Audio: An Einstein Perspective on Atrial Fibrillation
What is atrial fibrillation, or a-fib? Who has it, and why is it such a serious threat to health? What are the best and newest treatments?
For answers to all of these questions and more, we asked Einstein’s Sumeet Mainigi for his insights.
Dr. Mainigi is the director of Electrophysiology at Einstein Medical Center Philadelphia. He has specific expertise in ablation of atrial fibrillation, ventricular tachycardia, supraventricular tachycardias, and implantation of pacemakers, defibrillators, and biventricular devices.
Bill Fantini: It’s believed that 10,000,000 people, maybe more, have atrial fibrillation or A-fib, a kind of irregular heartbeat. Some don’t notice it, but for many others it can be extremely uncomfortable. It can lead to stroke or could even shorten your life. I’m Bill Fantini with Einstein Perspectives. We turn to Sumeet Mainigi, MD, director of electrophysiology at Einstein Medical Center, to learn more about A-fib, its causes, and a relatively new treatment that doesn’t require any drugs.
First, what is atrial fibrillation?
Dr. Mainigi: Atrial fibrillation is a very common arrhythmia, which is basically an irregular heartbeat that can cause people a variety of symptoms and predispose them to a number of different problems.
Bill Fantini: How common is it?
Dr. Mainigi: It’s thought that between five and 10,000,000 people have atrial fibrillation, but that’s estimated to probably be on the low side because there are a number of people who have not yet been diagnosed but probably are walking around with the problem.
Bill Fantini: So they’re not really aware they have it, then?
Dr. Mainigi: Symptoms range from subtle to quite severe and so, often they’re patients who really are just feeling palpitations or they sense that their heart is skipping a beat or they may be more short of breath than normal and may not recognize that there could be something seriously wrong with their heart. But on the flip side, sometimes people do present for the very first time with a devastating stroke as the first finding that they have atrial fibrillation.
Bill Fantini: Well, that would be an obvious sign, and these other symptoms … when would you suggest someone seek treatment?
Dr. Mainigi: If somebody has been experiencing palpitations, this sense of a skipped heartbeat, they feel their heart racing at times when it shouldn’t be, for instance, when they’re laying in bed or after eating, or if patients suddenly start to notice that they’re beginning to feel more short of breath than normal, perhaps at rest, perhaps with minimal activity, they’re just getting more winded. These are sometimes signs that the patient could have atrial fibrillation. Other things that people could sometimes develop are things like lightheadedness or dizziness, feeling that you were about to faint. These are other symptoms that can suggest that you could have this irregular heartbeat called atrial fibrillation.
Bill Fantini: How is it generally treated?
Dr. Mainigi: The treatments are pretty wide and varied. From the simplest treatments, what we really absolutely need to do very early on in the course of the disease is get patients on some kind of blood thinner, and the reason is that when somebody is having an irregular heartbeat, the heart just isn’t contracting the way it normally should. The electrical system is going haywire, the heart’s not beating normally, and as a result of that irregularity, blood can pool inside the heart. And when blood sits around, it could form a clot which could go up to your brain and caused a stroke. And that of course is one of the most devastating complications associated with atrial fibrillation.
So one of the most important priorities early on in the treatment is to get somebody on a blood thinner. But the other part of it is to, one, try to make them feel better. So we often use medications to try to slow down the heart rate, but then ultimately we hope that we can get rid of the problem and potentially cure them of the problem, and the way that we do that is with a variety of different treatments.
We may do something called a cardioversion where we’re going to do a shock to the heart while the person’s asleep to reset the heart back to normal, but more and more increasingly we’re performing minimally invasive procedures called ablation procedures where we actually will go in through a vein in the leg with small electrical wires called catheters and actually pinpoint the exact group of cells that are causing the problem in the heart, deliver some very precise electrical burns to cure them of the problem, and after they’re done, they go home with nothing to show for it but a couple Band-Aids in the leg. And the advantage of that approach is that’s the best chance for long-term control or cure of this problem.
Bill Fantini: Are there difficulties with any of the methods of treatment, including blood thinners?
Dr. Mainigi: Not everyone can qualify for every type of treatment. Blood thinners, unfortunately, often can cause problems on their own. While they’re very effective in reducing the risk of stroke, they do dispose you to bleeding and so often patients who’ve had bleeding before or continuing to have bleeding from their gut or other locations can’t tolerate these blood thinners. And sometimes we have elderly patients who are very frail and their doctors and their families don’t feel comfortable having them on a blood thinner. Fortunately, there are a few different medications that individuals can take for stroke prevention. So the old standby, which has been around for years, is a drug called Warfarin, and Warfarin is a well-known drug. Most people have someone who they know who has taken this. The advantage of Warfarin is it’s pretty easy. It’s one pill a day and it thins your blood and we understand it very well.
The problem with Warfarin is that it does require blood test monitoring, so you have to go in fairly often initially and then ultimately at least once a month, but early on it could be as frequent as once a week that you have to go get your blood checked, and the dose of the medication has to be adjusted up or down based on what the blood levels are showing us, and so sometimes it can be very difficult to get the blood level exactly right and patients often struggle with this with their primary care doctors for weeks or months on end.
The other disadvantage of the Warfarin is that vitamin K is the antidote for Warfarin, and so if you eat a lot of green leafy vegetables which have vitamin K, that can often undo the potential benefits of the Warfarin.
So that’s why there are these newer agents, and I say newer because they’re certainly newer than Warfarin, but they’ve been around now for seven, eight years and we have a lot of experience with them and those are drugs like Eliquis, Xarelto and Pradaxa that you often see advertised on television, and these medications will thin the blood without the need for monitoring. They just work, and you also don’t have to adjust your diet to get the benefit. The disadvantage of the medications is that they are not generic and so they often are quite expensive depending on your insurance plan and that sometimes can be prohibitive for some of our patients.
Bill Fantini: Is there any difference in effectiveness that’s been seen between the two types of drugs?
Dr. Mainigi: If we compare Warfarin to the newer group of drugs, which I’ll kind of group together as one entity, they have been found in large studies to be at least equivalent. There is a suggestion that the newer drugs perhaps are more effective in terms of reducing bleeding, particularly in the brain, and perhaps actually allowing people to live longer than those patients who were on Warfarin. Again, they’re at least equivalent, but there’s a suggestion that they may be better.
The good news is that we now have alternative treatments for stroke prevention as well, and Einstein was one of the first hospitals in the country to implant the Watchman device, which is a sort of umbrella-like plug that again gets implanted in a fairly minimally invasive fashion that will actually block off the area of the heart where clots form and therefore prevent a stroke from happening, and this device has been proven to actually be as good as taking a blood thinner for the rest of your life without needing to take a blood thinner the rest of their life, and so we’ve been doing this at Einstein for about three or four years and the program’s been doing wonderfully. The patients who’ve gotten it have truly benefited from not having to be on blood thinner, but still being protected against stroke when they’ve had this atrial fibrillation problem.
Bill Fantini: What’s the Watchman device like?
Dr. Mainigi: It’s a small device. It’s about, I guess about an inch or so in diameter and an inch in length, not electronic. It’s just sort of a mechanical device. It’s a metal umbrella-like device that, it’s like a metal cage that basically has a biopolymer or a cloth over it that comes compressed in a catheter and we go up from a vein in the leg, cross over into the left upper chamber of the heart to implant this in the very specific structure called the left atrial appendage that is the location where clots form and where strokes originate from.
Patients who have a reason to seek an alternative to blood thinners are the main patients that we’re looking at for Watchman implantation. So often patients on blood thinners do great for years and years and have no problems and that’s all that they need. But there are certain patients who can’t get a blood thinner or maintain on a blood thinner long-term because of the bleeding risks, because of fall risks, because of other consequences like high-risk occupations or hobbies. And in that group of patients will often have a discussion about the Watchman.
What we’ll typically do is see if they qualify for the device based on their heart anatomy and that’s often done with an ultrasound or a CAT scan, and if they do, we’ll go ahead and proceed with the procedure and in fact, in our experience they are very few people who’d like to go down the path of getting a Watchman who have not been able to have it done successfully.
Bill Fantini: Besides the potential for clotting, are there other risks associated with A-fib that could present dangerous potential consequences?
Dr. Mainigi: Atrial fibrillation is a problem for a number of reasons, so, one, as we talked about is stroke, but the other consequences are significant as well. So, first, people can feel terrible. I have patients who come into my office who feel like their chest is about to explode because the heart’s beating so rapidly. They feel like they’re about to pass out. They just feel absolutely miserable. Other patients come in, and there are much more subtle symptoms. They don’t notice that they are really, other than some fatigue.
Almost in every one, if I get them out of atrial fibrillation, they do notice a difference because often people have attributed the signs and symptoms of it to just getting older, when in fact they’ve actually had a serious heart problem. But the other more significant consequences is that over time the atrial fibrillation takes its toll on your heart. The heart’s beating fast and irregularly and heart begin to tire out, so it’s not unusual for the heart to enlarge in size or even weaken in strength when somebody has an irregular heartbeat and people often present with heart failure.
We know that patients who have atrial fibrillation have a higher mortality rate than patients who don’t have atrial fibrillation. This takes a consequence on your life expectancy, and we know more recently through large clinical trials that have just been published that in some patients if we can do the ablation procedure and cure them of the atrial fibrillation, we actually are starting to extend their lives. So there are a number of different consequences that are quite serious associated with this disease that’s often undetectable.
Bill Fantini: That is Dr. Sumeet Mainigi, director of Electrophysiology at Einstein Philadelphia. To make an appointment with Dr. Mainigi, call 1-800-EINSTEIN. I’m Bill Fantini with Einstein Perspectives.