Joel R 00:35
All right, hello again everyone, and welcome to this morning's Health Chat. My name is Joel with Adventist HealthCare, and I will be moderating today's conversation Shocking Discoveries: Electrophysiology and Your Heart Health. Before we begin, we have muted everyone to limit any background noise during today's Health chat. If you have any questions for our experts, we encourage you to please include them in the Q and A and we will address as many of them as time allows. We ask that you please only submit general health related questions, and for any specific concerns, we encourage you to speak with your health care providers. We are recording today's Health Chat for future viewing and will be accessible on our blog during heart month in February. We have two exciting experts joining us today. We have Dr. Alexander Asser, who is the director of the electrophysiology lab at Adventist HealthCare Shady Grove Medical Center. And our second expert is Dr. Tushina Jain. She is an electrophysiologist with Adventist HealthCare Cardiac Associates. Thank you both for joining us today, and we will go ahead and get started with our first question. All right, so our first question today is actually for you. Dr, Jain, it is on heart rhythm. And specifically, what is heart rhythm and why is it important to monitor for your health?
Tushina Jain, MD 01:57
Hi, so heart rhythm, essentially, is the hearts natural conduction system. The heart has natural pacemaker cells that initiate electrical activity in the heart, and the cells communicate with each other in order to allow that effective electrical conduction throughout the heart, which is then what's important for allowing the heart to pump efficiently and pump blood to the rest of the body, deliver oxygen, important nutrients to the rest of the body. So, it's essentially one of the main driving factors that kind of allows the heart to function normally. And yeah, it's important to monitor because issues with this can lead to decreased blood flow to other organs in the body. It can lead to several other problems down the line if it's untreated.
Joel R 02:52
Thank you for sharing that, and that answers an additional question that we received in reference to those risks that are associated with heart rhythm issues. Was there anything else you wanted to provide to that question at all.
Tushina Jain, MD 03:04
to the risks associated? So yeah. I mean, the main risks, one is symptoms wise, so, if there's an abnormal heart rhythm that causes a very fast heart rate or a very slow heart rate, for example, those kinds of issues can lead to severe symptoms of passing out, of fainting. In some cases, there are certain rhythm issues that can be more dangerous, that can potentially be life threatening as well, and then down the line, untreated rhythm issues potentially can lead to weakening of the heart muscle and lead to symptoms of heart failure, and certain rhythm issues also can increase risk of stroke.
Joel R 03:50
Yeah, so it's definitely important that we're monitoring that heart rhythm and checking in on that for sure. Dr. Asser, we received a question on AFib, and specifically, what is AFib and what causes AFib, or irregular heartbeat? Could you provide some information on that for us?
Alexander Asser, MD 04:08
Yeah, of course. Yeah. Once again, thanks for hosting this. This is great to talk to the community. We always enjoy helping out the community. So atrial fibrillation, also known as AFib, is one of the irregular heart arrhythmias that occurs in the upper chambers of the heart, the atria, instead of being in sinus rhythm, where all the cells are kind of in unison, kind of beating one electrical system, kind of system together efficiently. Atrial fibrillation essentially is chaos, a storm electrically in the upper chambers of the heart. Some symptoms that may occur when you have AFib are feeling your heart beating quickly, irregularly, if you're in a fluttering sensation in your chest. But some patients do not feel AFib, and then we call that silent AFib. Some of the issues with atrial fibrillation is that if it's not managed well or identified it could lead to a stroke, because when that atria, when the atria are not contracting normally, the blood can become a little bit stagnant, especially in something called the atrial appendage, and that clot could leave the heart and go to different parts of the body, especially the brain, and leading to a stroke. The other issue is, if atrial fibrillation is very rapidly conducted to the lower chambers of the heart, it could lead to congestive heart failure. So atrial fibrillation is a big issue. It's very common in the US, especially when you get older, or you have other comorbidities, such as high blood pressure, diabetes, sleep apnea, obesity, or problems with your heart itself, such as issues with the valves, or congestive heart failure.
Joel R 05:45
Okay, we received an additional question specifically about how much heart function would be lost by permanent AFib, or, you know, untreated AFib. So could you elaborate on that for us?
Alexander Asser, MD 05:56
Yeah, that's a great question. When we're talking about atrial fibrillation, usually we're talking about the atria. However, if atrial fibrillation is not treated appropriately, if the rate is too quick to the ventricles, it could lead to also weakening of the lower chambers of the heart, the ventricles, which could cause congestive heart failure. So once identified, once the AFib is identified, we want to treat it, certainly slow down the rate, try to convert patients back to sinus rhythm, restore the synchrony that Dr. Jain talked about the efficiency of the pumping of the heart. So, some patients can be in permanent AFIB and have no symptoms, and if they're closely monitored by a cardiologist to make sure the rate is well controlled. But other patients develop congestive heart failure, and we have to be more aggressive with them.
Joel R 06:43
Okay, we've heard a lot, I know, in our line of work, just different terminology associated with heart rhythm and specifically, AFib, some of these terms, like palpitations, flutters, arrhythmia, AFib. Can you explain the difference between those terms and maybe some of the different treatment options or recommendations for them?
Alexander Asser, MD 07:07
Of course. Let me turn my automatic lights back on. Of course. You know, in palpitations is a term that we use for a patient who feels their heartbeat. Normally we wouldn't expect someone to feel their heartbeat, but if you feel your heartbeat, we call that a palpitation. But we don't necessarily know what arrhythmia that is, or where it's coming from in the heart. It could be both the atrium or the ventral or both. It could be atrial fibrillation, this chaos, or it could be a different arrhythmia called atrial flutter, where you're also kind of in a very rapid atrial rhythm, but it's more kind of in a short circuit. It's kind of a program short circuit in the heart, okay, once the patient starts feeling symptoms, palpitations, usually we do further investigations, having them wear a monitor for a few weeks, that they take it home. We can try to see if we can figure out what arrhythmia or abnormal heart rhythm they may be experiencing and what's causing those symptoms. Now, sometimes people feel their heartbeat, but it's not an arrhythmia, it's just a forceful beat. Maybe they have high blood pressure, maybe they have anxiety. There could be other causes for them to feel a palpitation, even though it's the normal rhythm.
Joel R 08:25
Now we talked. Thank you for sharing that information with us. Are there any new or upcoming treatment options? I know things in heart care change rapidly. There's always new technologies, new ways to treat things. Are there new treatment options available for things like irregular heartbeat or some of those other conditions.
Alexander Asser, MD 08:44
Yeah, absolutely, we have so many different treatment options for patients with arrhythmias of the heart. But to kind of focus on atrial fibrillation itself, we have medications we use frequently. That's how we start. We slow down the heart rhythm. We give patients what are called antiarrhythmics, sometimes to convert them out of atrial fibrillation. There are not many new medications. Most of them have been around for a long time with pluses and minuses. But a lot of patients, especially when they're healthy and are very symptomatic from atrial fibrillation, we proceed to what's called an ablation where me and Dr. Jain are two ablationists. We do procedures on patients hearts where we put catheters through the veins, through little IVs, it's not open heart surgery, and we feed these small catheters through the vein, up into the heart, and we identify the triggers for atrial fibrillation or other arrhythmias they may have, we identify them, we map them with really cool, special three dimensional mapping systems, and then we can try to eliminate those signals. Now, the traditional way to eliminate those signals is to heat the tissue with a catheter called a radio frequency ablation catheter, but there are newer technologies that are out and coming out and still evolving. One of them called cryoablation. We've been using that for many years, but more recently, something called PFA, Pulse Field Ablation, and that is we, we are learning a lot more about that. There's a lot more really interesting research being done about PFA and we look forward to continue evolving the technologies for atrial fibrillation.
Joel R 10:27
I appreciate you bringing up ablation. We did receive a question in reference to the success rate for ablation procedures. Could you elaborate on that for us?
Alexander Asser, MD 10:35
Yeah, so if we're focusing on all arrhythmias, that's difficult to answer. Some patients are born with an extra wire in their heart, something called WPW, or they can have a short circuit called SVT, and the success rate, procedural success rate, for those is very high, in the high 90% range. Now, atrial fibrillation is very different. It's not just one extra wire or one trigger. There can be numerous different triggers in the heart causing atrial fibrillation. The other difficulty with saying what the success rate for an atrial fibrillation ablation is, it really depends on the patient. If you have a young, healthy, 20-year-old, the success rate for a one time atrial fibrillation ablation may be in the mid to 80% range to 90% but if you have an elderly patient who has many other illnesses or comorbidities, such as morbid obesity, sleep apnea, a weak heart valve issues, or has been an AFib for a very, very long time. Then doing an ablation, the success rate is much lower, more in the 60% range, and sometimes we have to repeat the procedure six months to a year or two later, if need be and go after other triggers in the heart.
Joel R 11:44
I appreciate you breaking that down for us. Dr. Jain, we received some questions in reference to heart beats, and specifically, extra beats or missing beats. Could you elaborate or provide some insight on that for us? Yeah,
Tushina Jain, MD 11:58
So extra heartbeats are a pretty common thing and usually very benign, but it can lead to symptoms for certain patients, which is basically, you know, they feel this extra pounding sensation every once in a while, sometimes that extra beat is then followed by a pause, which can actually lead to a sensation of a missed beat in that case. So sometimes it can actually be the same thing that a patient is feeling regardless. Those type of symptoms are typically benign, but sometimes they need medication or an ablation procedure as well to treat that. And you know, it's hard to evaluate without doing further monitoring. So, you know, if you're having symptoms like that, that's definitely something that you should see a provider for. So that we could provide a longer-term rhythm monitor to see exactly what's going on.
Joel R 12:55
Okay, I know we addressed in our first question of the session here about heart rhythm and heart rate. Could you explain for us when someone should maybe be concerned about their heart rate, or, you know, those feelings of missing heart beats, or things like that?
Tushina Jain, MD 13:13
Yeah, so technically, you know, we consider the normal heart rate between 60 to 100 beats per minute, but there's a lot of variation in that, and people's heart rates can definitely go lower than that, especially if you're resting, if you're sleeping, oftentimes, your heart rate can drop into like the 40s or even 30s, and you're resting, sleeping, it's okay. The main things to be concerned about are, if you have a persistently low heart rate or a persistently high heart rate with symptoms like shortness of breath, dizziness, fatigue, if you're doing activity and you feel like you can't get your heart rate up appropriately as you should be when you're exercising, or if your heart rate is just very fast for a very long time and you're not doing anything. So basically, sustained issues with the heart rate either too fast or too low, and especially associated with any symptoms, are when I would say that you should get evaluated.
Joel R 14:15
Okay, so really looking for those sustained feelings, those long-term feelings, all right, we also received a question in reference to just those signs or symptoms, and I know you both have kind of shared that sometimes there may not be any signs or symptoms, sometimes you may experience different symptoms. But could you provide some more context on that for us, Dr. Jain?
Tushina Jain, MD 14:40
yeah. So again, that's it depends on the kind of a rhythm issue that you're having, but oftentimes the symptoms are dizziness, lightheadedness, feeling like you're going to pass out, passing out, feeling the heart racing, feeling. Fatigued can also be a sign of it, which can be a more subtle sign of certain rhythm issues like having a low heart rate or atrial fibrillation, feeling like more easily fatigued with activity. Yep.
Joel R 15:16
Okay. We also received a question in reference to lifestyle changes and whether or not there were things that we can do to be proactive that would help treat or support our care for irregular heartbeat. Were there any recommendations you could provide for that?
Tushina Jain, MD 15:28
Yeah, so in general, I think that kind of having a heart healthy lifestyle, in general, in terms of a heart healthy diet, is important, because those things can also help with rhythm issues, weight loss, exercise, good sleep hygiene, stress reduction, stress and not getting adequate sleep, those things can particularly cause those extra heartbeats and palpitations and then alcohol reduction. Sometimes excessive alcohol intake can also predispose to rhythm issues like atrial fibrillation, smoking cessation. So again, a lot of the things that we think about as overall heart healthy and then managing other conditions like high blood pressure, diabetes, all of those can also contribute to rhythm issues, so making sure that you're seeing a doctor regularly and getting those other conditions treated.
Joel R 16:29
Really, those are really great practical tips for people to consider, especially when it comes to maintaining that heart health and keeping active. So, thank you for sharing those we did receive, and Dr. Asser, we'll transition back to you. We received a lot of questions in reference to Automated External Defibrillators or AEDs, and we wanted to ask a couple of questions about those. So, if we just want to start with, what is an AED and how does it impact heart rhythm?
Alexander Asser, MD 16:58
Yeah, I love talking about AEDs, because it's so important in our community. So just to clarify a kind of confusing point that a lot of patients in the community have, the difference between cardiac arrest and a heart attack. Sometimes these terms are used together. So, a heart attack is when one of your coronary arteries, arteries that are feeding your heart have a blockage. Now, heart attack will cause chest pain, but may lead to cardiac arrest. Having a blocked artery can cause your bottom chambers, your ventricles, to go into a chaotic, dangerous arrhythmia called ventricular tachycardia or ventricular fibrillation, and that will lead to cardiac arrest. Now, people can have cardiac arrest who do not have a heart attack. There are many congenital causes of this, unfortunately that can happen to athletes in their 20s or even younger. Also, if patients have a very weak heart muscle from a prior heart attack, or from just having a weak heart muscle, we call it cardiomyopathy, that could lead to a dangerous arrhythmia. So, it doesn't have to be a heart attack where someone drops down and suddenly goes into cardiac arrest. Now AED, and AED stands for an Automatic External Defibrillator. I think most people in the community have seen these hanging on the walls at malls or casinos or airports or in the hospital or in schools, but they're extremely important. They're really the only way that someone's really going to survive cardiac arrest unless they're extremely lucky. So, if someone were to pass out in the community, and you are the first person to witness it, you're the bystander, we would hope that you would just start CPR, even if you're not a trained medical professional, we would hope that you would do CPR at 120 beats a minute. There's a great video on the American Heart Association about going at the tempo of the Bee Gees song, Staying Alive. But we want you to do CPR. You don't need to provide any breaths to the patient. And then immediately, you want to either yourself, if you're by yourself, try to look for an AED, if you're in a place that has that, or ask for help and while someone is also calling 911, but if you have access to an AED, once again, you do not need to be trained. This is for any person in the community to pull that right off the wall, turn it on, put the patches on. There's instructions on it, and all you do is turn it on, and there's an automated voice that teaches you and tells you all the steps that need to be done. The device will automatically recognize if it's a dangerous arrhythmia, and if it is, such as ventricular tachycardia or ventricular fibrillation, it'll deliver a shock to the patient. You will not be hurt by that shock, even if you're touching the patient, although usually it'll tell you instructions to stand clear and if you do not get prompt resuscitation from cardiac arrest, the outcomes are dismal, unfortunately. In the US, if you have cardiac arrest outside of a hospital, about 6% survive. So that means 94% of patients who go into cardiac arrest outside of a hospital setting do not survive. It just takes about five to 10 minutes for the brain cells to start to die, if they don't get enough blood flow or oxygen. And I kind of tell patients, you know, I have a lot of, you know, see, in the community, people are scared to use an AED because I'm not a medic, I'm not medically trained. But I kind of try to tell patients, you know, it's no different than an extinguisher, a fire extinguisher. I don't think anyone's ever been trained in how to use a fire extinguisher, but if I saw a fire I would grab it off the wall and at least try to use it, you know, and so the trying is the most important. And there's no, there's no legality of messing up a defibrillator or an AED, or not doing it correctly. There's no concern for anyone the community to do it. And you really, you know, we unfortunately, see a lot of patients who do not survive cardiac arrest, but when the when they do survive, it's just amazing. It really is a miracle. The more people that help in the community, when someone goes into cardiac arrest, the more likely we're gonna have more people survive and get that 6% survival rate much higher.
Joel R 21:13
Absolutely, I appreciate you sharing the fact that anybody can do it. It is very supportive and, you know, user friendly from that standpoint, it does walk you through that process. So, it's so important. And you mentioned some of the locations that people may be seeing them around. Is there an easy way to find AEDs in a space? Or do you have any recommendations on that?
Alexander Asser, MD 21:35
Yeah, it's if you're in a foreign place. Obviously, it might be difficult. Let's say you're walking in a mall, you know, you just have to, you know, hopefully there'll be other bystanders there that you can while you're doing CPR, or having other people help through CPR, you can find someone to go look for the AED. One thing I would just say is, when you're just randomly walking through public spaces, just kind of note to yourself where that AED was, if you're walking in a mall, and you'll usually there's a little lightning bolt and it's in red, and it's written on the wall above the AED. Just kind of note to yourself that that there's a AED and where it is, and you can direct other people or yourself to go get that AED. Almost all schools in Montgomery County and in the area have AED’s there as well. It's always a concern about high school and middle school athletics. So, it's always important to make sure that the schools have AEDs that are functioning well, but that's probably the best way, you know, just to kind of remember, especially if you go to a place that you go, you frequent, you know a lot, make sure you know where the AED is. Gym, for instance.
Joel R 22:42
Absolutely, and you know, we've seen it so frequently in the news in the recent years about sports and athletes, it's just so important to know where those are and where you can access them just in case you need them. So, thank you for sharing that information with us. And so, we received several other additional questions in reference to arrhythmia and heart rhythm. So, I wanted to try, so I wanted to transition back to that. And staying with you, Dr. Asser, we had a question about left bundle branch block. We've actually received a couple of questions about that and in the chat today. So, I wanted to just ask, can you explain what it is and what can happen with someone who has that condition?
Alexander Asser, MD 23:21
Yeah, sure, no problem. So once again, like Dr Jain talked about earlier, the heart is a muscle. It's pumping blood to the rest of your body, but it's also an electrical system. So, the electricity normally starts in your sinus node, in the top of your right atrium, the two atria beat normally, and then the electricity goes through what's called your AV node, which is a kind of a bundle of wires, but then it rapidly goes to the bottom two ventricles, through two main kind of highways, two wires. One's called the left bundle branch, and one's called the right bundle branch. The right bundle branch goes to the right ventricle, which is small in most patients, and the left ventricle has a left bundle branch, which actually is formed of two different smaller wires called fascicles. Now if what, if the left bundle branch is blocked, we call that left bundle branch block. That can happen spontaneously, but it does concern us and alert us that there could be an underlying cardiac reason for that left bundle branch block. The most common reason someone develops a left bundle branch block is because there's been damage done in the heart, whether it is a heart attack, that has damaged those wires, or it could be weakening of the heart muscle, almost like a stretching of the ventricle, which stretches the wire and damages the wire, and then there can be other causes that are more rare. When we see a left bundle branch block, we now worry that there's damage done to the wires. So, a few things can, even if the heart muscle is normal and it's strong, we do worry a little bit about the other right bundle branch, because if that wire were to get blocked in the future, then you would have an extremely slow heart rhythm, what we call complete heart block. And you may pass out, or you may feel very dizzy, and you would need a pacemaker implanted. Just having a left bundle branch block without any other structural heart disease, we just follow those patients longitudinally and make sure that they don't have any other concerning symptoms or arrhythmias.
Joel R 25:26
And is that something that could just be caused by underlying I know you mentioned some other health conditions, but is it generally something that is due to those underlying health conditions, or could it be supported by aging or other conditions to that extent?
Alexander Asser, MD 25:40
You know the wire is just like any other part of your heart. After you get a little bit older, unfortunately, I kind of tell patients like an insulation on a wire fraying a little bit, but for many years of good living, those wires can stop working. So, age certainly increases the chances of having conduction disease. It's usual when we put a pacemaker in that they're elderly patients, although we do have young patients that require pacemakers as well. But once again, the most important thing is, once we identify someone with a left bundle branch block or any conduction disease, for that matter, issues with the wires, we want to investigate further with further testing, make sure that it's not a dangerous situation, or that there's something wrong with the heart muscle itself.
Joel R 26:28
Dr. Jain, we received a question on SVT. Could you explain what SVT is, and is it something to be concerned about, or should it be concerning?
Tushina Jain, MD 26:38
Sure? So, SVT stands for Super Ventricular Tachycardia, and it's a type of rhythm issue that originates in the top chamber of the heart. But it actually is kind of a broad term because it can include several different types of specific rhythm issues still, and usually it's a benign condition. But it can cause, like, very severe symptoms for a patient, very rapid heart rate, extremely fast, sometimes that can potentially lead to losing consciousness, passing out. And then, you know, sometimes it can be treated very conservatively, with just maneuvers that the patient sometimes can do that can help terminate the episode, like coughing, for example, bearing down what we call vapal maneuvers to kind of slow the heart rate down, but sometimes you need medication or an ablation procedure as well, can be very effective at treating these. Some of the SVT types can actually be more dangerous if you have like an extra wire in the heart that Dr. Asser mentioned earlier, like an extra electrical connection between the top and bottom chambers of the heart, that can be very dangerous, and in certain cases, can lead to more significant consequences in addition to passing out and so it does need to be treated early.
Joel R 28:07
Alright, thank you for sharing that with us. The next question that we had, which I'll also ask you, Dr Jain, is, why does your heartbeat appear to speed up and slow down when you inhale and exhale?
Tushina Jain, MD 28:21
Yeah, so that's actually a very natural and normal process of the body, and it has to do with how the breathing process interacts with the autonomic nervous system. But basically, when you inhale, your diaphragm moves down your chest, expands, and subsequently there's a change in the heart rate. Usually it speeds up, and then the opposite happens when you exhale, and it's a very normal thing, it usually actually indicates that you have a very healthy heart and healthy electrical system. So, it's nothing to be concerned about.
Joel R 29:02
Thank you. And Dr. Asser, we had a question about premature ventricular contractions. Could you explain for us what that is and some of the causes for that as well?
Alexander Asser, MD 29:14
Yeah, absolutely. So Premature Ventricular Contractions, or PVCs, is where, instead of having our normal rhythm going through the normal wires, like I described before, sinus to the ventricles, one of the cells, or grouping of cells in the bottom ventricle, beats early and kind of independently. Now, almost all adults have some percentage of PVCs. It's pretty rare that I have a patient wear a monitor for a few weeks and they have zero PVCs, although we see it. So, it's usually a benign finding. It's usually not anything dangerous. Some patients have 20% PVCs and don't feel that there's anything wrong, and it was picked up incidentally by their primary care doctor, maybe on an EKG or a smart watch or something else, and other patients feel them with shortness of breath or palpitation, where they feel their heartbeat in their chest, especially if they have a pause after that premature beat, they may feel that. So, we usually do a little bit more investigation. If patients are very symptomatic from it, or if they have a lot of PVCs, we usually want to rule out any other kind of associated heart problems, such as a weak heart muscle or problems with the coronaries of the patient. But usually, it's a benign finding. If patients are very symptomatic, we have treatments medications we can give, such as beta blockers or calcium channel blockers, and very rarely, but in certain circumstances, me and Dr. Jain, and other electrophysiologists will do an ablation for PVCs, but usually that's not necessary.
Joel R 30:53
Thank you. We received another question, which I'll also pass off to you, is on the topic of the Watchman device, and what that is, and how it is used to support patients with AFib. Could you explain that for us?
Alexander Asser, MD 31:06
Yeah, that's a great question, you know. So, we talked about atrial fibrillation before, and we talked about risk of stroke, but we didn't talk about how to prevent a stroke. So, the most important therapy we have and the most powerful therapy we have to prevent strokes in patients with atrial fibrillation are called blood thinners. There's a few of them. There's the old version called Warfarin or Coumadin that we use a lot, works very well, but we have newer drugs that we use. I'm sure the people have seen them advertised on TV, unfortunately. But there's Eliquis and Xarelto, one called Savaysa, one called Pradaxa. And these medications work great. There's a risk, however, of bleeding with these medications, but they really reduce risk of stroke. Now, in some of our patients, they can't tolerate blood thinners, they may have had a major bleed or a fall where they hit their head. So, we find that the risk of bleeding may outweigh the risk of stroke, so therefore we get into a situation where we can't give them a blood thinner safely. So that's really where the Watchman is invaluable. So, this is a device that's inserted, similar to when we do an ablation through the groin. We put a large catheter up into the heart and into that left atrium, the same location where we would do an AFib ablation. And essentially, it's a device, like a plug that we insert into the most common place where blood clots form an atrial fibrillation called the left atrial appendage. This is a little pouch that sits on the side of the left atrium, and the blood flow is very stagnant in there, in the patient who's in atrial fibrillation, and this plug, this device, sits in that left atrial appendage, and over time, kind of scars over and closes off that appendage and significantly reduces the risk of AFib, even for patients that are off blood thinners long term. So, it gives us another option for patients that otherwise cannot be protected from stroke, who have atrial fibrillation. Now, one question I get a lot is patients who have symptomatic atrial fibrillation have heard about or seen advertisements for the Watchmen, and they say, oh, I would like that. That sounds great to prevent my AFib. The Watchman device itself won't prevent their atrial fibrillation. They won't feel any better with a Watchman, but it will allow us to eventually come off blood thinners safely.
Joel R 33:24
Alright? Thank you for that information. Dr, Jain, we've received some questions in the Q and A and also, previous to today's conversation about smart watches. I know, in the last couple of years, there's been a variety of different new, you know, wristwatches or different things that can help you track your heart rate, can help you track all sorts of different things with your health. Someone wanted some information in reference to their smartwatch indicating that they occasionally have AFib. And what could that mean? And we also were just curious if you would recommend using a smart watch to help track or monitor your heart rhythm.
Tushina Jain, MD 34:06
Yeah, sure. So, yeah, I think smart watches are a good tool for monitoring this. They actually have been FDA approved to monitor for AFib in particular, and the newer technologies of the smart watches have an ECG monitor. So basically, you know, when we do an ECG in the office or in the hospital, we put leads on the patient's chest in order to get a clear image of the electrical activity in the heart and EKG. So, these watches, they have built in electrodes that serve as the leads, but it's a very limited picture, so it's not like a full 12 lead EKG, what we call. But it still provides a good assessment of the rhythm, and in particular, it's good for detecting atrial fibrillation, not so much for other rhythm issues necessarily. But basically, it can notify if there is an irregularity in the heart rhythm, which might indicate atrial fibrillation. It's not, you know, sufficient in order to make like a diagnosis, I would say, you know, I you definitely need to then see a doctor, an electrophysiologist, have it confirmed. But oftentimes patients can show the tracings of the abnormal rhythm so that we can actually review it in the office, confirm the diagnosis, get an EKG, maybe another rhythm monitor if we need, but it's a good way to detect it early on. Oftentimes, when patients don't have symptoms of atrial fibrillation, they might be having it, and they don't realize it. So, it can be a good tool for identifying it early. And then once you know that you have atrial fibrillation, it can also be good to see how much atrial fibrillation you're having, if you're having it frequently, what your heart rates are. So yeah, it's, it's a good tool for, kind of, the initial assessment and for monitoring once you have a diagnosis.
Joel R 36:07
Okay, it's good to hear that based off of, you know, you see so many people with smart watches nowadays and getting that information and making it so accessible for you to at least have that early, you know, notice, to reach out to your doctor to get that additional information and to confirm that diagnosis is really, really important. So, thank you for sharing that with us. We received a question, and this will also be for you, Dr. Jain, in reference to sleep apnea and heart arrhythmia. Could you discuss or provide for some information about the you know the connection between those two?
Tushina Jain, MD 36:43
Yes. So, in sleep apnea, sometimes at night, basically, the oxygen levels can drop because of an obstruction in the upper airway, and that can predispose to certain rhythm issues. In particular, atrial fibrillation, it can be a risk factor for that. And if you have sleep apnea that is not treated, that can predispose you to have more episodes of atrial fibrillation, it can make treatment more difficult. Also, sleep apnea sometimes can cause a slowing of the heart rate at night when you have low oxygen levels, then the heart rate can also slowdown in response to that. So, it is important to get evaluated for that, if there's a concern for it, and then get treated with CPAP machines to treat that. The more severe the sleep apnea is, and the more likely it is to cause these rhythm issues. Often, if it's mild, it's not necessarily going to be an issue, but the more severe it is, if you're a little bit older, it can be more of a trigger.
Joel R 37:49
It’s just something to be and to be aware of. Alright, we also received one additional question, Dr. Jain, in reference to exercise, I know we talked about, you know, what we can be doing to be proactive about, you know, preventing or managing those symptoms of heart arrhythmia and heart monitoring. But someone wanted to know, should exercise be avoided with heart arrhythmia concerns?
Tushina Jain, MD 38:16
Yeah, so I would say no. In general, exercise is always beneficial, and it's sometimes it can be helpful in preventing these rhythm issues as well, like we discussed, and whatever you feel comfortable doing, and as long as you're not having like severe symptoms, it's yes, exercise is good, and I would recommend it.
Joel R 38:42
Thank you for emphasizing that for us. I believe at this point, we've gone through many of the questions that we've received prior to today's conversation, so I'd like to take some time to go through our Q and A questions. For those of you who are on today's call, we invite you to please submit your questions to the Q and A we'll try and answer as many of them as we can before our end of time today. So, the first question that I have from this, from the Q and A, was in reference to halter monitors, and Dr. Asser, I may ask this one of you first, using a halter monitor for diagnosis is it sounds like was the, a common practice. But this individual had a question in reference to loop recorders and whether or not those are in practice as well. So, yeah,
Alexander Asser 39:27
No problem. So, we use all different types of monitoring of patients’ heart rhythm. In the older days, maybe 10, 15, 20 years ago, we had these very large Holter monitors that patients had to wear on their belt. It was very bulky, very uncomfortable. Nowadays we have much more sophisticated monitors that we can place on patients, little patch monitors that patients can wear up to two weeks or even longer. They're usually waterproof. Some of them can transmit daily information, or even real live data, other ones the device needs returned to the vendor in a prepaid package, and then we can download and look at what the arrhythmias are. It's very helpful for patients who are having frequent symptoms that we want to try to identify what the mechanism is of that arrhythmia, are they having atrial fibrillation? How much atrial fibrillation are they having? Are they having PVCs or PACs? What is the cause of their symptoms? And sometimes we identify that they're not having an arrhythmia as a cause of their symptoms, and it might not even be their heart that really helps kind of narrow the focus for maybe their primary care doctors to look for other causes of their symptoms. Now, a loop recorder is a special procedure that me and Dr. Jain perform. It's a very simple outpatient procedure, but we do it at the hospital right now, but it's not done under any anesthesia, and essentially, it's a small device that goes under the skin, and the battery can last over five years, and it gives us data that's sent through the patient's cell phone usually, although, if you don't have a cell phone that we also provide a monitoring device, and it will send us data to our office. Now, it's not live data, but it'll trigger an event, if the patient goes into an arrhythmia, it'll automatically save that or if a patient themselves has a concerning symptom, they can press a button on their phone or their monitor, and it'll save that arrhythmia, or whatever heart rhythm they may or may not be having at that time, and then we can review it. Now a loop recorder, so you can imagine, if a patient has very concerning symptoms, for instance, maybe they pass out, but it only occurs a few times a year. Can be very hard to pick up that what the causes or mechanism of that passing out is with a two-week monitor. So, the loop recorder, because the battery lasts up to five years, is really invaluable in these rare arrhythmias, and even atrial fibrillation. So atrial fibrillation, like we talked about before, can be silent in patients. So sometimes a patient has a stroke, but we don't know the cause of this stroke, and we call that a cryptogenic stroke, and so we're very worried that they may have silent atrial fibrillation that has not yet been identified. So that's another reason we place this loop recorder, to allow us to give long term data, to look for any atrial fibrillation, because if we found atrial fibrillation immediately, we would place that patient on a blood thinner if they could or Watchman device if they couldn't.
Joel R 42:26
There's definitely plenty of options at the disposal in order to track and monitor that heart rhythm for determining best courses for treatment moving forward. So, thank you for sharing that for us. Dr. Jain, I wanted to ask, we received a question, and then I know we talked briefly at the beginning. Well, we've actually talked a little bit about it throughout our conversation today. But ablation procedures, someone was interested in knowing what that procedure looks like for a patient and what the recovery process and time looks like.
Tushina Jain, MD 42:57
So, most of the procedures we for the ablation procedures, patients come to the hospital the day of the procedure, if it's scheduled as an outpatient, you get anesthesia for the procedure, depending on the type of procedure for atrial fibrillation ablations, we typically do general anesthesia. And again, the access for most of these ablation procedures is through a vein in the in the groin area, so it's access through that vein and putting up catheters through the vein using x-ray guidance. And so, it's not externally that invasive. It's not open-heart surgery. And typically, patients might stay overnight in the hospital one night, just for monitoring, especially after an atrial fibrillation procedure. And then, as long as everything is going well, go home the next day. And then, typically, we just tell patients to take it easy in terms of activity for a few days, no like excessive exertion. But other than that, it's pretty quick recovery time, I would say, because when you leave the hospital, you really just have that access site to the vein. You have a little dressing on it, and that's about it.
Joel R 44:14
Thank you for sharing that. Dr. Asser, we've received a question in reference to AFib and atrial flutter. And I know we talked a little bit about the differences at the beginning, would you be able to just restate those?
Alexander Asser, MD 44:27
No problem, no problem. They’re very similar. So the symptoms may be the same and the treatment may be the same, but from an electrophysiology standpoint, for me and Dr. Jain, the treatment may be a little bit different, but so atrial fibrillation, once again, instead of being a normal sinus rhythm where you have a uniform atrial signal and electricity going through the atria, atrial fibrillation is just electrical chaos, essentially an electrical storm, all the heart cells are not talking to each other in the atria, and they're beating independently, and usually very rapidly. Atrial flutter is also a rapid arrhythmia of the upper chambers of the heart, the atria, but it's a short circuit, so almost like a loop kind of going through the atria. There's different reasons for patients to have that. They may have scar tissue, but you can have a very normal heart, and it's just essentially bad luck where you have a little channel of tissue, usually near what's called the tricuspid valve, where the electricity can, kind of do a short circuit through. And we do ablations for atrial flutter. Our outcomes for atrial flutter ablations are significantly higher than atrial fibrillation. Now one of the confusing parts is for patients who have atrial fibrillation or atrial flutter, they frequently also have the other arrhythmia. So, it's very common where we have patients who we first identify with atrial flutter, but it turns out they also have atrial fibrillation, where, when we have them wear a monitor, a Holter monitor, or a patch monitor, or in the future, after we've dealt with it. And vice versa, if patients had atrial flutter, and we do an ablation for that, we always want to monitor them going forward for possible also having atrial fibrillation.
Joel R 46:13
Okay, okay, we also for the topic, specifically of AFib, someone was curious about what the probability is that you could experience multiple incidents involving AFib, you know, if you.
Alexander Asser, MD 46:29
So, you know, everyone's heart is a little bit different, and everyone's AFib is a little bit different. You can have lone AFib, which means that you have just one episode of AFib, and we have an obvious cause for that atrial fibrillation. For instance, if you're in the hospital and you're very ill, maybe have pneumonia. It's very common that we'll see the heart become very irritable electrically and frequently go into atrial fibrillation while the patients are sick. But once that pneumonia or that underlying cause is treated, they may never have atrial fibrillation again, although we have to kind of still investigate the heart function and make sure there's nothing else underlying. For other patients, it depends on what their health is. The older you are, the sicker you are, the longer you've been in AFib, the more AFib you're going to have. So, when we identify someone with AFib, atrial fibrillation, we want to try to cut it off early on. You know, cut it off at the pass. In the older days, we used to not do ablations. Early on, we tried multiple different medications. The problem is, the more AFib you have, the harder it is to treat. So nowadays, when we identify a patient that may get recurrent AFib or having recurrent atrial fibrillation, we do try to be pretty aggressive in the appropriate patients to prevent this kind of downstream effects of having more and more AFib. Okay, but certainly the sicker you are, the more obese you are, if you drink a lot of alcohol, if you have sleep apnea, like Dr. Jain talked about, if you have other comorbidities, a weak heart, you're going to have more AFib, unfortunately it can be harder to treat.
Joel R 48:05
So, it's important to be aware of those comorbidities for that topic. Alright, and we have time for just one more quick question here. And Dr. Jain, I want to go back to you in reference to the conversation that we had with smartwatches. You know, we hear a lot of terminology in the field of cardiology about different providers and their focus and what care they provide. Could you explain if someone notices something that might be off with their smartwatch, who would be the best person to talk to first, and how that process would work?
Tushina Jain, MD 48:41
So, I think it depends on the setting you're in. Really, a general cardiologist definitely can evaluate that first, if you would prefer that, you know, they can look at the reading, they can definitely make the diagnosis of atrial fibrillation and also start medication for that. But it's also reasonable to see an electrophysiologist directly. You know, at the end of the day, we are still cardiologists. We manage all the cardiac issues as well. Dr. Asser and I, so you know, if there's anything concerning, we would be happy to see you, you know, right off the bat. And we can also, you know, do all the other management for the cardiac conditions as well. So, I think either way is okay,
Joel R 49:29
Alright. Thank you for sharing that with us and for answering for both of you for answering all of our questions today. I do just want to take a few moments to just thank everyone for joining our call this this morning, if you are interested in any other wellness classes or future Health Chats, we encourage you to visit AdventistHealthCare.com and click on classes and events for the latest information. To learn more about Dr. Asser and Dr Jain, please visit AdventistHealthCare.com and click on Find a Doctor. There will be a follow up email to today's conversation that will provide information to their profiles on our website as well, and it will also include additional information and heart health resources. This February, you can also learn your risk for heart disease and receive additional heart health tips. And we encourage you to follow Adventist HealthCare on social media to get that information. I want to thank our experts again. Dr. Asser and Dr. Jain, for answering all of our questions. We appreciate the wonderful information that you both have provided for us today, and I hope everyone has a great rest of their day.
50:32
Thanks. Thank you. Applause.
