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Melanie Cole (Host): According to the American Heart Association, at least two and a half million Americans are living with atrial fibrillation or a-fib. A-fib is an irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications. However, people who have atrial fibrillation can live normal, active lives. My guest today is Dr. Andy Brenyo. He's a clinical cardiac electrophysiologist at Greenville Health System. Welcome to the show, Dr. Brenyo. So what is an arrhythmia and how can it go wrong sometimes?

Dr. Andrew Brenyo (Guest): An arrhythmia is an irregularity in the electrical coordination of a heartbeat. Every heartbeat is controlled -- like any other pump -- there's a valve component and an electrical component. So, when you lose coordination of the actual electrical function you develop irregularity in the heartbeat. This can be manifest through symptoms including a sense of the irregularity, a sense of skipping, chest pain, etc. Where it can go wrong is when the arrhythmia either results in symptoms that are bothersome and affect the quality of life or if it represents an increased risk for other complications long-term, like heart attack, stroke or heart weakness.

Melanie: So, you mentioned a few symptoms. Would someone know if they had atrial fibrillation?

Dr. Brenyo: When you look at the most common rhythm that we face and treat as both a cardiologist and a cardiac electrophysiologist, atrial fibrillation represents the most common arrhythmia that we see. The unfortunate element of atrial fibrillation is the majority of patients are not fully aware that they have the abnormal rhythm. They either assume that they're just a little more fatigued this week or their shortness of breath when they exert themselves is because they're out of shape, so if you look at the majority of a-fib patients, patients are eight times more likely to have no or minimal symptoms when they are in a-fib, so one out of every eight patients actually has overt, really bothersome symptoms. So, the important thing on our end is providing education for the majority of patients who don’t have symptoms to monitor their blood pressure, monitor their heart rate so that if they do have such an arrhythmia it can detected and presented to a physician in an effort to hopefully minimize their risk of negative complications down the road.

Melanie: How's it diagnosed?

Dr. Brenyo: The gold standard for diagnosis is primarily an EKG or electrocardiogram. However, one of the items that we have been working through the community to increase the use and penetrance of are the kind of remote monitoring and rhythm elements of smart phones and applications that can actually diagnose a-fib quite regularly and with a good degree of accuracy. So, yes, an EKG is actually the gold standard for diagnosis, but the kind of rhythm information you can get from simple phone apps or those that you purchase on say, Amazon or some on-line, you know, vendor. Those are actually really good for detecting atrial fibrillation.
Other symptoms can just be that patients come in and they have symptoms of irregularity or as we discussed, chest pain, shortness of breath, lightheadedness. All of those things can provide a historical element for diagnosis, but the EKG still represents the most common way that patients are diagnosed.

Melanie: So, then, let's speak about some of the goals of treatment and what the first line of defense would be. What would you do, Dr. Brenyo, if somebody is diagnosed with this, and what do they do first?

Dr. Brenyo: So, there's two elements to the care of this arrhythmia, and the most important first step is assessing stroke risk. Atrial fibrillation is the most common cause of preventable strokes in the United States with a very high morbidity and lasting effect, essentially, to my way of thinking representing a derailment of somebody's quality of life -- a sudden change. So, we sit down with every patient who has a-fib and talk about their clinical risk factors for a stroke down the line. Depending upon their medical history, we may prescribe a blood thinner to minimize or prevent their risk of stroke or we may just continue to monitor if they are really healthy and young.
For patients who have more in the way of medical problems, they're more likely to be prescribed a blood thinner. So, that's the first and most important element of our discussion and clinical time and developing your relationship with the physician for a-fib. The second element is dealing with patients who have symptoms and minimizing their risks of complications besides stroke down the line. When you look at patients who have symptoms for their a-fib -- or symptoms of their a-fib -- the first step generally is the initiation of a rhythm drug called an anti-arrhythmic drug that can help minimize their risk of returning into a-fib and shorten the duration of their episodes. They're not perfect, so oftentimes we have to either change medical therapy or continue the evaluation process over a series of visits, potentially culminating in discussion of procedural ablation therapy to try to control the rhythm.
So, usually, the first steps are two things. One, assessing stroke risk. Two, dealing with symptoms or assessing symptoms to determine if a subsequent medication is required to treat their a-fib.

Melanie: So, after you've done the stroke assessment and possibly medicational intervention, then you're looking to rate and rhythm control. What does that involve in your department as an electrophysiologist?

Dr. Brenyo: So, rate control is for patients who don't really have symptoms and are fine being in atrial fibrillation. There's no problem with being in a-fib if you have no symptoms. If your heart goes too fast for too long, it's just like a car engine. If you run a car engine too fast for too long, you never change the oil, you never do anything to it -- it'll burn out. Your heart's the same way. So, when we utilize medications to control the rate, what we're doing is preventing heart weakness from developing over time. That can be done by a cardiologist. It can be done by your electrophysiologist. Generally speaking, it is done by some form of heart doctor. When it comes to actually trying to control the rhythm and keep a patient in normal rhythm as opposed to atrial fib, that's usually where an electrophysiologist gets involved, although again, we can be involved just for rate control. So, that's where we would start one of the rhythm drugs to try to prevent atrial fib or shorten the episodes that you may have. In addition, when you even look at patients who have fast rates, if we can't get their heart rate slowed down with medications, we can consider the use of things like a pacemaker, primarily as a last resort. However, it is something that we do deploy when we're utilizing a lot of medication and not being very successful in keeping their heart rate under control.

Melanie: So, what's next for the person living with atrial fibrillation? In catheter ablation, in all of these things that you've discussed, can they live a normal life? What should they be on the lookout for as far as lifestyle modification and activity?

Dr. Brenyo: Procedural therapy for a-fib has come a long way, and we've discussed pacemakers for patients who don't have much in the way of symptoms -- they still would need to be assessed for stroke and be on a blood thinner. For patients who have symptoms or are deemed to be good candidates for ablation, our goal with that therapy is to preserve their quality of life and essentially return them to being as normal as possible. Patients can live with a-fib as long as we prevent stroke through the use of blood thinner, the likelihood that it's going to alter life expectancy significantly is very low. So, it's not going to result in you living any shorter, but what it will do is affect your ability to travel on the weekends and not have to worry that your heart is going to go out of rhythm. That's where ablation therapy comes into play. My expectation for my patients is that we're able to return them back to the quality of life or as close as we can to what they had prior to the diagnosis of a-fib.
The other elements of a-fib care is assessing whether or not lifestyle modification is going to also affect their a-fib. We know that patients who are overweight are significantly more likely to develop atrial fibrillation and after an ablation, we know that patients who lose weight after their ablation do much, much better than patients who don't lose weight. So, we're very aggressive in terms of trying to encourage our patients to even lose five pounds after their ablation -- anything that they can do will not only help them, but also help us in terms of making it easier for us to care for them. So, that's one of the things that we continue to assess. Other medical conditions like high blood pressure, diabetes -- they will all improve, and potentially, I’ve seen many patients see those medical conditions completely resolve through lifestyle modifications. This is one of those times when we try to intervene and get to the patient to be a coach and cheerleader for them to lose weight and alter their lifestyle.

Melanie: It's great information. Thank you so much, Dr. Brenyo, for being with us today. You're listening to Inside Health with Greenville Health System, and for more information, you can go to ghs.org. That's ghs.org. This is Melanie Cole. Thanks so much for listening.