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Treatment Options for Atrial Fibrillation
Cardiac Electrophysiologist Joshua Leichman, MD describes risk factors and treatment options for atrial fibrillation, medicational as well as surgical, and how best to manage and live with atrial fibrillation.
Featured Speaker:
Dr. Leichman completed a general internal medicine internship and residency at the Lahey Clinic Medical Center in Burlington, Massachusetts. He then completed a cardiology research fellowship and a general cardiology fellowship at the University of Texas Houston Medical School in Houston, Texas. He also completed a clinical cardiac electrophysiology fellowship from Cedars Sinai Medical Center in Los Angeles, California.
Learn more about Joshua Leichman, MD
Joshua Leichman, MD
Joshua Leichman, MD, received his medical degree from the Keck School of Medicine of the University of Southern California in Los Angeles, California. As an undergraduate, he earned a Bachelor of Science degree in biochemistry from Brandeis University in Waltham, Massachusetts.Dr. Leichman completed a general internal medicine internship and residency at the Lahey Clinic Medical Center in Burlington, Massachusetts. He then completed a cardiology research fellowship and a general cardiology fellowship at the University of Texas Houston Medical School in Houston, Texas. He also completed a clinical cardiac electrophysiology fellowship from Cedars Sinai Medical Center in Los Angeles, California.
Learn more about Joshua Leichman, MD
Transcription:
Melanie Cole (Host): According to the Center for Disease Control and Prevention, between two and six million Americans may have atrial fibrillation and many people don’t even know that they have it. My guest today is Dr. Joshua Leichman, he’s a cardiac electrophysiologist and a member of the medical staff at Temecula Valley Hospital. Dr. Leichman what is atrial fibrillation and who is at risk for it?
Dr. Joshua Leichman (Guest): Atrial fibrillation is a very rapid disorganized rhythm in the top chambers of the heart called the atrium. It can lead to very fast rhythms in the bottom chamber of the heart. It can be caused by a myriad of conditions including age, obesity, coronary artery disease, diabetes, thyroid disease.
Melanie: What is the risk for untreated atrial fibrillation for people who hear what you just said as far as the risk factors, but again some people don’t always know that they have it. Are there complications that could arise from not having it diagnosed?
Dr. Leichman: Yes, I think the biggest complication is stroke. Atrial fibrillation is a five fold risk factor for stroke. It’s important that we try and diagnose people with atrial fibrillation when it’s possible and to treat them appropriately with blood thinning medications if they have enough risks for stroke. Some of the other complications that can occur with atrial fibrillation, especially in patients who do not realize they have atrial fibrillation is heart failure. Atrial fibrillation itself can lead to weakening of the heart and lead to symptoms of shortness of breath, fluid in the lungs or even fluid in the belly and the leg.
Melanie: Doctor, since some people don’t know that they have it, are there some symptoms? Would they feel their heart pounding? Do they feel extra anxiety? Is there something that they would notice that would send them into get checked in the first place?
Dr. Leichman: Unfortunately there aren’t a lot of – when people are asymptomatic they don’t feel anything and a lot of the symptoms could be other things. It could be anxiety. For patients who are asymptomatic, the big risk is developing heart failure, in which case they develop shortness of breath and fatigue and these can be some of the first signs of heart failure.
Melanie: How is it diagnosed? If it’s something that’s diagnosed intermittently, how do you diagnose it to somebody – wear something at home? Can you catch it in the office? How is it diagnosed?
Dr. Leichman: There would have to be some sort of suspicion that you have atrial fibrillation in order to do testing to try and diagnosed asymptomatic atrial fibrillation. Some of these testing can be wearable monitors or even implantable monitors that can look for abnormalities in the patient’s rhythm over a period of time.
Melanie: Then speak about the first line of defense, once you realize this is what somebody has, what are the goals in treatment for atrial fibrillation?
Dr. Leichman: So I think you have to divide it into patients who are asymptomatic and then patients who are symptomatic. The first line of treatment for asymptomatic patients is preventing stroke. As I said, there’s a five fold increase in the risk for stroke in patients for atrial fibrillation. It is important that if patients have certain risk factors that they receive the appropriate type of medication to prevent stroke, which is blood thinning medication, and there are many types of blood thinning medications out there. The other line of defense in patients who are asymptomatic is controlling the rate. When I say controlling the rate, I mean the ventricular rate. Atrial fibrillation in itself is very, very fast but we want to control how fast the ventricles go because it’s rapid rate in the ventricles that will lead to heart failure and the potential cardiomyopathy so some of these medications are just rate controlling medications like beta blockers or calcium channel blockers and on occasion a medication called digoxin. When we look at the symptomatic patients we have to consider what the symptoms are and how to treat those symptoms. Again, we have to treat the risk for stroke. If they have risk factors, they should be treated with blood thinning medication. If they have a fast heart rate, they should be slowed down. These patients we also consider two underlying therapy, one medical meaning antiarrhythmic therapy, medications that can prevent the arrhythmia from starting or even terminate the arrhythmia sometimes, and the other line of therapy is an ablative strategy where we go into the heart and modify the heart tissue to prevent atrial fibrillation from starting in the first place.
Melanie: Speak a little bit more doctor about the ablative therapy. What is that? What does that procedure look like for a patient?
Dr. Leichman: So an ablative strategy is one where we try to modify the tissue in the top chambers where atrial fibrillation comes from. Atrial fibrillation generally is in the early stages and is triggered. It is triggered from specific areas in the heart called the pulmonary vein, and so there are different ways of electrically isolating these areas, the pulmonary veins. The two modalities that we have that are approved are 1) with radiofrequency ablation. This is heating the tissue around the vein to electrically silence that tissue or cryoablation which is cooling or freezing the tissue to electrically silence the area that creates the atrial fibrillation. These are invasive procedures but done through veins and in the heart, there’s no need for open heart or opening in the sternum to do these procedures. They’re generally outpatient type procedures. Sometimes patients can be sent home the same day and sometimes they stay overnight and are discharged the next day.
Melanie: When does the afib discussion become interventional or curative as far as the medications and you talked about ablation. How do you make that decision with the patient based on what you’ve already tried?
Dr. Leichman: Well we always talk about medications first as these are generally easy to start, not always easy to take. When we talk about taking medication, we talk about suppression of atrial fibrillation. We’re not talking about curing a disease process. Even when we talk about ablation, which generally will come if the patient isn’t able to tolerate the medication, the medications don’t work, the medications cause a risk that we don’t think is worth taking, then ablation becomes a conversation. If the patient has heart failure, ablation should become the conversation. The conversation also has to be that ablation is not always curative. That the success rates for the cure of atrial fibrillation are not 100%. They range anywhere between 50% and 70% with the first ablation, but I think it’s important for the patient to understand that there is no 100% cure for atrial fibrillation. They also need to understand that other lifestyle factors need to be modified, things such as obesity and sleep apnea and treatment of hypertension and coronary artery disease. As these are not treated, there’s less likelihood of atrial fibrillation treatment with either medications or ablation being successful.
Melanie: Then wrap it up for us Dr. Leichman, and tell the listeners what you would like them to know about managing their atrial fibrillation and living with it because is it something that someone can lie a long life with and have medicational intervention or an interventional procedure and that they can go on and live a normal life?
Dr. Leichman: So atrial fibrillation is a disease process that can cause symptoms. It can cause heart failure, but it can also be lived with. I think getting atrial fibrillation under control with medications, whether it’s rate control or antiarrhythmic therapy is attainable and is a safe and viable option for many patients. It is a disease process that many people live with for many years and don’t know about and can live for many, many more years with significant problems. The importance is of course preventing stroke and being on appropriate blood thinning medications when the risk factors indicate that you should be on them, and if the symptoms are significant and if the medications aren’t doing their job then ablation really should be considered. It should also be considered in patients who have heart failure that is thought to be secondary to atrial fibrillation or have heart failure that’s exacerbated or made worse by atrial fibrillation. Atrial fibrillation has to be seen as a chronic disease process. It’s a disease that will have to treated throughout their lifetime. Risk factors need to be addressed, but it is something that people can live with and can be treated successfully.
Melanie: Thank you so much doctor for joining us today and sharing your expertise and explaining atrial fibrillation and the treatment options available. You’re listening to TBH Health Chat with Temecula Valley Hospital. For more information, please visit temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): According to the Center for Disease Control and Prevention, between two and six million Americans may have atrial fibrillation and many people don’t even know that they have it. My guest today is Dr. Joshua Leichman, he’s a cardiac electrophysiologist and a member of the medical staff at Temecula Valley Hospital. Dr. Leichman what is atrial fibrillation and who is at risk for it?
Dr. Joshua Leichman (Guest): Atrial fibrillation is a very rapid disorganized rhythm in the top chambers of the heart called the atrium. It can lead to very fast rhythms in the bottom chamber of the heart. It can be caused by a myriad of conditions including age, obesity, coronary artery disease, diabetes, thyroid disease.
Melanie: What is the risk for untreated atrial fibrillation for people who hear what you just said as far as the risk factors, but again some people don’t always know that they have it. Are there complications that could arise from not having it diagnosed?
Dr. Leichman: Yes, I think the biggest complication is stroke. Atrial fibrillation is a five fold risk factor for stroke. It’s important that we try and diagnose people with atrial fibrillation when it’s possible and to treat them appropriately with blood thinning medications if they have enough risks for stroke. Some of the other complications that can occur with atrial fibrillation, especially in patients who do not realize they have atrial fibrillation is heart failure. Atrial fibrillation itself can lead to weakening of the heart and lead to symptoms of shortness of breath, fluid in the lungs or even fluid in the belly and the leg.
Melanie: Doctor, since some people don’t know that they have it, are there some symptoms? Would they feel their heart pounding? Do they feel extra anxiety? Is there something that they would notice that would send them into get checked in the first place?
Dr. Leichman: Unfortunately there aren’t a lot of – when people are asymptomatic they don’t feel anything and a lot of the symptoms could be other things. It could be anxiety. For patients who are asymptomatic, the big risk is developing heart failure, in which case they develop shortness of breath and fatigue and these can be some of the first signs of heart failure.
Melanie: How is it diagnosed? If it’s something that’s diagnosed intermittently, how do you diagnose it to somebody – wear something at home? Can you catch it in the office? How is it diagnosed?
Dr. Leichman: There would have to be some sort of suspicion that you have atrial fibrillation in order to do testing to try and diagnosed asymptomatic atrial fibrillation. Some of these testing can be wearable monitors or even implantable monitors that can look for abnormalities in the patient’s rhythm over a period of time.
Melanie: Then speak about the first line of defense, once you realize this is what somebody has, what are the goals in treatment for atrial fibrillation?
Dr. Leichman: So I think you have to divide it into patients who are asymptomatic and then patients who are symptomatic. The first line of treatment for asymptomatic patients is preventing stroke. As I said, there’s a five fold increase in the risk for stroke in patients for atrial fibrillation. It is important that if patients have certain risk factors that they receive the appropriate type of medication to prevent stroke, which is blood thinning medication, and there are many types of blood thinning medications out there. The other line of defense in patients who are asymptomatic is controlling the rate. When I say controlling the rate, I mean the ventricular rate. Atrial fibrillation in itself is very, very fast but we want to control how fast the ventricles go because it’s rapid rate in the ventricles that will lead to heart failure and the potential cardiomyopathy so some of these medications are just rate controlling medications like beta blockers or calcium channel blockers and on occasion a medication called digoxin. When we look at the symptomatic patients we have to consider what the symptoms are and how to treat those symptoms. Again, we have to treat the risk for stroke. If they have risk factors, they should be treated with blood thinning medication. If they have a fast heart rate, they should be slowed down. These patients we also consider two underlying therapy, one medical meaning antiarrhythmic therapy, medications that can prevent the arrhythmia from starting or even terminate the arrhythmia sometimes, and the other line of therapy is an ablative strategy where we go into the heart and modify the heart tissue to prevent atrial fibrillation from starting in the first place.
Melanie: Speak a little bit more doctor about the ablative therapy. What is that? What does that procedure look like for a patient?
Dr. Leichman: So an ablative strategy is one where we try to modify the tissue in the top chambers where atrial fibrillation comes from. Atrial fibrillation generally is in the early stages and is triggered. It is triggered from specific areas in the heart called the pulmonary vein, and so there are different ways of electrically isolating these areas, the pulmonary veins. The two modalities that we have that are approved are 1) with radiofrequency ablation. This is heating the tissue around the vein to electrically silence that tissue or cryoablation which is cooling or freezing the tissue to electrically silence the area that creates the atrial fibrillation. These are invasive procedures but done through veins and in the heart, there’s no need for open heart or opening in the sternum to do these procedures. They’re generally outpatient type procedures. Sometimes patients can be sent home the same day and sometimes they stay overnight and are discharged the next day.
Melanie: When does the afib discussion become interventional or curative as far as the medications and you talked about ablation. How do you make that decision with the patient based on what you’ve already tried?
Dr. Leichman: Well we always talk about medications first as these are generally easy to start, not always easy to take. When we talk about taking medication, we talk about suppression of atrial fibrillation. We’re not talking about curing a disease process. Even when we talk about ablation, which generally will come if the patient isn’t able to tolerate the medication, the medications don’t work, the medications cause a risk that we don’t think is worth taking, then ablation becomes a conversation. If the patient has heart failure, ablation should become the conversation. The conversation also has to be that ablation is not always curative. That the success rates for the cure of atrial fibrillation are not 100%. They range anywhere between 50% and 70% with the first ablation, but I think it’s important for the patient to understand that there is no 100% cure for atrial fibrillation. They also need to understand that other lifestyle factors need to be modified, things such as obesity and sleep apnea and treatment of hypertension and coronary artery disease. As these are not treated, there’s less likelihood of atrial fibrillation treatment with either medications or ablation being successful.
Melanie: Then wrap it up for us Dr. Leichman, and tell the listeners what you would like them to know about managing their atrial fibrillation and living with it because is it something that someone can lie a long life with and have medicational intervention or an interventional procedure and that they can go on and live a normal life?
Dr. Leichman: So atrial fibrillation is a disease process that can cause symptoms. It can cause heart failure, but it can also be lived with. I think getting atrial fibrillation under control with medications, whether it’s rate control or antiarrhythmic therapy is attainable and is a safe and viable option for many patients. It is a disease process that many people live with for many years and don’t know about and can live for many, many more years with significant problems. The importance is of course preventing stroke and being on appropriate blood thinning medications when the risk factors indicate that you should be on them, and if the symptoms are significant and if the medications aren’t doing their job then ablation really should be considered. It should also be considered in patients who have heart failure that is thought to be secondary to atrial fibrillation or have heart failure that’s exacerbated or made worse by atrial fibrillation. Atrial fibrillation has to be seen as a chronic disease process. It’s a disease that will have to treated throughout their lifetime. Risk factors need to be addressed, but it is something that people can live with and can be treated successfully.
Melanie: Thank you so much doctor for joining us today and sharing your expertise and explaining atrial fibrillation and the treatment options available. You’re listening to TBH Health Chat with Temecula Valley Hospital. For more information, please visit temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.