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thank you all. how's everyone doing? good. it's a tough, tough act to follow john. it is tough. i'm going to do my best. i want to thank mellanie and everyone at stopafib.org for having me here. it's a real privilege tobe here and mellanie hit me up for two talks and i happily obliged. so you'll have tohear me twice but luckily you'll have a break in between. what i'm going to do isgive you an overview on how we, as physicians who really have focused ourlives on afib think about treatment. the point is not to overload you withinformation. you can read this. you'll have the slides. the materials will be there.
the point is to give you a framework ofhow we think. there will be more detail than i would ever expect any audience toto take in, but it's there for you to come back to and digest. the reasoni thought this was important is to really lay out how the advice you'regoing to get now is even different from the advice you may have received two, three years ago. and this is true for rate and rhythm control and also for preventing strokes.so the first thing you have to deal with when we're dealing with afib iswhich path are you going to go down? there's a fork in the road. rate control in afib is when youreally focus only on keeping the heart
rates in a reasonable range so that youdon't experience symptoms or other consequences, typically of the extremelyfast heart rates that can occur. and those may occur at rest. they may occurwith exercise. they may occur unpredictably and may be triggered bymany of the things you heard dr. day talk about in terms of triggers. andsometimes those triggers are not just those that provoke you into afib. theymay provoke the heart rates to behave erratically as well. rhythm control is when, as dr. daysaid, you really make it a commitment to
keep the heart in normal sinus rhythm andthereby avoid the consequences of the fast and unpredictable variation inheart rates that you that you have. so the problem we have sometimes is theinherent bias that we think one side of the road is sunny and one side of theroad is cloudy, but in truth, this fork may emerge in your life multiple times.how many of you have seen more than one doctor for your afib? how many times, every time you go to a doctor, something changes, they change something? yeah, not an uncommon situation. so the reason we think about rhythm control is when theafib is causing symptoms, and the symptoms vary, and all of you know this betterthan your doctor or better than me.
the problem is is the way we, as healthcare providers, think about what these symptoms are. sometimes what happens is, a physician who has a lot of things to care for and has to make sure that allof you, not just your upper chambers of your heart are functioning, may not have the time, resources or understanding to go through all of the symptoms. and it'shard to connect the dots if you don't know what afib could possibly cause. sosometimes some doctors may ask you if you have palpitations, and if you don't,you must not have symptoms of afib, and that's not true. what we see here is that thereare many different things that can happen. the fatigue, the weakness, thetiredness we just heard from a patient,
can be a real problem for patients. and that's often expressed in different ways. that can be someone justbecoming irritable. i had a patient's spouse complain that she knew when herhusband was in afib because he just got grumpy. and she commented when he was wearing the holter monitor when he was grumpy and it tracked when he was in afib. her notes matched spot on. so these symptoms can be very, very subtle. what we have not done a good job of is figuring out a way how to quantifythese symptoms or in some way measure them in the same patient. there arequestionnaires, scales and instruments this one comes from europe,
and many of us acknowledge that theway the european societies have started to think about afib in some waysexceeds the framework that we have in the u.s. there's good and bad, and a lot ofgood doctors will take some from here and some from there and piece it together.but the ehra scale really talks about disability and symptoms, and it's afunctional scale of what is interfering with your daily life. so should rhythmcontrol be used without overt symptoms? again, this is one of those things whereyou have to connect the dots. and you're all here because you know about afib;it must have an impact in your lives. but in some patients, heart rates are not soobvious if they're out of range. now, this
is a patient that has good heart ratecontrol and this is a monitor that he wore, and this is the two-day snapshot.and what you can see here is that the general range of 60 to 100 is where you kind of want people's heart rates to be, and you can see where the average is, which is a single dot, and where the range was for that day. he felt mostly fine, but heeven triggered some diary events that you can see up here and he was in afib24% of the time. now, this person has good heart rate control and he felt fairly well, so rhythm control may be fine, but some patients may have very fast heartrates and feel perfectly fine. and that is a situation where, although they're notovertly symptomatic, we as their
providers are concerned that those heartrates can cause problems. and as part of that, the heart failure, the inability for the heart to squeezeand work as that pump to give the rest of your body the blood that it needs, that even maynot be so obvious. now, afib can cause heart failure a lot of ways. and theimportant thing to understand is that prolonged periods of excessively fastheart rates, and in some cases, not excessively fast heart rates, diminishthe heart's ability to contract. and that is in the acute phase very quickly whileit's happening, but also in the chronic
phase, even after that afib episode were to terminate. and the way that's seen is in two ways, but the most common is that the ejection fraction declines. that means your systolic function of the left ventricle, that's what we call it, the squeeze of the heart has weakened. most of the time, it's reversible. and the other thing tonote is that patients who have diseased hearts for other reasons, prior heart attacks, coronary disease, maybe a thick heart from hypertension, may be the ones that are most vulnerable. andas heart failure develops, you get in this vicious cycle where the heartprogressively becomes dependent on
atrial function. so sinus rhythm isn'tjust happiness on an ekg; that means that the upper chambers, the atria, aresqueezing in synchrony with the lower chambers, and your pump is working onfour cylinders and not just two. and what happens in heart failure is that thoselower two cylinders, the ventricles, end up not working as well, so that the uppertwo cylinders, the atria, need to squeeze a little bit more. and that worksin two ways. the systolic dysfunction, which is a squeeze of the lower chambersand the left ventricle in particular, and the diastolic dysfunction, which is theability of those lower chambers to relax to allow the blood to come in. and if theheart is thick from high blood pressure
or other reasons, it stiffens. and when itstiffens, it can't relax, and if it can't relax, the atrium has to squeeze andsupply more. this is nothing to really stare at for very long, but it tellsyou the mechanisms that we now see in terms of what how the fast heart ratescan lead to heart failure. there are many ways that this happens and this is a massivearea of understanding where we're just starting to really learn the cellularand the energetic and biochemical mechanisms for this. and what does happen over time is you, as i said, get in this vicious cycle. the terms here arenot important, but what you have to appreciate is that afib causes heartfailure and heart failure causes afib.
one can beget another, and our goal is to help you break that cycle. so how does the doctor decide what torecommend? how does a doctor decide what fork you should take and what to advise you on? and the problem with this is that a lot of this decision making is a matter ofperspective and anytime we say it's a matter of perspective, you have to worrythat there's some bias thrown in there that may not really reflect an objectivedecision that's personalized for you. william evans and peter swann wrote thisin 1953 after they observed 20 patients, all men. "...the condition did notjeopardize life in a single instance and did not prove even a handicap to themajority." "longevity is unaffected."
"reassurance should be the uppermost in treatment..." "...continuous digitalization," digoxin, which we'll talk about, "...is the ideal treatment," and an urge to re-instate sinus rhythm should be suppressed." 1953, okay? good thing you're here today in 2015 and not in 1953 because you know what wouldhave happened in terms of your treatment here. this is wrong. so the road not taken is a matter of perspective. and in someways, a matter of your perspective, but also your doctor's perspective. welooked at this and looked 163,000 patients who had a new diagnosis in the va of afib and we'd asked a simple question. ifthey went to a primary care or general
medicine doctor, or if they went to acardiologist, which includes an ep, electrophysiologist, was the initialtreatment different? and if you adjust for everything, and we even adjust fortheir travel time, how far they had to go, and balance the group so that thedistance to the cardiologist was the same as a distance to the primary care doctors.and what you can see is that the cardiologist, if they were seen bya cardiologist, they were almost twice as likely to be prescribed rhythm controldrugs. and the gap actually got worse over time. so it could be that somepatients self-selected themselves even though we tried to adjust for that,but the almost 2x difference
suggests that this is clearly a matterof perspective. and what does that mean? well, perspective is how we interpret theevidence, and how i as an ep and my colleagues as a cardiologist and even amongst us friends and colleagues, interpret in evidence is going to vary based onthe lens we're looking through. and what has happened in some circles is, there'sbeen a lot of weight on older data that really has lost relevance. thistrial is a trial that's often quoted in circles outside of ep, the affirmed trial,occurred almost 15 years ago now, where they looked at rate versus rhythmcontrol. both groups got anticoagulation, but they looked at thisand looked to see, was there an outcome
difference whether you started withantiarrhythmics or whether you started with rate control medications, but the important thing to note is it doesn't really generalize tomost people with afib because they threw out or didn't enroll anybody withsymptoms. so when you look at the data of a firm and you show that, in fact, thepeople who are on rate control had a trend towards better survival, you'remissing the point because this excluded patients with symptoms. so the reason iam passing this on to you is that you educate your peers, and sometimes yourproviders, about the way we've moved away from some of these trials. and you'regoing to hear more about ablation and
rhythm control trials in the afternoon. idon't want to go through too many of those drug trials because you're gonnahear about that later. again, in the affirm trial, they also saidthere was no difference in quality of life. well, that's because they didn'thave a problem with quality of life when they enrolled in the trial. so this is not relevant, butsomehow this data in this trial, with it's catchy name, gets brought on andgets talked about and talked about and talked about again. and my colleague, which you'll see, dr. sanjiv narayan, i'm so glad he has called his trial firm and his approach firm, because we need to get
away from affirm. so the severity of afibshould also influence decision, and antiarrhythmics have inherent risks thatexceed risks of rate control, to the extent that sometimes doctors mayrightfully, or not, become concerned about using these drugs. but thewillingness to try rhythm control really is one where it depends on the potentialbenefit, and the severity of afib can influence that potential for benefit. soyou have to weigh the risks and benefits of the therapy, okay? the problem was the next one, this button,"trust me, i'm a doctor." so the doctor would look at the scale, figure outwhat's right for the patient and make a
decision, and we're just not thereanymore. in fact, we now have volumes of text and information talking aboutinterpreting benefits and risks, teaching doctors how to do this. shared decision-making, partnering withthe patient and making that decision together. and in fact, the top-linerecommendation from the aha/acc/hrs, the professional american society guidelinesabout what to do in afib is first and foremost, it should be a shareddecision-making process. it's not about the individual drug. it's not about thisor that. some of those things are important, but top-line recommendation ispartnering with your patient. so let's
again get back to the severity issue. you heard a little bit about this from dr. day. the severity and the way we think aboutthe afib is more of an issue of how it behaves and less of an issue of how muchor how often you have it, the duration or the burden. paroxysmal afib is when itcomes and goes on its own, but unpredictably, and that's a huge problem.persistent is when it starts on its own, but as youheard from a patient, it doesn't go away on its own. something hasto be done, often a cardioversion. and permanent afib is a tricky term becausethere's a judgment implied in the term
and we don't love it, but it means thatyou've tried and tried and tried and you can't get someone out of it. and thereason this is defined by behavior and not burden is if someone comes to myoffice and tells me that they've been in afib for the last six months, i'm doing adisservice by calling that permanent. we don't know what that is yet. we haven't challenged it with behavior. and sometimes what we will doin a patient who has symptoms is to see how the afib will behave just so that wecan classify this to help prognosticate treatment. in the natural time course ofafib, this is classical, every patient's different, is you may have afib thatyou don't even know about, short, little
bursts, couple seconds. oh, that felt funny. oh, i felt a littleflutter. maybe it was something i ate. maybe it was the ice cube i swallowed,don't know. it then becomes more symptomatic as it gets longer and thenover time, months, years, longer sometimes, becomepersistent or even permanent. and we have developed the classification aroundthis scheme. there are flavors of how this has been modified, but this isreally how, again, we think about the behavior. now, it's not just aboutcharacterizing your symptoms and how it works, but actually, these provide someinsight into the mechanisms and what's
going on, and in turn, how we might ablate it, which you'll hear about in the afternoon. paroxysmal afib typically occurs inhealthier hearts that are irritable and often you can succeed by taking awaythe irritability. and if the irritability is gone, the heart has a tendency toavoid going into this on its own. once you have persistent afib, you need something, that shock to get out, you have to do more, and permanent afib may be that it's very difficult to affect that because the heart is in fact scarred. whatthat does tell us is there's a window of opportunity for attempting rhythmcontrol. you really have to time this
well so this also influences how wethink about what to do. okay, what drugs can be used? there are alot of drugs and a lot of choices. there are antiarrhythmic drugs that are shownhere on the left. there are rate control drugs shown on the right, and we don'twant to get into many of the details because it really varies on what you canuse. i'm going to give you a framework on how we think about it, but there are alot of different options here there's no one right drug. the way we have evolvedto think about rhythm control is we look at patients and determine whether theyhave structural heart disease or not. and if they don't have structural heartdisease, you have greater latitude in
using certain drugs. what has changed,again in the last couple of years is, we've made a clear distinction aboutwhat we want to use first-line, and what we want to use second-line, such as amiodarone not being used first-line. and the reason we care so much is thatthere are drugs on the left, these are all antiarrhythmics used for manyreasons, they all have problems. you have a lot of serious acute and chronicadverse effects, and we have to think very carefully about what we use. two ofthese drugs, sotalol and dofetilide, to maintain rhythm work extremely well, andagain this is informational, but nothing you should know. the pointis is that they have a lot of problems.
you have to bring patients to thehospital for dofetilide, and more commonly, we're now doing that for sotalol for up to three days to load them to make sure it's safeso this doesn't happen. this is calledtorsade de pointes, or a form of polymorphic ventricular tachycardia thatis because the body is seeing exceedingly high levels of these threedrugs. so you have to watch these drugs and do them carefully. this isessentially equivalent to sudden cardiac death and that's what you of coursedon't want. so there is appropriate reservation, but as experienced capablephysicians and healthcare systems that
are resourced, you can get on these drugsand be very safe and not have problems. let's talk a little bit about amiodarone. so amiodarone used to be a favorite in many people. it'seasy to prescribe, it rarely causes arrhythmias, and it's well tolerated inthe short term. the problem is it deposits everywhere. it stays in your bodyand can take months or longer to be eliminated. every time you take amiodarone, a little bit of iodine is released in the bloodstream, and there are some dose-dependent effects, especially on the thyroid, the lung and the liver. it alsointerferes with warfarin so we now don't used this first-line unless there are noother options really remaining, which can
happen. dronedarone is a new drug, relativelynew, that is supposed to have been amiodarone without the badness of it. ithas no iodine released. it has no accumulation effects, but now, we'relearning it's actually not terribly effective in most patients and canprovoke heart failure, so it's fallen a bit out of favor in the u.s. as well.let's talk about rate control. how do we decide what to use first-line? this ishighly variable, and you need to ask your doctor why they are recommending whatthey're doing because there is not a ton of evidence in terms of whetherbeta-blockers, metoprolol, atenolol, others,
or calcium-channel blockers, diltiazem,verapamil, are better. it's a personalized decision based on how well someone'sgoing to tolerate them and in some cases, whether heart failure is a co-existingcondition. so again we think about how to do afib rate control the same way. we have certain first-linedrugs based on other accompanying diseases, and we try to avoid amiodarone, which rarely can be used just to control the rate. so this again is amatter of discussion and personalization. what about digoxin? well, digoxin's got a lot of press lately. we're partly to blame for that. we did a big study that gotsome press back in last august where we
looked at a 160,000 patients and found, in newly diagnosed afib, not long-standing afib, but new afib, and we wanted to see if there was a problem with the drug. and we found anincreased risk of mortality with digoxin. this was not a randomized trial, and youdon't prove that it was definitively the cause, but it got a lot of press, andthere's been a lot of studies afterwards. and the point of this isn't that youshould stop your digoxin. it isn't that it's going to necessarilykill patients. it's an observational study. there are many potential causes. the pointof this study is to have a conversation amongst us as physicians and amongst our patients and us as physicians about what
really are the best choices. maybe thisis right, but could there be other options that could do just as well, ifnot a better job. how fast or slow should my heart beat? there's no right answer.it's highly individualized based on symptoms and avoidance of extreme heartrates. and the trials of strict and lenient control just haven't been verygood. so we have guidelines, and again, i'm showing this to you to give you insighton what we think what we're held to in terms of accountability. in patients withafib-related symptoms during activity, the adequacy of heart rate control should beassessed during exertion, adjusting treatment as necessary to keep the ratewithin physiologic range. don't just look
at your resting heart rate, see what itdoes with exercise. so i'm going to close here. there is a lot to digest and we're gonna have a little bit of time for questions. i will be at the break, but thechoice of rate or rhythm control is a highly, highly personalized decision thatis guided by symptoms, which may not be apparent, quality of life and now, theimpending risk of heart failure. that's something that's relatively new. so one is, are you in tune with your symptoms? are the things that are nuisances in your life there, and could they be associated with afib? and thesecond point is more important. is your doctor in tune with you to personalizethis decision. and within each of these
strategies, there are numerous drugs theycould be chosen based on individual circumstances. there's no decision, thisis not a permanent fork in the road. you may revisit this many, many times overthe course of your life. so no decision is final, none irrevocable, and the bestdecision here really is one that's made through a shared decision-making processwith you and your doctor. thank you.