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.”
So thanks everyone. And um yeah, I'll try to leave plenty of time for uh questions at the end. Um, you know, by way of introduction, I'm an electrophysiologist at UCSF. So you'll probably hear more about ablation than you wanna hear today, but I try to put, you know, I, I, and, and I late because it works, but honestly, I just manage a lot of AF patients and I use drugs, I use, you know, anticoagulation, obviously, all the usual things. Um, so, um, You know, we'll talk about overall Afib management, how things have sort of changed, some of the new data that's come in and um we'll talk a little bit about ablation, but hopefully, it's helpful for you guys and we'll have plenty of questions, I'm sure. So I was, you know, trying to cast things in terms of a case. So, you know, this patient is a 51 year old man. He has renal insufficiency, hypertension, obesity. He actually had a pacemaker put in for sick sinus syndrome. So someone that other realm of someone you might see. And um he actually came into pacemaker clinic complaining of palpitations. Um, you know, on exam, he's, uh, 280 pounds, blood pressure is a little bit high, uh, He's on aspirin and lisinopril for hypertension, a little bit of renal insufficiency. And, you know, when we look at the logs from the pacemaker, what we see is ATR means, you know, high atrial rate, and he had a 30-minute and a 15-minute episode of AFib, uh, detected by his pacemaker. And that 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, where all our patients have pacemakers, and then lo and behold, even though some of them without symptoms, it picks up AFib. And then, what do you do with that? You know, do you need to start everyone on antithrombotic therapy? Do you need to treat all the AFib? Um, and that's the question for this guy is, you know, so now, He had palpitations, now his pacemaker picked up Afib, and when you start, would you go based on that? Is that enough, um, you know, to start him on anticoagulation? 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 Afib, but about 24% of people getting pacemakers in various studies had AFib 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 in. I mean, basically, All pacemakers have diagnostic capabilities now. They're all remote, so they're transmitting to us, you know, whenever they pick up AFib. And um, so if you monitor people 24/7 for 18 months, it's not so surprising that uh about a quarter of them will have some Afib detected. You know, this is from a study that combined data from 3 studies, um, basically showing even 5 minutes of detected Afib increased people's 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 AFib for 24 hours. Um, 5 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 antithrombotic therapy. It's not only when it gets to be more than 24 hours anymore. And then this is from the Crystal AS study, which was implantable monitors and looked at basically um You know, people who, who had a stroke of unknown origin, and they got implant in a loop recorders looking at the incidence of Afib, and what I mainly wanted to Highlighter. These are people who all study primary care. Here we go, thanks. So the red line is when they had their embolic event. The black is when they had a fib. This is a subset of people in that study who had embolic events while they had their implantable monitor. Just highlighting that, you know, yeah, some people went into afib and then had an embolic event or were in Afib after their embolic event, but a lot of the time, the actual episode of afib. It is not necessarily the same time they have their embolic events. So, 70% of people had no episodes within 30 days of their actual event, um, but likely it's still, you know, they're intermittent afib, you have a, a more prothrombotic milieu. And 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, Eliquis or Xarelto 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 AFib. So, um, if you have reasons to be anticoagulated, there are studies looking at intermittent anticoagulation with wearables, but that's totally unproven, but they, they need to stay on it, uh, regularly, you know, intermittent anticoagulation doesn't. Uh, work as far as, as far as we know. And then the other question I get a lot, and sometimes, you know, referred patients just for this. You know, we know now Chad's vasc is sort of the risk stratification score we use, right, to start anticoagulation. Um, but what about Chad's vasc? We know two or more. People merit anticoagulation. We know Chaz Vask zero, so lone Afib, we typically don't anticoagulate. But what about the Chaz Vask1? This guy had a, he's 51, he has hypertension, um. Patients also ask, 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 answer is no. I mean, all these studies basically were epidemiology studies where people just checked 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. It's still important, obviously, for the future to prevent embolic 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 anticoagulation. 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, anticoagulated, 180,000 people. And, you know, this is looking at Chazves 2 in women since female gender, you know, we don't consider that alone a risk factor, but female plus another risk factor is 2 versus Chaz West 1 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 practice is one, and all the data, you know, one of the reasons the guidelines in the US gave the option of anticoagulation for CHADSFS1 is just because of warfarin, it was such a hassle to initiate it and maintain it and monitor it. With the DAX, it's really much less cumbersome. And if you look at guidelines, you know, this is the US guidelines on the left, AHA ACC HRS which for Chavas one gives you the option of aspirin or oral anticoagulation. But if you look at the Canadian guidelines and the European guidelines, they both recommend oral anticoagulation. You know, it's strong for the Canadian, a 2-A meaning not quite a class one, but most people are in favor. So, my own opinion is You know, if you look at the um Chas VS score, Chazvasc 0, 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 anticoagulate people because strokes, as you know, are, 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 his episodes. 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 the thirty-minute episodes, and the question is, you know, what type of anticoagulation and this guy with Chad asked one are you gonna start, um, aspirin, warfarin, or, you know, which of the DA. 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 AFib. You know, for coronary artery disease, yes, um, a secondary prevention, but really it does not work. So, it's kind of an old lore, well, aspirin's probably better than nothing, but really, it's not cause it has side effects and, 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 DAC. And You know, this is the, the available ones. I think any one of them are fine. The only little things I usually point out are that, you know, rivaroxaban or Xarelto compared to Eliquis or ixaban, they actually have the same half-lifes. In fact, the the half-life for rivaroxaban is actually a little shorter. So why is Xarelto once a day and Eliquis is twice a day? Um, it's just cause that was, that's what they did in the study, and, and they both worked. I mean, rivaroxaban was equivalent to warfarin and apixaban was better. Um, rivaroxaban does have a, 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, of Xarelto and Eliquis, the bleeding risk was actually slightly higher with Xarelto. So for, for people with higher bleeding risk, I prefer Eliquis. Um, again, if there are people for compliance reasons, really, like once a day instead of twice a day, then I think Xarelto is OK. You know, the other point I make is for, for Divigoran, we use this less often, um, the direct thrombin inhibitor. It's the one that's most renally excreted, so probably worse to use in your patients with renal insufficiency like this one. but it also doesn't interact. With uh the SIP 3A4, all those uh medication interactions. So 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 renally cleared. Eliquis, least renally cleared. So people with renal insufficiency. Um, and again, and you guys know there's dose reduction for a combination of older age and renal insufficiency, um, but, uh, Eliquis is probably the best to use in 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 DAC compared to warfarin, and less bleeding on a DAC compared to warfarin. So, you know, it's very few patients I have these days still on warfarin. Uh there's people because of cost or they've just been on it forever, prefer it. Um, people with mechanical valves, DA, you know, been shown 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 Dox 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 don't have to worry about diet, and you're just taking a, a pill once or twice a day. So again, you know, looking at stroke risk, ChadS VS 0. Low and those are the patients that don't require anticoagulation, but pretty much everyone else I try and get on, on an anticoagulant. So this patient got started on Epixaban, having more AF, noticed some palpitations. Again, his pacemaker shows uh that he's having more AFib. 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 AFib, 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, the data, um. So we all know Affirm was this older study in the 90s. First study, 4000 patients that randomized patients to rate versus rhythm control. So just, um, you know, AV nodal blockers, beta blockers, calcium channel blockers, or DI or some combination thereof, um versus anti-arrhythmics to maintain sinus rhythm. And that when you looked over 5 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 it's kind of I think told people to just leave people alone if they were in Afib 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 narrhythmics didn't work so well, so that even people in the rhythm control arm, only about 60% were actually in normal rhythm at the end, and people in the rate control arm, actually 40% of those were in normal rhythm cause they just had an occasional episode and got enrolled. So, we weren't so good at keeping people in normal rhythm versus AF. And if you look at who actually stayed in normal rhythm as opposed to the randomization, um, there was a 50% lower mortality in people who stayed in sinus 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 who maintained sinus rhythm, and that's why they had a lower mortality. Um, people who are anticoagulated had a lower mortality. People who use 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 rhythm. This, I'm asked this question a lot, and again, I don't wanna get Too much on this, but I think patients bring it up. There is more and more data that even on anticoagulation, the presence of AFib 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 AFib 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 happen 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 anticoagulation, if you do brain MRI's, you'll see more small vessel and, and asymptomatic small embolic events of people in Afib 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 Afib versus not, even though, uh, 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 cardiovert them or try various drugs? Um, and what I wanted to mention, cause this is where I think we need help from, from you guys, um, which is risk factor modification. Which is really a big part of the AFib 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, um, 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, of 15 kg, right? It was about 30 pounds, 32 pounds compared to those with general advice. And if you look at You know, the, the number of episodes and the duration of episodes, you know, pretty dramatic decrease in the amount of Afib people are having just by losing a significant amount of weight. Again, I wanna minimize, as we all know, just losing weight and keeping it off is not so easy. Um, but that clearly, and there's studies, pre-clinical animal studies showing that you actually get more atrial fibrosis and that epicardial fat. Um, release of cytokines that also contributes electrophysiologically from AS. There's a lot kind of mounting basic science data that obesity, um, is, is worsens and contributes to, uh, afib. This was this reverse AF study, so the top row of pie charts. At baseline where people who did not lose weight, people who lost 3 to 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 is those who progressed from paroxysmal to persistent, and yellow is those who regressed from persistent to paroxysmal, and in gray is those who became free of AF. And if you look at the group who lost the most weight, I mean, it's pretty dramatic. I mean, half of them are now free of AF and a third actually regressed from persistent to paroxysmal, and the orange slice of people who progressed is much smaller than these other groups. So, pretty impressive just with weight loss. And this is an ablation study, which I won't harp on other than to say, no, this is an ablation outcome with single procedure or multiple procedure success. And if, you know, someone said this is a new fancy catheter that will increase your freedom from AF from 26% to 62% after. One procedure, or 48% to 87% after multiple procedures, right? Everyone would wanna 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, you know, that's much easier to do, not easier, but much 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 coronary artery 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 WPW and AVNRT forever, uh, people think AFib is a quick fix, and, um, it can be, but it has to go along with treating all these other issues or the AFib's just gonna come back. So it's, you know, weight management, it's hyperlipidemia, it's glucose intolerance, it's hypertension, it's sleep apnea. We've talked about, you know, setting up an AFib lifestyle modification clinic. But we don't really have the bandwidth cause we're dealing with all these other patients with AFib andVT and ablation. Um, and that's where again, we need, uh, your help. I used to follow all my Afib ablation patients forever, once a year, um, but I just, my, the 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 5 years with more AF and they're getting older, um, and all these processes that led to AF just continue. Um, so this patient got started on CPAP again, really important, I think, if they have sleep apnea, it's kind of one of the standard questions we ask them now, do you snore? Um, and we have a direct line to Dave Klayman, 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 he had more, he tried an anti-arrhythmic, you know, then the question is, what do you do when he continues to have AFib? 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, uh, one anti-arrhythmic drug. And, you know, for younger athletic patients, it's also um a class 2A, meaning mostly consider it even without trying a drug. So for a young patient who's facing many years of antiarrhythmics 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. Uh, the next step after affirm to say, well, if drugs didn't really work, is ablation better, um, and would that improve the outcome, uh, of patients with Afib. So they're randomized again, 1100 to ablation, 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 so ablation was better, has been better in 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 got crossed over to ablation. About 10% of the patients who were randomized to ablation decided they didn't want an ablation and ended up getting drugs. And again, if you look on Who got actually ablated. So it's not quite the same as who maintained sinus rhythm, it's who got the ablation procedure. There was a reduction in mortality by about 30% over 5 years. Um, but again, it's again a post hoc analysis and maybe those patients who got ablated were 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 standpoint is, again, if you're gonna treat Afib, whether you start with a drug or start with ablation, um, in the end, the people who are in sinus rhythm, um, did, uh, better, and either is probably OK. But I think probably a more relevant study, you may have seen in the New England Journal is this East AFNT 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 AFib. Um, they didn't have a particular strategy for rhythm control. So the, the chart over here shows what people got. So most people got, you know, the common anti-arrhythmic drugs we use, flecainide or propafenone. Um, a little bit of amiodarone, and some people got AF ablation if needed, but it wasn't really an ablation study, so only 8% in the initial group, and at 2 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 upfront, some people got it if the drugs weren't working, but if the drugs were working, they stayed on, on their drugs. And it, 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, you know, their primary outcome, which was death, stroke, or hospitalization, that there was a 5% benefit. In early rhythm control compared to just usual care, um, without a difference in prolonging hospital stay. Yeah, how do you, oh, I guess I show this too, 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 mortality in, in death and in stroke. Again, about 0.3%. Um, so not a huge difference, but a small difference. And importantly, about 3/4 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? Do I treat every patient with AF with, you know, with 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 ablating people or giving them antiarrhythmic drugs. But if you take 300 AF patients a year, um, and treat them with rhythm control and anticoagulation, you'll basically save one life and one stroke a year, right? That's a 0.3%, at the expense of three non-serious, non-life threatening drug or ablation complications, you know, maybe syncope or pacemaker or drug toxicity or Tapanon. So, You know, there's some benefit, there's some downside, and this is kind of the discussion, uh, 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? We go down, you know, again, I would say for rhythm control, either a drug or ablation is fine to start with. Um, but I do think Most people who show up in persistent AF should at least have an initial attempt to maintain sinus rhythm, um, cause many people will Maybe get accommodated to it, but feel better once they get a sinus rhythm. So I'll try at least the cardioversion in 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 weigh sort of all these risks and benefits based on their age and other comorbidities. And that comorbidity is obviously a factor into this as well. The other two ablation studies I wanted to mention, both in New England Journey Journal, um, were these cryob 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 upfront, um, who hadn't been on a drug yet to ablation versus drug therapy. You know, and both showed They weren't looking at mortality, but in terms of maintaining normal rhythm, um, ablation was much better, right? So not 100%. In the 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 to get. If you're talking about a cure like zero AF, you're looking at about 57% after one ablation out 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 their AFib. You know, is a fib ablation a cure? As I said, um, you know, this is a study, this is what our data, we looked at years ago, but even people with no Afib at 1 year, if you follow people, this is now 123, and 4 years out, you'll see the freedom from AF starts to fall off. And right, we see this with our patients who've 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, the Other triggers forming and some of the imperfections of ablation where, where the, the pulmonary veins can reconnect. But it's not a You know, WPW you ablate it 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 have multiple procedures, the outcome is better. But, and again, there's some people, the good news is, is, there's the 70% who had a procedure and had no AF for 5 years. So they're great, right? We're, um, we fixed them, they're living their life, they're off their drugs, and they feel happy. Um, but again, uh, over time, the same process that led to AFib leads to it again. You know, do we ever need to treat or ablate asymptomatic AF? I, I think it should be considered, um, certainly in people who are young. I change the slide every year cause I'm 56, so, right now, 56 is, is young. Um, you know, we have these debates and EPs, well, some people say 65, 70, I don't know, but if, you know, if I'm 50, I wouldn't wanna have the next 30 years of anticoagulants and blood thinners and drugs. So I think it, it should be considered. Um, some people with AF will get a cardiomyopathy, right? Just from AF irregularity and rapid rates, they'll get, uh, a drop in their heart function, and most certainly people should be treated. And then we've learned people with tachy Brady, you know, people have AF in these conversion pauses, who would normally get a pacemaker. If we ablate 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 where they can't fly a plane, and had some commercial airline pilots, people in the army. Um, where, um, where ablation, should be, uh, considered. This was an airline pilot. Who was totally asymptomatic, but his Holter, his kind of routine Holter show going in and out of A-fib, and um also some pauses, and they, they initially took his license away, but in the lab, he just had a single pulmonary vein trigger we ablated, and then he was fixed and went back to flying. So, there are some young people where we can really fix their AFib. It is in the guidelines for tacky-Brady syndrome. It's reasonable to offer ablation 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 risks and 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, are at increased risk of stroke if their uh chance vascular is greater than equal to one. Female gender alone or low in Afib, again, we still don't anticoagulate, but everyone else would think about anticoagulation. Aspirin, not really useful for uh thrombombolic protection. The NA and DA, 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, to be on a NAC. Again, this risk factor modification is really um a big issue in managing these patients. And again, we, we really need help with this weight loss, sleep apnea, hypertension, that should be the kind of upfront assessment and assessing and treating those things can, can reduce. Both their overall burden and even if they're candidates for ablation still prevent later recurrences. Um, I think most patients with nuance of persistent Afib, even if they're not that symptomatic, deserve an attempt at sinus rhythm, we'll give them a cardioversion, see how they feel, and then discuss where to go. Um, whether it's a catheter or balloon, I'd left it out, but there's studies showing that basically equivalent in terms of outcome. You know, PV isolation, pulmonary vein isolation is the mainstay for AF 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 added on is, you know, when do you refer an AFib patient? Um, and I think there's, you know, for at least initial discussions, you know, most patients, it's probably worth having them meet with a cardiologist or EP, um. You know, I've talked to patients just about anticoagulation when they don't wanna take it. Usually, I have to convince them to take it. But, um, these CSS one patients, patients who are worried that they've got coronary disease also, they're on an aspirin. Um, 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 um should, should have discussions sooner rather than later, um, in terms of therapies for AF. I think anyone who's symptomatic, who's considering therapy should, should have a discussion. Um, and then I didn't get in cause it's a whole another 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 wanna take their, their DA 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 anticoagulant or having a stroke despite an anticoagulant. 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 EP. 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 managing their Afib until it becomes more bothersome, more problematic. But if someone that just has, you know, you wanna refer someone for new or recent onset AF, they really haven't had a full evaluation, things like that, an echo or a monitor for how much they're having or labs. They haven't even been started on anticoagulant yet, or they have associated, you know, valvular heart disease that might be contributing to AF. Um, generally we like those to get their initial evaluation. Um, through cardiology. They're also not as biased as we are at EP 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, cause 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 cause it's safe to just start out of the hospital, but you're just pushing other complications down the road like hyperthyroidism and hepatic, and I've seen horrible lung toxicity. So if people aren't responding to the first line drugs, then I, I have a low threshold to, to think about other options. Again, people just interested in talking about ablation. Again, this issue of people who are 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 anticoagulation where you'd like them to have a, a discussion about appendage occlusion devices. There's probably other categories I haven't qualified, but I thought I'd just mention those as sort of general, um. There he is. So, this is obviously Mount Tam up in Marin, so I live up in Marin. Um, but I hope that was overall helpful. Um, hopefully I didn't get too much into the, the weeds, um, cause again, the general gist of afib, obviously, anticoagulation, I didn't get too much into rate control, you know, we usually don't use dig much anymore, but beta blockers or calcium channel blockers, um, and then beyond that, If they're symptomatic, continuing to have episodes, uh, you know, that's where these other, uh, issues should be considered. And I think just in general, fatigue is a real symptom from AFib, 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 and asymptomatic and Go has AFib and a cardioversion and it recurs, and they're really asymptomatic. Absolutely, you know, anticoagagulate, that they just have chronic Afib, leave them alone. Um, and I have, I, I do that as well. Um, I've just seen a lot of people in their 40s and 50s 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 MR 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.
