This practical, data-fueled talk from Edward P. Gerstenfeld, MD, MS, FACC, chief of the UCSF Cardiac Electrophysiology and Arrhythmia Service, will help PCPs better understand how to assess stroke risk; make treatment decisions, such as anticoagulation therapy versus catheter ablation; and educate their patients on the necessity of addressing such factors as obesity and sleep apnea. Learn when to consider treatment for asymptomatic A-fib patients and why aspirin therapy is “not better than nothing.”
thanks to everyone and you try to leave plenty of time for questions at the end. Um you know, by way of introduction on electro physiologists at UCSF you'll probably hear more about ablation than you want to hear today. But I try to put, you know, I believe because it works. But honestly I just manage a lot of af patients and I use drugs I use, you know, anti coagulation, obviously all the usual things. Um so um we will talk about overall if management, how things have sort of changed some of the new data that's come in and we'll talk a little bit about ablation, but hopefully it's helpful for you guys and we'll have plenty of questions for sure. So I was trying to cast things in terms of a case. So, you know, this patient is a 51 year old man. He has real insufficiency, hypertension, obesity, had a pacemaker put in for sick sinus syndrome to some of the other realms when you might see. And he actually came into pacemaker clinton complaining of palpitations. Um you know, an exam, he's uh £280 blood pressure is a little bit high. Uh it's an aspirin and Singapore for hypertension, but we don't sufficiency and when we look at the logs from the pacemaker, what we see these eight er means, you know, high atrial rate and he had a 30 minute and a 15 minute episode of a fib detected by his pacemaker and it may seem a little bit esoteric, but we see this all the time and you guys see it also, I know because often, you know, you'll end up getting the emails or be cc'd on them from pacemaker clinic for all our patients of pacemakers. And then lo and behold even though some of them without symptoms it picks up a fib. And then what do you do with that? You know, you need to start everyone on antibiotic therapy. Do you need to treat all the a. Fib? Um And that's the question for this guy is, you know, so now he had computations. Now his pacemaker picked up a fib and when you start, when you go based on that, is that enough um you know, to start him on anti coagulation. So this is just from a series of studies of people with implanted devices for various reasons, implanted pacemakers and over 18 months, you know, most people getting pacemakers are older, obviously older people get a fib but about 24% of people getting pacemakers in various studies high to a fib diagnosed over 18 months of follow up. So as I'm sure you all know, um this is pretty common once you put the pacemaker and I mean basically all pacemakers have diagnostic capabilities. Now they're all remotes. So they're transmitting to us, you know, whenever they pick up a fib and so humanity people 24 7 for 18 months. It's not so surprising that about a quarter of them will have some detective, you know, this is from a study that combined data from three studies um basically showing even five minutes of detected a fib increased people stroke risk kind of an hour was the longest um Was the best I guess predictor in terms of future stroke. But we used to say oh you have to have a third for 24 hours um five minutes. You know, I probably wouldn't get too crazy about but certainly getting longer than an hour. It is associated with stroke. And we need to think about antifa robotic therapy. It's not only when it gets to be more than 24 hours anymore. And then this is from the crystal last study which was implantable monitors and looked at basically um you know people who who had a stroke of unknown origin and they got implantable loop recorders looking at the incidents of a fib would have mainly wanted a highlighter. These are people who always we go, thanks. So the red line is when they had their symbolic event. The black is when they had a fib. This is a subset of people in that study who had um bolic events while they had their implantable monitor, just highlighting that, you know, Yeah. Some people went into a fib and then had a symbolic event or were in a fib after their symbolic event. But a lot of the time, the actual episode of a fib is not necessarily the same time. They have the symbolic event. So 70% of people had no episodes within 30 days of their actual event. But likely it's still, you know, they're intermittent a fib you have a more pro robotic milieu. So the message is, you know, some people will say, well I know when I have a fib, why don't I just take my you know eloquence? There's or alto or or medicine when I have an episode. And You know, the answer back to those patients is one we know for every episode. People feel there's at least 10, you know, from prolonged monitoring episodes when they're sleeping that they don't feel and that we know that strokes don't always correlate with a fib. So um if you have reasons to be any coagulated. There are studies looking at intermittent anti coagulation with wearables, but that's totally unproven. But they need to stay on it regularly. You know, intermittent antique regulation doesn't uh work as far as far as we know. And then the other question I get a lot sometimes, you know, referred patients just for this, we know now chazz vast is sort of the risk stratification score we use right to start antique regulation. Um But what about chad's vast. We know two or more people merit antique regulation. We know china's vast. Zero. So lonely. Typically don't anti coagulate. But what about the Chaz vast one? This guy had his 51 his hypertension. Um patients also asked, well I have hypertension, but I'm on drugs and it's treated. Um Does that mean I don't have that risk factor anymore? And the interest. No I mean all these studies basically where epidemiology studies where people just check that they had a history of hypertension. So as long as they have that history even treated hypertension, it still counts as a risk factor is still important obviously for the future prevent symbolic events, heart attacks but it still counts as a risk factor even if it's treated. And you know these are just two studies. This one was a Danish registry, 23,000 people. It's hard to find people who aren't treated. Um but they all were non valvular af patients who weren't um on any coagulation. And at a year follow up even one risk factor tripled the stroke risk and tripled the mortality risk. Um and then this is from a national Taiwanese database. Again, patients who are not uh any coagulated 100 and 80,000 people. And this is looking at Jazz fest two in women since female gender. You know, we don't consider that alone a risk factor, but female plus another risk factor is two versus Chaz vest. One in males. And you'll see that each risk factor alone, even age. You know what about when you hit 65 is that enough? So just age 65 to 74 tripled um your stroke risk. So you know overall um 2.5% per year stroke risk with one additional risk factor. Um you know beyond female gender. So my own practices ones and all the data. You know one of the reasons the guidelines in the U. S. Gave the option of antique regulation for chad's vest. One is just because of warfare. It was such a hassle to initiate it and maintain it and monitor it with the dough exits. Really much less cumbersome. And if you look at guidelines, you know this is the U. S. Guidelines and the left H. A. C. C. H. R. S. Which for Chaz vest one gives you the option of aspirin or oral anti regulation. But if you look at the Canadian guidelines of the european guidelines they both recommend oral anti regulation. You know it's a strong for the Canadian to a meaning not quite a class one that most people are in favor. So my own opinion is you know if you look at the chad score, chads vast zero really no hypertension, no vascular disease. Uh age under 65. I mean I prefer under 60 even you know those are the low risk patients. And basically I look for any other reason I have a pretty low threshold to regulate people because strokes as you know are bad. Um So you know when we look at this guy's pacemaker again in a few months it gives us kind of a little table of this episode. So they're coming and going you can see some of them last a day, some last less long. Um, but it kind of gives you a pattern and so now you know he's having more than just a 30 minute episodes. And the question is you know what type of antique regulation And this guy which has just one, are you gonna start um Aspirin warfarin or you know, which is the dough ax one message I wanted to get across is that you know, most every study has shown that aspirin really does nothing for stroke prevention in a fib you know the card majority disease. Yes. Um a secondary prevention but really does not work. So it was kind of an old lower well Aspirin is probably better than nothing. But really it's not because it has side effects. And so um, we shouldn't, if we think someone has significant risk factors for stroke, we shouldn't be using aspirin. Um, you know, we should be using a dough ac and you know this is the available ones. I think any one of them are fine. The only little things that usually point out are that, you know, River rocks Urbanism Alto compared to eloquence or pick Saban. They actually have the same half life. In fact that the half life for Riverwalk Saban is actually a little shorter. So why is Xarelto once a day And eloquence is twice a day. Um, it's just because that was, that's what they did in the study and and they both worked. I mean River Rocks band was equivalent to warfare and a pixel band was better. Um River Rocks even does have a higher relative starting dose so that your peak is higher and it lasts a little bit longer. And in more recent comparative studies of Toronto and Ela quis, the bleeding risk was actually slightly higher. What's Geraldo? So for for people at higher bleeding risk, I prefer Ela quis. Um Again, if there are people for compliance reasons really like once a day instead of twice a day, then I think Geraldo is okay. The other point I make is for the bigotry and we use this less often the direct thrombin inhibitor. It's the one that's most really excreted, so probably worse to use in your patients with renal insufficiency, like this one. Um But it also doesn't interact with uh the cet three A for all those medication interactions if you have someone for example on multiple HIV meds um or other meds where you're worried about interactions. Uh Pradaxa actually has the fewest drug interactions, but the most really clear Ela quis least really clear. So people with renal insufficiency. Um And again you guys know there's those reduction for a combination of older age and renal insufficiency. Um But eloquence is probably the best to use the patients with renal insufficiency. And again, comparing all these agents with warfarin, it's not just that it's equivalent to warfarin for stroke reduction. They're actually better you have fewer strokes on a doe at compared to Warfarin and less bleeding on a doe compared to Warfarin. So you know it's very few patients I have these days still on Warfarin, there's people because of cost or there has been on a forever prefer it. Um People with mechanical valves tax you know and so not to work. So they're still on Warfarin. And then a recent paper actually showed people with rheumatic valve disease in particular mitral stenosis, have a higher stroke risk with the wax compared to Warfarin. So you may see some rheumatic mitral stenosis patients still on Warfarin but most of the time um you know they're just much easier, you have to worry about diet and you're just taking a pill once or twice a day. So again, you know, looking at stroke risk chad's vast zero. Lo and those are the patients that don't require any regulation but pretty much everyone else I try and get on on an an acquired, so this patient got started on a pixel ban having morayef noticed some palpitations again as pacemaker shows that he's having more a fib. Um And the question comes up, you know, he's having palpitations. He's having a fib when you know, is it enough to just control his heart rate and leave him in a fib or is it worth, you know, now that he's progressing more into persistent af is it worth trying to get him back into sinus rhythm And again this is questions where you're likely involved potentially. Um others but I think it's still worth uh you know you certainly being involved in those decisions and knowing the data. Um So we all know a firm was this older study in the nineties First study 4000 patients that randomized patients to rate versus rhythm control. So just um you know a v nodal blockers. Beta blockers, constant channel blockers or did or some combination thereof versus anti arrhythmic to maintain sinus rhythm. And then when you looked over five years there was no difference in mortality. People hoped rhythm control would help people live longer. If anything the rhythm control arm trended towards a little worse mortality. Um But there was no benefit to maintaining sinus rhythm. And this kind of I think told people to just leave people alone if they were in a fib and not symptomatic which you know many of us think was probably a mistake. Um And probably is held up by more recent data. Um You know one of the problems with the firm we all know now was that you know over time the algorithmic didn't work so well so that even people in the rhythm control arm only about 60% were actually a normal rhythm at the end. And people in the rate control arm actually 40% of those were normal rhythm because they just had an occasional episode and got enrolled so we weren't so good at keeping people in normal rhythm versus A. F. And if you look at who actually stayed in normal rhythm as opposed to the randomization. Um There was a 50% lower mortality and people who stayed in science rhythm, you know with the caveat that this is a post hoc retrospective analysis. So maybe those we don't know if those people were healthier for other reasons. People have maintained sinus rhythm and that's why they had a lower mortality. Um People who are anti coagulated a little mortality. People who used rhythm control drugs actually had a higher mortality. And that's one of the questions is you know, was the adverse event from the drugs kind of balancing the benefit of being in in normal river this. I'm asked this question a lot and again I don't want to get too much on this, but I think patients bring it up. There is more and more data that even on anti coagulation, the presence of aphids is associated. Again, just an association with more dementia of various causes. And I think with all our patients living longer. Um It is a big concern. Um There are a lot of retrospective studies showing this. So this is a meta analysis that people with a fib had clearly from multiple studies. Um More dementia including vascular and alzheimer's dementia than other patients. There isn't you know there's a lot of observational data saying, well people who happened to be in normal rhythm or had an ablation had less dementia. There's no prospective data saying if you could keep people in sinus rhythm it'll it'll change that outcome. But there are studies showing even on any regulation if you do brain M. R. S. You'll see more small vessel and an asymptomatic, small anabolic events and people in who aren't. So um you know, I think it's something where uh it's something to consider um when you're considering leaving someone in a fib versus not even though it's at this point I would say an association and not causation. Um So you know, what are the options to get this patient back in rhythm? Are we gonna cardioverter them or try various drugs? Um And what I wanted to mention because this is where I think we need help from from you guys. Um which is a risk factor modification Which is really a big part of the 8th of epidemic, which is you know, obesity in in our country. Um you know, this was a study that randomized 150 people to either aggressive weight management where they really enrolled them in an exercise program versus just kind of general advice to lose weight. The people who got in the exercise program and regular nutrition and counseling lost the european studies. So 15 kg right was about £30.32 pounds compared to those with general advice. And if you look at, you know the number of episodes and the duration of episodes, you know pretty dramatic decrease in the amount of people are having just by losing a significant amount of weight. Again I want to minimize as we all know just losing weight and keeping it off is not so easy. Um But that clearly and their studies preclinical animal studies showing that you actually get more atrial fibrosis and that epic are ideal fat um releases cytokines. That also contributes electro physiologically from a s. There's a lot kind of mounting basic science data that obesity um is worsens and contributes to a fib. This was this reverse af study. So the top row of pie charts At baseline were people who did not lose weight. People who lost 3-9% of their body weight and people who lost greater than 10%. And then for the people who lost weight kind of what happened to their af pattern in purple as those who progressed from paroxysmal to persistent and yellow is those who regressed from persistent or paroxysmal and in gray, those who became free of af and if you look at the group who lost the most weight, it's pretty dramatic. I mean half of them are now free of a f. And a third actually regressed from persistent to paroxysmal and the orange slice of people who progress is much smaller than these other groups. So pretty impressive. Just with weight loss and this is an ablation study which I want hard by and other than to say this is ablation outcome with single procedure multiple procedures, success. And if you know someone said this is a new fancy catheter that will increase your freedom from a f from 26% to 62% after one procedure or 48% to 87% after multiple procedures. Right? Everyone would want to buy that catheter. But if you say well this is just risk factor modification, weight loss treating sleep apnea and associated risk factors hypertension. Um No that's much easier to do. Not easier but much do more doable. Um But really impressive and I think it it highlights the fact that I'll kind of talk about throughout this. Talk that just an ablation alone you know I treat a fib like Carnegie heart disease right? No one's gonna put a stent in someone and say you're fixed. You have to also treat their lipids and you keep them on Plavix and aspirin and weight loss. Um But then you know I think by the ep community curing things like W. P. W. And A. D. N. R. T. Forever people think a fib is a quick fix and um it can be but it has to go along with treating all these other issues with the is just gonna come back. So it's you know weight management it's hyper leukemia. It's glucose intolerance. It's hypertension and sleep apnea. We've talked about you know, setting up an aphids, lifestyle modification clinic, but we don't really have the bandwidth because we're dealing with all these other patients with Svt and ablation. Um And that's where again, we need uh your help. I used to follow all my ablation patients forever once a year. Um but I just, my clinic is too full, so I see him for a year and then I kind of pass them back to the cardiologist or internist and if if patients don't take care of these problems, they'll be back in five years morayef and they're getting older. Um and all these processes that lead to a f just continue. Um So this patient got started on CPAp again, really important, I think if they have sleep apnea is kind of one of the standard questions we asked them. Now you snore. Um and we have a direct line to Dave claimant who runs the sleep center at UCSF to do sleep studies and get people started on CPAP um Weight loss, treat their blood pressure and lipids. And, you know, at least initially this guy had a dramatic decrease in af episodes. Um ultimately had more, he tried an anti arrhythmic, you know, then the question is, what do you do when he continues to have a fib I think, you know, you're not likely involved in anti arrhythmic decisions. Um But just pointing out that, you know, once drugs, one drug hasn't worked. Um you know ablation should be considered. It's currently the, you know, class one level of evidence A for people who have broken through one anti arrhythmic drug and you know, for younger athletic patients, it's also um a class to a meeting mostly consider it even without trying a drug. So for young patients facing many years of anti arrhythmic of anticoagulants, um you know, again, we don't mind talking to those patients at least to present the option of catheter ablation. Um cabana was again, another large randomized trial kind of the future. The next step after a firm to say, well if drugs didn't really work as ablation better. Um and with that improve the outcome of patients with a fib so they're randomized again, 1100 to ablation and 1000 to drug therapy. Um In the end, when they looked at the primary endpoint, which was stroke bleeding or cardiac arrest again, there was no difference in the intention to treat analysis, although maybe it's better that ablation is now trending at least better and not worse. Um mortality was no different. But you know, ablation people, this is freedom from af ablation was better, has been better. Almost every study, you know, at least twice as good than drug therapy in terms of maintaining sinus rhythm Again, when you do, you know, the problem with all these studies was about 30% crossover rate. So about 20% of the patients randomized to drugs had recurrences and get crossed over to ablation. About 10% of the patients who were randomized ablation decided they didn't want an ablation and ended up getting drugs. And again, if you look on who got actually a bladed, so it's not quite the same as who maintained sinus rhythm is who got the ablation procedure. There was a reduction in mortality by about 30% over five years. But again, it's again a post hoc analysis and maybe those patients who got a bladed, we're in better shape and that's why that happened, but it's more kind of provocative. The way I look at it from a firm stand point is again, if you're gonna treat a fib whether you start with a drug or start with ablation um in the end, the people who are in sinus rhythm um did better and either is probably okay. But I think probably a more relevant study you may have seen in New England Journal is this East af net study um Published in 2020 and I like it because it was more of a real life study. Didn't look at a particular drug, didn't look at a particular strategy, but they randomized again um you know, done in europe, about 2700 people to either rhythm control or what they call usual care, which is just rate control of a fib um they didn't have a particular strategy for rhythm control. So the chart over here shows what people got. So most people got, you know, the common anti arrhythmic drugs, we used like an item path unknown um a little bit of um Iannarone and some people got a f ablation if needed, but it wasn't really an ablation studies, only 8% in the initial group. And at two years when the drugs weren't working, it went up to 20%. So again here, I think they used ablation in the right way. Some people got it up front, Some people got it if the drugs weren't working, but the drugs were working, they stayed on on their drugs. And and it's importantly, early rhythm control. So people were treated within a year of their af onset and that may be one reason why this was kind of the first study that showed benefit to maintenance of sinus rhythm in terms of um their primary outcome, which was death stroke or hospitalization, that there was a 5% benefit in early rhythm control compared to just usual care. Without a difference in prolonging hospital ST How do you? Oh I guess I showed this to, so this is the overall difference, but importantly in the study and this is analyzed the denominator of person years. Um but even though the differences were small, the people who had early rhythm control actually did have a small but significant reduction in more in death and in stroke again about 0.3%. Um not a huge difference but a small difference. And importantly, about three quarters of these patients weren't symptomatic, they were called asymptomatic um by their by the study. So, you know, how do I factor that into my practice the way treat every patient with a f with, you know, drugs or ablation? I think the way you put the numbers in, cause I didn't mention it, but you know, there there are some complications of a blading. People are giving them anti arrhythmic drugs, but if you take 300 af patients a year um and treat them with rhythm control in any regulation, you basically save one life and one stroke a year. Right, That's the 10.3% at the expense of three non serious non life threatening drug or ablation complications. You know, maybe think it be a pacemaker, a drug toxicity or Empanada. So, you know, there's some benefit, there's some downside. And this is kind of the discussion we have with patients especially, you know, if they're very symptomatic, it's easy, they're symptomatic, a drug doesn't work. We usually go on to ablation, but for people a lot of people are minimally symptomatic and that minimal symptom is usually fatigue, right? People just say, I feel tired um What do you do with those patients may go down, you know again, I would say for rhythm control either a drug revelation is fine to start with. Um But I do think most people who show up and persistent af should at least have an initial attempt to maintain sinus rhythm um because many people will maybe get accommodated to it, but feel better once they get in sinus rhythm. So I'll try at least a cardioversion and almost everyone see if they feel better and then we have, you know, if they don't feel any better, most of them do and then we can have the discussion about what we need to do to keep them in rhythm. Um If they don't we can then way sort of all these risks and benefits based on their age and other comorbidities and that comorbidities obviously factor into this as well. The other two ablation studies I wanted to mention both in New England Journey Journal um were these cryo balloons, which is a particular technique of ablation using a balloon as opposed to a catheter early af and stop af first. So both were first line ablation studies. They randomized people up front who hadn't been on a drug yet to ablation versus drug therapy, you know, and both showed they were looking at mortality, but in terms of maintaining normal rhythm um ablation was much better. Right? So not 100% in this study on the right, 75% at a year who got ablation only about 45% in drug therapy. The reason it's lower in this group, 57 versus 32 is these patients all had implantable loop recorders. So 24 7 monitoring of their rhythm. The right group is based on symptoms but I think they're useful numbers together, you're talking about a cure like zero af. You're looking at about 57% after one ablation of a year. If you're looking at freedom from symptomatic af it's better about 75%. But this will probably bump ablation as a you know, option even for first line therapy for particularly young active patients who are bothered by the a. Fib, you know, is the ablation a cure as they said, um You know, this is a study, this is what our data we looked at years ago. But even people with no if it about a year if you follow people this is now 123 and four years out, you'll see the freedom from A. F. Starts to fall off and we see this with our patients that had an ablation. Again, I think part of this is all these risk factors um that we're not treating as well as, you know, the other triggers forming and some of the imperfections of ablation where where the pullman advance can reconnect but it's not, you know, W. P. W. You a bladed and you're done. I think we have to watch these patients um really for the rest of their lives for for recurrences if they had multiple procedures the outcomes better. But and again there's some people the good news is there's there's the 70% who had a procedure and had no way for five years. So they're great, right? Where um we fixed them, they're living their life, they're off their drugs and they feel happy. Um But again, over time, the same process that led to leads to it. Again, you know, do we ever need to treat or blade asymptomatic af I think it should be considered? Um certainly in people who are young, I change this slide every year because I'm 56. So right now they also 56 is young. Um you know, we have these debates and gps, well, some people say 65, 70, I don't know. But if, you know, if I'm 50, I wouldn't want to have the next 30 years of a coagulants and blood thinners and drugs. So I think it should be considered. Um Some people with a F will get a cardiomyopathy right, just from a f irregularity and rapid rates. They'll get a drop in their heart function. And those certainly people should be treated. And then we've learned people with tacky brady. You know, people have a F. In these conversion pauses who would normally get a pacemaker if we blame them and fix their af they end up not needing a pacemaker. So those are some groups and then um you know, some high risk occupations, but they can't fly a plane and have some commercial airline pilots. People in the army um where where ablation should be considered. This was an airline pilot who was a totally asymptomatic. But his holter is kind of routine holter show going in and out of a fib and also some pauses and they initially took his license away. But in the lab he just had a single pulmonary vein trigger with a bladed and then he was fixed and went back to flying. So there are some young people where we can really fix their E. Fib. It is in the guidelines for attacking brady syndrome, it's reasonable to offer oblation as an alternative to pacemaker. Um And for asymptomatic af it could be considered in selected patients, you know at high volume centers weighing the benefits doesn't mean everyone needs it done so again um patients with af again even getting up to an hour or more in duration um already increased risk of stroke if their chance Vance is greater than equal to one female gender alone or alone. A fib. Again we still don't and regulate. But everyone else would think about any regulation. Aspirin not really useful for for metabolic protection and no actually do X. They're all not just equivalent but better than warfarin. So I think most patients uh you know, unless there's really cost issues um should be on a no ac again this risk factor modification is really a big issue in managing these patients. And again we really need help with this weight loss, sleep out in the hypertension. That should be the kind of up front assessment and assessing and treating those things can can reduce both their overall burden. And even if their candidates for ablation still prevent later recurrences. Um I think most patients with new onset persistent a fib, even if they're not that symptomatic deserve an attempt at sinus rhythm will give McCarthy version, see how they feel and then discuss where to go um whether it's a catheter balloon, I left it out but their studies showing that basically equivalent in terms of outcome, you know, PB isolation point of vein isolation is the mainstay for a half ablation in terms of the ablation approach and there's newer technologies that are coming soon. Um You know, one of the questions I was asked to address, I sort of edit on is you know, when do you refer a patient? Um And I think, you know, for at least initial discussions, you know, most patients it's probably worth having to meet with a cardiologist or ep. Um You know, I've talked to patients just about any coagulation when they don't want to take it. Usually I have to convince them to take it. But this has asked one patients, patients who are worried that they've got carded disease. Also there on an aspirin, we're happy to help, you know with patients looking at the risks and benefits. Think of young and here I said 70. But you know, a young patient with new onset af should have discussions sooner rather than later. Um In terms of therapies for a f. I think anyone who's symptomatic who's considering therapy should should have a discussion. Um And then I didn't get it because it's a whole other area of left atrial appendage occlusion devices. Um You know watchmen there's there's several different ones. I'm not a big fan of you know like they advertise of putting this in because people mountain bike and don't want to take their their dough act because they have risks and complications. Um And they're not they they decrease bleeding risk but they're not foolproof in terms of stroke but for people who are having you know really have high stroke risk but can't tolerate an anti coagulant or having a stroke despite an anti coagulant. Um Then they should be considered for left atrial appendage occlusion device and that's certainly something that that we can help with. Um Another common question that seems to come up is when to refer to cardiology versus E. P. Um In general we like things to go through cardiologist first but not necessarily always. So you know someone with depends also on your level. I mean many internists are happy management until it becomes more bothersome, more problematic but as someone that just has you know you want to refer someone for new or recent onset af they really haven't had a full evaluation. Things like an echo or monitor for how much they're having or labs. They haven't even been started on a coagulant yet, or they have associated no valvular heart disease that might be contributing to a f um generally would like those to get their initial evaluation um through cardiology. They're also not as biased as we rdp who tend to shuttle people off to ablation maybe sooner. Um Maybe that's better. Maybe that's not, but on the other hand, I think if you've got a young patient with symptomatic af I would probably have a low threshold to send that patient to ep sooner. Um Because I think um they have a potential uh fix and and treating the af sooner is probably better than waiting. Um People who are having recurrent af, despite anti arrhythmic drugs, I really hate, personally, amiodarone, although I know a lot of people like it because it's safe to just start out of the hospital, but you're just pushing other complications down the road, like hyperthyroidism and paddock. And I've seen horrible lung toxicity. So if people aren't responding to the first line drugs, then I have a low threshold to to think about other options. Again, people just interested in talking about ablation. Again, this issue of people having pauses um where you can potentially avoid a pacemaker. And again, those patients who are having uh bleeding issues. Um You know, often older patients falls can't tolerate any regulation where you'd like them to have a discussion about appendage, occlusion devices, There's probably other categories haven't qualified. But I thought I just mentioned that was a sort of general um There it is. So this is obviously mount tam up in marin. So I live up the marin. Um I hope that was overall helpful. Hopefully I didn't get too much into the weeds. Um because again the general gist of a fib obviously any coagulation, I didn't get too much into rate control. You know, we usually don't use much anymore, but beta blockers or council channel blockers. Um And then beyond that, if they're symptomatic continuing to have episodes, uh you know, that's where these other issues should be considered. And I think just in general fatigue is a real symptom from a fib. So um you know, just telling them they have to learn to live with it. Obviously no one here knows that, but that's that's not a great option. Um And again, it's not to say someone who's 85 asymptomatic and goes has a fib and a cardioversion at Rikers and they're really asymptomatic, absolutely, you know, anti coagulate that they just have chronic a fib leave them alone. Um I do that as well. Um I've just seen a lot of people in their forties and fifties where they've done, you know just rate control and it's not until like 8, 10 years later that their atrium dilates, then they start having M. R. And shortness of breath and heart failure symptoms. So I think in young patients um even without a lot of symptoms, uh you know, it's worth a discussion about maintaining sinus rhythm.