before offering anybody um an ablation in that standpoint, um, and that's true for sort of interstitial disease as well as pulmonary hypertension. Very elderly patients, I say that because you know as the procedure gets safer, more effective, and faster, we're certainly um you know, our tolerance for doing patients well into their, you know, later 80s is getting a lot higher, so I don't treat anybody and there's no number. You can't say oh above this number I won't do it anymore. No, I'm gonna meet the patient, how do they look? Are they an excellent 85 year old or or even maybe 90 year old, but, but our own comfort with with that is, is sort of um. Evolving, but yeah, I mean a 100 year old, no we're not doing that, um, so and then and back to our prior point, really severe left atrial myopathy, you know, if someone comes in and they tell me, you know, hey, I've, um, I, I, I watched a video on atrial fibrillation ablation last night on YouTube. I wanna have one. I've been in afib since 1978 and my left atrium is bigger than your head. I'm probably not gonna do that, you know, it's just not gonna work. Severe untreated valvular disease, specifically things like mitral stenosis, and mitral stenosis is where you see those gigantic atria, you know, the rheumatic heart disease and whatnot where the um the atria dilates. It's, it's exceedingly unlikely that they will ever remain in normal rhythm long term. But let's talk a little bit more about obesity. So one of my good buddies, um, first of all, this is what I was telling you before, the, the success is not great in obesity, the complications go up in obesity. Everyone knows this from, um, our procedural subspecialty. But one bit one like beacon of hope is that um a buddy of mine did this really nice study where he took obese patients who underwent bariatric surgery and successfully lost weight. He matched them against people who were obese who never lost weight, and he actually matched them against normal non-obese patients. The patients who underwent bariatric surgery and lost weight. Did every bit as well as never obese patients, which is remarkable so it it's not like you're gonna lose weight and kind of spin your wheels and never gain any traction you will demonstrably benefit um from losing that weight and then going um for ablation, but if you don't lose weight, then your outcome long term from an arrhythmia standpoint is rather dismal. So that thus the, the, the impotence for, you know, um. Uh, you know, asking patients to seriously deal with with weight loss. Um, all right, cryptogenic stroke is an important topic, so one thing we learned from the crystal AF trial is that the longer you look in a quote unquote cryptogenic stroke, the more likely you are to find atrial fibrillation. So the days of kind of throwing a 48 hour monitor on someone and then declaring them free of afib. Uh, you know, are over, um, all these patients should have long term monitoring because it's upwards of 33% of people who have cryptogenic stroke will ultimately turn positive for Afib, and you will understand why they had their stroke. So loop recorders are very definitely the best way to do this, OK. You want to do at least a 30 day outpatient monitor. That's because one, let's find it the least invasive way we possibly can if we're going to, but also for insurance reasons many um insurance carriers will not approve a loop recorder unless they've already done an extended outpatient cardiac monitor, which pretty much makes sense. I don't fault them on that one, but loop recorders now last several years, you know, and it's no trouble to the patient whatsoever. It takes 5 minutes to implant. Um, and you get your answer that way, um, so they're highly, highly useful in that scenario. I got a lot of questions, um, you know, before this talk about anticoagulation and the struggles, um, you know, with that so let me go through that a little while. Obviously we all use the Chads VA score. It is not perfect. No one has ever claimed it's perfect, um, but it is our best tool for predicting, um, you know, stroke risk, um, as laid out here. But one point that I want to make about the Chad's vast score is I, I would stop thinking of the Chad's vast score as a mathematical risk of you having a clot in the appendage. That is actually not the case. Instead, think of the Chad's vast score is. Way of calculating endothelial health, OK? Because it turns out that Chad's vast score predicts stroke even in people who don't have afib, OK? So it's actually just a, it's how how much at risk you are and there's a reason why I went through this first. Because the question that comes up for you guys and for me every single day of our lives is right, I've had an ablation. I'm not having any atrial fibrillation anymore. If atrial fibrillation causes the risk for stroke and I'm not having atrial fibrillation, so therefore I'm not gonna have stroke and I can come off my, you know, blood thinner literally every single day of my life I have this conversation 100 times. The problem is is that never have we had a study that ever confirmed that. OK, every time we look at this with large trials, even meta-analysis, it is either that we have no statistical benefit of ablation to reducing stroke, or if it does have a signal of reducing the risk of stroke it. Definitely doesn't go back to zero, so you can't tell them that your risk is now gone. It might be slightly lower and in reality, yes, every last one of us electrophysiologists think that a successful early ablation in an otherwise normal atrium is going to substantially reduce the risk of stroke, but that is more clinical intuition than it is something that's ever, ever been borne out in. The literature, so I have to tell people I'm sorry, even if I do planet Earth's greatest afib ablation that's ever been done in the history of mankind, you're staying on your eloques, right? So that that's, that's the sad reality of it, or you're gonna make an informed decision to say I think my stroke risk is sufficiently low. I'm gonna come off of it, but I understand that there is a non-zero risk of stroke going forward. Um, I put this, um, article in here because I think it was a really, really nice commentary and when you wanna sit down and go through it in a little bit more detail and not just take my kind of 32nd opinion on this, these, these authors really, really lay out the, the conundrum of postoperative, um, you know, or post ablation stroke risk, um, in great detail, so this is, this is available. Another good topic is what I kind of referred to as situational atrial fibrillation. This isn't really a technical term, it's just the way that I was describing it. So to give you examples, OK, what to do with atrial fibrillation around, you know, perioperative or if you come in in a car crash and your heart goes into afib, or severe COVID or or flu or pneumonia or something. What are we doing with people who we find some afib, but it's in the context of an acute ostensibly reversible stressor, what do you do long term? Alright, so this is sort of my approach to this because of course we get this question all the time. The very, very first question has to be, is it actually new? So plenty of people have had afib, you don't know about it, then something bad happens to it which invariably is going to cause their previously low level Afib to act up a little bit more and now you become aware of it for the first time. That doesn't mean it's new, right? It just means it's new to you. I sort of jokingly refer to this as acute recognition of chronic disease, right? Um, so you go through the history, OK, if they are symptomatic in this new atrial fibrillation, I feel tired, I feel my heart racing, you know, so on and so forth. Did you ever feel this in the past? Did you write it off before, you know, oh, you know what, in retrospect, uh, you know, I've kind of been feeling this on and off. OK, that's probably not new. If you look at the echo and they have moderate or severe left atrial dilation with no other reason, again, I don't care what you say, it is not new. You've had this for a long time. And the other thing is if you come in and you know you're ill, you have COVID, and you have very persistent afib and we're having the cardio virtue out of it after a week or two of hospitalization. The fact that it kind of came in for the very first time as persistent, that's just not really the way that Afib usually behaves. If it's truly new, then guess what? You're gonna take a history and they're gonna say I've never felt this ever again, you know, before, um, today. I know I'm, I know I'm in it now and this is a brand new symptom. The left atrium's gonna look stone cold normal on the echocardiogram, and they might have an hour of afib on telemetry that goes away on its own yet you still get consulted, you know, because it's there, but that's the way true new Afib behaves. So start your process by saying, um, is it actually new and operate under the assumption that it probably isn't new, but you might be pleasantly surprised if it is, OK, because that that changes dramatically the way that you treat it. If you in terms of what to do about it, OK, well, anticoagulation, so if you think it really isn't new or they're persistent, yeah, you got anti coagulate them, OK? If they had 10 minutes of afib on telly and you think it is absolutely brand new, well then, no, I'm not sure you need to anticoagulate that if you think it's gonna get better when the reversible precipitant is gone, you're gonna very definitely make sure you're right with some downstream monitoring, but OK, maybe you don't have to do anything much at that time. Um, if it's persistent, we always say a trial of sinus rhythm or early, you know, intervention to get them in sinus rhythm. So if they're a good candidate, don't let them go home in afib. You know, TEE cardiovert, um, you know, and let them go home or at worst, if they're nice and rate controlled, bring them back 4 weeks later after uninterrupted anticoagulation for an outpatient cardioversion, but 4 weeks is not a big deal. 6 months, 2 years, 3 years of of like letting the Afib go, that's a very big deal. If they are having substantial issues, you know, perioperatively and whatnot, then yeah, most of us will probably do a short course of an antiarrhythmic traditionally because it's so mindlessly easy 3 months of amiodarone, then get rid of it, um, and don't let them, you know, um, sort of get stuck on amiodarone for years when when they don't need to and then they get downstream side effects from that medicine, um. But in almost every one of these cases you then need to follow this up with monitoring, so something like a 30 day monitor upon discharge to see again if it was not new, then it's likely to recur, um, you know what's the burden, what's the heart rate, all that kind of stuff, it's gonna guide your further management, um, and then let's just say you decide that it was new, it's gone, we're taking you off the meds, no anticoagulation. I still think that you need to operate with data and so I asked them, you've got to have some means by which you're gonna monitor. It can be one of the watches now, get a card to your mobile, whatever it is, you need to have some way in which you're going to keep eyes on this because heaven forbid you stop all the meds, you stop the anticoagulation, then you find out you're wrong by way of a stroke, right? So that that's just not something I'm willing to get wrong. Alright, so there were a couple of kind of more specific questions that I was gonna tackle directly, um, so one was, OK, what's the best study to study to cite when patients ask, do I really need to be on ELIS the rest of my life? I haven't had afib in 3 years, um, that look at the ones that I included in there. Those are the best, um, the data is there, the data is rather convincing. There will almost certainly be iterations of those studies going forward where if you took. Otherwise low risk people with brand new Afib got really, really quick ablation and they're not having any more um Afib down the road. Those people, yeah, we suspect they may be able to come off of their um anticoagulation down the road, but no such trial has been done thus yet, um. How can we advocate for lower costs for eliquis? Yes, it, it's the perennial pain in the butt every single day of our lives, um, so obviously you know you can get people the 1st 30 days, um, free, you know, with the, the, the printable coupons that that'll save people up front, um, for people who really are kind of um financially challenged, um, and, um. Uh, and, and kind of don't have the means to avoid, uh, to afford any of the medications. There are cost assistance programs, so we do this every day in clinic. We're filling out the paperwork and getting the costs, you know, reduced for patients, um, and, uh, and that works for the great majority of people it does not work for everybody, um. One point that probably everyone has figured out is that for whatever reason insurance carriers seem to prefer one of the DAs over all the others, and it's never predictable and it's different from one to the other, so they might charge you through the nose for a Pixaban, but then. Give you Rivaroxaban at a very reasonable cost and so I always tell people, look, I'm gonna send you home on something call up your insurance um provider ask them which one will you give me for low cost, and then I just change the prescription as fast as humanly possible. OK, so I want them to be on the cheapest one. Um, you know, as, as you guys know, we don't make a red cent off of any of that nonsense, so I wish it was all free, um, but it is hard and you know, to find people affordable options. There are the rare people out there who can't afford any of it no matter what we try. Warfarin is the alternative obviously for people who can't, and that's just awful because warfarin should probably go the way of the dodo bird here soon, um, but, um, but then the only other option I would say is that um. You know if if they cannot take any of them and maybe they're unwilling or unable to take warfarin for specific reasons, then technically that's a form of noncompliance, right? They're not misbehaving, they just can't comply with the with the regimen, um, despite their best efforts, um, and then at that point, you know, consider watchmen, right? So you know if you directly compare the long term cost of Watchmen versus the long term. Cost of Eliquis or or Xarelto at the current prices, it's actually quite favorable. I think the out of pocket cost was estimated at something just a little over $2600 you know, grand total for the average person going through Watchman, which is not a small amount of money for many of our patients, um, but when you say, yeah, I'm paying $400 you know, for every refill of my, uh, you know, Eliquis, I'm sorry, that adds up real quickly if it's gonna be a medicine you're on the rest of your life. Um, so hopefully that helps, I mean, I don't I don't have the, I don't have the answer long term, I will say that, you know, um, I think. Apixaban and Rivaroxaban were both um uh included in the inflation Reduction Act as um 10 of the medications that were marked for mandatory price reductions um that is not a perfect solution. There there are all sorts of concerns about, you know, insurance companies passing on the costs in different ways and and so it's not uh uh a cure all and even still that wouldn't even take effect until 2026 if that bill even holds up. Um, so there are ways that the government's trying to intervene, but as you might expect, it doesn't happen fast or efficient enough. Um, uh, so this was sort of a similar question asking about the bigotran, yeah, sure, use the bigot train if you can, um, you know, again, I'm not that picky. If you can find the DA that you can accept, um, from a financial standpoint, then go on that one, What are some concept misconceptions um providers or patients have about ablations or certain antiarrhythmic therapies um that I have to clean up, um. Ah, I don't know. I'd actually be more interested in which ones you guys see, um, I would say, um. Uh, probably what I've already gone through that like ablation is for people who've only tried a bunch of medicines and failed and it's sort of last line therapy, yeah, that's not real anymore, obviously that reflects outdated, um, practice, um, the concern that this is a big one, a concern that people say, well, you know I've got friends and they all told me that they have to have multiple ablations, so how many am I gonna have, you know. That's such a hard question to answer, um, but the way that I answer it for people is that, um, look, if you truly are the modern day example, your Afib is is very recent, your left atrium is normal size, no scar tissue, you're you're not, you don't have ongoing drivers of Afib like untreated sleep apnea or alcohol or overweight or all these things. If you're just an average person coming in for an early Afib ablation, you may never need another one. It's very possible, OK? If it's been going on forever, um, and all of those other things are true, yeah, it's very possible you're gonna need more than one, and that's, that's the God's honest truth. So, um, so that's one of the big questions that I get all the time. Um, and maybe when I'm finished talking, others will chime in about, um, things that they, um, um, you know, have, have encountered in terms of questions. I mean, in terms of anti-arrhythmic therapies, um, yeah, again I've already told you what I think about droneterone, um, you know, or MLA. I just think it's way too expensive for most of our patients and the number of people that succeed are near 0. I think Daetilide is underutilized. It's just a pain in the butt to have to come in and get loaded on it for 3 days, but it's a highly, it's probably our second strongest medicine to. Amiodarone and without the long term side effects um that amiodarone has so I think that's probably underutilized but I would argue that defetilide is sort of under the purview of an electrophysiologist only. I don't think people should be loading um diphetilide elsewhere in the system um. And um, so those are, those are I guess two of the big ones. 000, here's a good one. I'm just trying to think of these as I go. So fleanide Fleconide is a big source of, of, um, you know, controversy. Um, so people say, well, look, if I've got coronary disease, I can't use fleconide. That's that's actually not true. So where the data came for fleconide being a bad idea in coronary artery disease was actually, um, when it was when it was studied in clinical trials to try to suppress ventricular ectopy after an MI so literally someone has coronary disease, they had an MI they probably completed. MI or maybe got revas um but they're having a lot of ventricular ectomy after that they said, OK, well let's try to suppress all that with fleconide and there was an increase in mortality at that time. That is so very different than saying I have mild non-obstructive coronary disease with no scar whatsoever on non-invasive imaging, um, I have no ischemia whatsoever and I'd like to use it for Afib. Yeah, 100% that person can use fleconide, OK? It is the ischemia and the scar that gets you in trouble with fleconide, not the presence of small plaque. So, um, that's sort of a myth that that needs to be undone, um, for some people. What else? How can the general cardiology team best prep patients uh about what to expect from referral to EP? How can we identify sooner which patients are best suited for referral to EP? Yeah. So good questions. I mean, I think that nowadays, you know, we're trying to do these EP ED to EP pathways and and other such measures to try to get people into an electrophysiologist's office as soon as possible um when they're identified as atrial fibrillation for all of the reasons we just went through, right? Like that that's sort of the idea so the sooner the better. Um, and really and truly anybody you see who is otherwise young, functional, um, you know, just needs to tackle their Afib and needs to tackle it as soon as possible for long term benefit. There should be zero delay. There, there shouldn't be, well, I gave it my best over the last 5 years. Let me, you know, turf it to EP now. No, not really, um, just, just send it to EP. Um, now, again, keep in mind all the things we just talked about. So if you say, well, hey, look, this person is newly diagnosed with Afib, let's get him into EP as soon as we can. They're 101 years old, you know, no, I mean, no, we're not doing ablations on on people over 100, um, and so, um, so you use some common sense there, um, but yeah, pretty much try, try not to, um, to drag your feet at all actually. But like what to expect, OK, so you can kind of jokingly say we're the electricians, that's what I say when we when I see them in clinic, um. And by and large you're going to the EP clinic because we think there's the possibility of needing something more, right? That's the idea. Electrophysiologists are doing something more than what we have done with anticoagulation and rate control and maybe beginnings of anti rhythmic therapy. We think you might need something more like more complex antiarrhythmic therapy or specifically ablation. And I would begin to prep them for the idea of what an ablation is, at least in general terms. They're gonna talk to you about ablation. It's an in and out, same day procedure. Go home, sleep in your own bed, takes about an hour all through the groin, no cutting, no big scars, you know, and they'll go through it in much more detail with you when you see. And they're like, OK, fine, because the great majority of people, I would say 80-90% of people who arrive in EP clinic having been referred, they do not know why they're there. I say, hey, do you, I start, I start literally every one of my visits this way. Do you know why you're here? No, I have no idea. I just saw it on my schedule. Oh right. You know, and, and then, and then I've gotta build it all from the from the ground up, um, so, um, but yeah, that, that would be the general conversation that I would have with people about a fib, but I'm not putting it on everybody else to kind of go through it in nitty gritty detail. Most of us like to spend a fair amount of time drawing out what an ablation is and talking them through it and giving them their options and and that's kind of what we're there for, um, but hopefully that's helpful. Are there any emerging technologies you wish to see coming to Santera in the near future that may replace our current management? There are no groundbreaking ones. Pulse field ablation would have been the answer to this, but it's here now, and the, the probably most useful technologic advances coming down the pipe are just improvements in pulsed field ablation, better catheters, more targeted, um, you know, more efficient, so on and so forth, um, that's probably all that is the, the big deal. Um, the only other thing that I would say that sort of falls under this category maybe is that I think that the um the threshold to proceed with um Watchmen will continue to diminish, right? So Watchman is very safe, it is highly effective, um, people do not want to be on blood thinners the rest of their lives and so. I think that if I have a crystal ball, which I do not, and I look into it, um, I will say down the road, almost certainly we're going to be doing, you know, concomitant watchmen and afib ablations for nearly everybody who's a good candidate because you're already there, right? I'm doing an ablation 5 millimeters away from where a watchman goes. Why am I going to bring them back for a second? You know, procedure and why am I gonna tell them stay on this medicine the whole rest of your life. I do think that's the way that'll go, but that is obviously very much not the case at the moment. um, you can't just throw a watchman in everybody. Um, Alright, so in summary, rhythm control is superior to rate control. Time to rhythm control matters. Ablation is superior to anti-rhythmics for the rhythm control. Pulsed field ablation is now available and is fast and is safe. There is actual mortality benefit for heart failure patients, even end stage heart failure patients for cryptogenic stroke, the longer you look, the more afib you find. And importantly, stroke risk is not removed after successful ablation. All right, probably have some time for questions, I would assume. Published July 14, 2025 Created by Related Presenters Jeffery Hedley, M.D. Sentara Cardiology Specialists View full profile
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