Your iPhone Can Affect Your Pacemaker

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Have you seen energy drinks cause significantly abnormal

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rhythms in young people?

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Their heart rate variability changes because the heart rate is not changing too

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much. So to answer the question is yes.

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Welcome to Next Phase Human podcast.

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This is a space where we talk about all things related to health,

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and health is not defined by set tracks of conventional medicine or

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wellness medicine or what you do in your day-to-day life.

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I do believe health is a compendium of all these things.

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And plenty of times when you're in doctor's offices,

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of course, there's a limit to that time, and there are questions that are left

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unanswered on different topics. Those topics may be related to health, may be

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related to procedures you may or may not need, and may be related to some of

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the day-to-day questions, what you can do about prevention.

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So this is a space to have all those conversations

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with the goal that as we age,

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a number does not define our limits, and our genes don't become our

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destiny.

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Unlocking the next phase of health, this is Next Phase Human.

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I'm your host, Rasham Sandhu, and today I have with me is Dr.

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Gurjit Singh, a renowned electrophysiologist, former

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director of electrophysiology lab at Henry Ford, currently

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chief medical officer of California Cardiovascular Institute, and

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medical director of AFib and electrophysiology at Dignity

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Health Bakersfield and Adventist Health Bakersfield, California.

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Welcome, Dr. Singh.

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Thank you, Dr. Sandhu, for having me and giving me this opportunity.

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Can you tell us

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a little bit about yourself, what your background is, and what you

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do in day to day?

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Absolutely. So I'm a cardiac electrophysiologist.

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It's basically a heart rhythm doctor.

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I call myself an electrician, so most patients understand that pretty easy.

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I did all my training, I did my medical school in India and then came

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to Henry Ford Hospital in Detroit, Michigan, where I did my internal medicine

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residency for three years. Did a year of heart-failure

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transplant training as well. Was not a fellowship, but was

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an additional training before I joined the cardiology fellowship at

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Henry Ford.

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So I switched to cardiac electrophysiology, so did my EP fellowship at

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Henry Ford and stayed on as faculty for almost eight years at Henry Ford, where

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I led the EP lab, was the director there, trained

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cardiology fellows as well as EP fellows and then medical students.

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So I had a busy academic practice. I ran the robotic programs,

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founded the Society for Magnetic Navigation, called SCRN,

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before moving to Bakersfield. And been here for

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almost four and a half, five years now with Dr.

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Sandhu, and then we run a busy private practice, where I

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not only practice cardiac electrophysiology, but all aspects of cardiology and

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primary medicine as well. So as you rightly said, we got to

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age well.

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And today our topic will be atrial fibrillation, but before I'll

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answer my claim to fame,

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I end up discovering when iPhone 12 got launched, the

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iPhone came with inbuilt

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magnets inside the phone, which allowed the phone to be

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charged on the Qi charger.

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Mm-hmm.

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And we

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as an electrophysiologist, I implant pacemakers, defibrillators, and these

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devices have a fail-safe mechanisms inbuilt.

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For some reasons, if these devices fail, we can put an

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external magnet to change their

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capability of what they do.

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So our hypothesis was that putting an iPhone magnet or iPhone itself

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on a

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live defibrillator should not affect those

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devices because the magnetic field is small.

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But to our surprise, when we tested in a patient with appropriate approvals

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and everything, we showed the iPhone 12 actually can turn

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off a patient's defibrillator.

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What it does is basically makes the defibrillator stop looking at the intrinsic

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heart rhythm, and that in turn deactivates a device.

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So we published this

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patient data in Heart Rhythm Society, and it became an international

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sensation because we all knew that magnets are bad for ICDs and

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pacemaker, but nobody had actually proven in a real human for the first time.

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So from there on, basically, I started getting calls from Apple and

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then all the FDAs. So I was on the panel for the FDA,

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with all the device companies to figure out what's the best recommendation.

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What do we do? We went back and forth.

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Should the device companies should change their sensors inside, or does

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Apple should take away the magnets?

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And the end result was basically the recommendation came in that

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patients with pacemakers and defibrillators should stay away from strong

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magnetic fields, at least six inches away.

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So keep your phones or anything which has magnets six inches away from your device.

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So that'll hold true even today for any iPhone or any other phone for that

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matter.

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Correct.

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I tested devices. I took Apple Watches,

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headsets, and actually checked the magnetic field and everything.

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Even your regular phone, wherever there are cameras, there is a magnet inside.

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So we all generate magnetic fields.

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But again, the bottom line is keep six inches away from your body.

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So that'll be kind of a safety just to kind of explain it to people

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that your defibrillator is a device that will shock

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you internally if there's an abnormal heart rhythm, essentially

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saving your life. So if turning off therapy can be quite problematic.

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Correct. That's absolutely correct.

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Now, the chances of that happening is very, very low, but there could be one

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patient sitting somewhere laying down with a phone in his pocket, especially

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males have the tendency to put their phones in the pocket, and you could turn off

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your defibrillator, and you may not get the therapy.

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Perfect. Well, that's good to know. And let's start today.

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We're going to focus primarily on atrial fibrillation

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Millions of Americans have it. There are several misconceptions

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about it. A lot of people

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may know what AFib is or have a basic idea, but there are a lot of

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misconceptions and fears, and we'll go through them one by one.

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So first of all, for

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listeners who are not in medicine,

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can you tell us, for a layperson, how would you explain what

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atrial fibrillation is?

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Yeah. So atrial fibrillation, as the name suggests, atria, and they are

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fibrillating. So before we go into the disease, we need to know what the normal

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human heart does. So the human heart is basically the size of your fist, sitting in

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the middle of the chest. It's like a car engine. It's pumping blood.

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It receives blood, it sends the blood to the lungs to get it cleaned.

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The clean blood comes back to your heart, and it gets pumped out.

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So the heart has four chambers, two top and two bottom.

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The top are called the atria. The bottom are called the ventricles.

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The atriums, they contract first, push the blood down through

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the valves into the bottom chamber, and then the ventricles will squeeze and push

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the blood out to the body and to the lungs.

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And a normal human heart, if you hold it in your hand, it will not beat on

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its own. The heart is a muscle. It needs a signal.

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So me and you are born with a pacemaker given by the

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higher power. It's called a sinus node, sitting in the right top chamber.

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That actually creates your heartbeat, 50 beats a minute, 60 beats a

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minute. So think about it as like a car's battery.

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It's sending impulses every 60 times a minute.

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That electricity travels in the top chamber, makes the top squeeze, the

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atrium, and then there is a wire inside the heart called the AV node,

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atrioventricular node.

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So just to clarify, it's a highly conducting tissue.

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It's a highly conductive tissue. The whole heart is a muscle, but then it's also

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conducting electricity, and it's the only organ in the whole body which is actually

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moving. Rest, everything is stable and stationary.

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This is the only moving

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organ, which is squeezing and conducting electricity, so a very highly

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complex organ. So anyways, the blood goes to the bottom chamber and then

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comes out of the body. So that's a normal human heart, and when we

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do an electrocardiogram, we can see the heart's electricity.

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So the top beats first, then there's a time delay, and the bottom follows.

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On an EKG, it's called a P wave and a QRS.

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So when me and you right now in normal rhythm, our heart is beating at 60 beats a

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minute, so that's normal sinus rhythm. So now we know what normal is.

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When people or patients go in atrial fibrillation, the top

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chambers stop listening to that pacemaker and start

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fibrillating. It starts beating in a very irregular,

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chaotic manner. There is no rhyme and reason.

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A lot of things we do in electrophysiology have some circuits.

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We can define the wavefront and things like that.

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During atrial fibrillation, the top chambers are basically squeezing in a very

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haphazard manner. So the top chamber loses

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their squeezing capacity, and the rhythm becomes irregular.

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So the definition of an atrial fibrillation, you have to have a

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30-second documentation of an irregularly

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irregular rhythm on an electrocardiogram or a variable or any

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kind of recording of the heartbeat.

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So that is what the definition of atrial fibrillation is.

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So a lot of these

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thought process will come, okay, is every irregular rhythm

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atrial fibrillation? Because people get alerts on their variables all the time.

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So would they worry every time they see an irregular

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flag on a variable? Is it AFib always, or could there be other things that it

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could be pointing out?

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Correct. Just somebody has an irregular rhythm doesn't mean they have AFib.

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Again, you have to look at the data.

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If you're doing a one-minute EKG, you have to show it to somebody.

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See, all these variables or all these

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devices, they have what we call a PPG, a

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photoplethysmography.

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Mm-hmm.

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So what these variables, like an Apple Watch or a Garmin or all

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these sensors, they

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send a

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light signal towards your wrist or towards your palm, and then the

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light intensity changes based on your blood flow.

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Mm-hmm.

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So what these devices are doing, they are actually measuring from one

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beat to the second beat. That's all they know.

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But they don't know where is the beat coming from.

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If you have an extra heartbeat called a premature atrial contraction,

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called a PAC, or a premature ventricular contraction, called a

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PVC, that can fool these devices. So again, as I said above,

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loss of a normal P wave on an electrocardiogram or a

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variable, and if we show it for 30 seconds consistently,

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then we call the rhythm as atrial fibrillation.

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But again, to answer your question, if your watch or your variable

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tells you that there is some irregularity, it's better to get it checked.

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And generally, the thought process always has been heart disease is a

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disease of older people. Could young people have AFib, too?

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Yeah, that notion is changing. Atrial fibrillation,

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when I was in training, this is what my mentor taught me, that it's the

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wrinkle of the heart. But I can tell you,

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our average patient now who are coming to our clinics in atrial fibrillation, I'm

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talking about 30s and 40 years of age.

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Mm-hmm.

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The whole health, and that's why we're doing these podcasts, our people

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are not aging the way they're supposed to age. So it's all connected.

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So the disease is manifesting early.

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Plus, also now because we have all these variables, we are detecting more of these

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rhythms. Before, we didn't have the technology.

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So there are the two explanations for early detection of these rhythm problems.

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So

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could there be,

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do you feel AFib, or do you not have to?

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You could still have AFib and not know about it?

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Absolutely. So almost half the patients who I see on a daily

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basis feel AFib, and half do not. Especially if you're a female.

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Mm-hmm.

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They don't feel their AFib, and on the worse, if you're diabetic.

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As we all know, diabetic patients have changing in their autonomic nervous

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system. They have nerve injury or neuropathy, so they don't feel their symptoms.

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So the common symptoms of atrial fibrillation are mostly a fast

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pulse, an irregular pulse, some unease in the body People

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can get short of breath, they can get tired.

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Fatigue is a very common symptom for atrial fibrillation.

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If you are underlying heart disease, you have low blood pressure, you can get

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almost passing out symptoms. But the most common symptom my patients

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tell me is that something is not right in my body.

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That's the most common symptom I see from atrial fibrillation.

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So if they feel they're just not feeling right, regardless of age, could be

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a younger person, could be an older person, this could be one of the things.

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Correct.

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It may not be the thing, it could be one of the things you look for.

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Absolutely. If you don't have an alternative explanation, it could be

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atrial fibrillation.

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Got it. So I presume, how long have you been practicing

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now in this space?

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Practicing electrophysiology since 2014.

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So you must have seen thousands of AFib patients and treated.

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That's what the bread and butter for all the electrophysiologists in this country

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is.

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So tell me a couple stories which really stick

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out,

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shocking stories.

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What did you find most shocking when you treated a patient like AFib?

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What sticks out in memory?

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So, obviously, we treat a lot of AFib patients.

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And I'll tell you one more thing, no two AFibs are same in terms of their

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presentations and in what they have inside.

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So a lot of patients say, "Oh, this patient had an ablation done, this had this

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done, and they did this." So I'll tell everybody, please do not compare your

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atrial fibrillation to other patients.

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So again, atrial fibrillation causes a lot of problem.

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It creates the blood to clot in the heart.

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So I've seen patients who their first presentation is a massive stroke in a young

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person. So again, that is a shocking story.

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If somebody would have detected AFib early on a patient, something could have been

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done. A lot of AFib. AFib increases the risk of heart failure five

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times. It increases the risk of stroke five times.

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It actually changes your mortality.

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Patients who have atrial fibrillation, they are on a different trajectory

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altogether. AFib brings chronic kidney disease, worsened

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kidney impairment. The worst now, or the new data coming out, atrial fibrillation

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is linked to dementia, and there is some data showing that early treatment of

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atrial fibrillation with ablation does help or prevent some dementia.

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I'll tell you a recent story. A patient came to me, atrial fibrillation diagnosed

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almost 15 years ago.

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And I can tell you, most people agree that the longer you stay in AFib,

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now we're talking about two different kinds of AFib.

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The AFib, one is called paroxysmal AFib, when the AFib episode comes and

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goes, goes away on its own, or we do something.

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That's called paroxysmal atrial fibrillation.

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If you stay in the rhythm continuously for more than seven days,

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we call it persistent AFib. And these definitions

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help us figuring out the underlying pathophysiology or what is

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happening inside the heart at the molecular level or at the structural level.

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So the shocking story, this patient for 15 years of AFib has heart

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failure.

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Everybody abandoned his rhythm, and they said he came to me with symptoms of

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fatigue, tiredness. His heart pumping was somewhat weak, and we

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discussed that it's too late now. He's a relatively young person.

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And usually at that stage, if we feel that somebody's having symptoms from

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AFib, we usually give them a strategy called an AV node ablation, pace

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and ablate. Patient said no. He said, "Can you do something about it?" Long story

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short, I started treating his AFib.

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We did procedures, and we also have the capability now of doing what we call

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an epicardial ablation. So when I do my procedures, I go from inside the

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heart. I work with some surgeons who can go-

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Can you explain it for the listeners what AFib

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ablation is before we-

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Correct. Ablation is a therapy where we go inside the heart,

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not by opening the chest. We go through the groin to the femoral veins, and we go

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inside the heart with tiny tubes called catheters.

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Those catheters help us map the atria electricity,

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and based on what the scientific literature has shown,

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pulmonary vein, so all the blood coming back from your lungs, you have

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a right lung and a left lung. Both of these lungs have these tubes called pulmonary

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veins. These tubes are draining blood into your left upper chamber.

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Right before they enter the heart, the lining of these tubes is where

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90% of the AFibs actually get triggered, so that's called pulmonary vein

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trigger. Back in 1999, Michel Haissaguerre from

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Bordeaux, he's the one who actually discovered.

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They took patients with atrial fibrillation, they put catheters, mapping catheters,

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and they waited for AFib to start, and they figured out 90% of the AFib

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started in one of those four tubes.

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So the ablation in layman explanation is we are going to go inside your heart,

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and I'm going to isolate, create electrical scar in your heart around

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the openings of those four tubes. You can do by burning, called the radiofrequency.

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You can do by freezing, called cryo energy.

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And these days, the new kid in the block is called electroporation or pulse field

306
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ablation. So once we isolate those four tubes, the

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AFib can start in those pulmonary veins, but it will not enter your

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main heart, and you will remain in normal rhythm. So that's what an ablation is.

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So what we do is called endocardial. We're going from inside the heart.

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On that patient we talked about, we did also what we call an epicardial.

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Heart is a thick structure. The atrial tissue, the wall is at least four to six

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millimeter, depending on which way you look at it, and then you can also burn

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from the outside. So believe me or not, and that patient has been six months after

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treatment. He's in normal rhythm after 15 years of AFib.

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Heart failure's improved. His life has changed.

316
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So again, I

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see those shocking stories pretty much every other day in the clinic where

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we have done something for AFib.

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And is it correct to say,

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in the past, so you defined atrial fibrillation as paroxysmal, which is the early

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pathway, and then you defined it as persistent, which is

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well established, has been there for a long time.

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Right.

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And those are harder to treat. So is it a fair statement several years ago that was

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really not considered treatable, that you will just manage it?

326
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You're not going to try to get the person out of it?

327
00:17:56.244 --> 00:17:58.723
Absolutely. So there were a couple of trials which were done

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in olden times. We call now them olden times, and the famous one is called the

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00:18:03.264 --> 00:18:06.854
AFIRM trial, where basically they took patients with AFib, persistent and

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paroxysmal, mostly paroxysmal

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Half the group was treated with the regular medications, control the rate, keep the

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blood thinners on, and see what happens. The other one had ablation done.

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And that time, the trial with those technologies showed it doesn't

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matter you do rate control versus rhythm control.

335
00:18:22.788 --> 00:18:26.468
You keep them in AFib or you don't keep them AFib, patient have the same outcomes.

336
00:18:26.488 --> 00:18:30.308
Things have changed. 20 years later now with the new technology, with the

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aggressiveness, and with more early diagnosis, I believe the

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trajectory after an AFib ablation for most patients is changing

339
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in a positive way.

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And then there is something called long-standing persistent.

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When somebody's in AFib for more than one year, we call them a long-standing.

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And the reason we define these things is, again, AFib is not just one

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particular disease. A lot of things I do as an electrophysiologist, people are born

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with extra wires called WPW, AVNRTs.

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We go in the heart, actually find the little tiny wire, and burn it.

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Those are curable rhythms. AFib is a final representation

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of many different things happening to your heart, and the final disease shows up

348
00:19:07.508 --> 00:19:11.248
as an AFib on an EKG. But behind the AFib, we're talking about the triggers we

349
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talked about.

350
00:19:12.748 --> 00:19:16.348
So trigger is one thing, but the second component of the atrial fibrillation world

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is the substrate. What is happening at the structural level in the

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atrium? What is causing fibrosis?

353
00:19:23.508 --> 00:19:25.268
The more scarring, we call it scar.

354
00:19:25.348 --> 00:19:28.748
When I go inside the heart, when I make a 3D map, I can see which part of the heart

355
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has scarring and not. So the more scarring,

356
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you have a bad substrate, the longer you're going to stay in AFib or you become

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persistent AFib. The third thing we talk about is the ionic level.

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At the cellular level, what is changing?

359
00:19:40.888 --> 00:19:44.488
And the fourth is your genetic predisposition, and the fifth is your age.

360
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So all these things actually combine together to bring out paroxysmal versus

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persistent atrial fibrillation.

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00:19:50.628 --> 00:19:52.468
So when you talked about substrate,

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just to clarify, we are talking about modifiable risk factors

364
00:19:57.148 --> 00:20:00.568
that people can fix in their day-to-day life. What would those be?

365
00:20:01.168 --> 00:20:04.738
So again, as everything in medicine, there is something we talk about risk factors

366
00:20:05.008 --> 00:20:07.448
or the comorbidities for a patient.

367
00:20:08.188 --> 00:20:10.968
So there are modifiable risk factors, just like for atrial fibrillation, and a

368
00:20:11.028 --> 00:20:14.698
non-modifiable. So what are non-modifiable risk factors?

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00:20:14.808 --> 00:20:16.688
Number one is your age. You cannot change your age.

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You're going to grow old, right? Number two is your genetics.

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00:20:20.248 --> 00:20:23.948
We know that non-Hispanic whites have the highest incidence of AFib.

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Then comes the Hispanics. Actually, having a African

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American descent or

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Black Americans have lower AFib. And there is data that because the

375
00:20:34.368 --> 00:20:38.108
atrias are smaller, they actually have less AFib compared to whites,

376
00:20:38.528 --> 00:20:41.348
and then obviously Asians. So there is some genetic predisposition.

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00:20:41.728 --> 00:20:44.978
European whites have the highest risk of gene, and there are so many,

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00:20:46.148 --> 00:20:49.968
we call this single nucleotide polymorphism. Now, there is a big studies going on.

379
00:20:50.208 --> 00:20:53.188
So there are some genes which predict that you are going to have a higher risk of

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00:20:53.248 --> 00:20:56.398
atrial fibrillation. So again, those are non-modifiable. We cannot change them.

381
00:20:57.128 --> 00:21:00.848
What is modifiable is your standard, your hypertension, your diabetes,

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00:21:01.608 --> 00:21:05.048
obstructive sleep apnea, smoking, weight,

383
00:21:05.648 --> 00:21:09.608
obesity, exercise. All those are what we call the modifiable risk

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00:21:09.648 --> 00:21:11.987
factors. All these things work, and diabetes.

385
00:21:12.308 --> 00:21:16.168
All these things work together in one form or fashion to create

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00:21:16.208 --> 00:21:19.768
the right milieu or the substrate to bring out the AFib.

387
00:21:21.128 --> 00:21:21.498
And then,

388
00:21:22.868 --> 00:21:26.408
as I said, the AFib, usually there's a trigger for AFib, and then there is

389
00:21:26.428 --> 00:21:29.368
something to maintain the AFib. So there are two separate things in different

390
00:21:29.388 --> 00:21:32.308
patients, or there could be two same thing in the same patients.

391
00:21:32.808 --> 00:21:36.328
A lot of patients start the AFib as what we call paroxysmal.

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00:21:36.468 --> 00:21:40.188
AFib starts, goes away. There are some patients from day one,

393
00:21:40.388 --> 00:21:42.028
they become what we call persistent AFib.

394
00:21:42.088 --> 00:21:43.788
The moment they go in AFib, they stay in AFib.

395
00:21:44.168 --> 00:21:46.388
So again, there is something going different from those patients.

396
00:21:47.288 --> 00:21:51.068
Okay. So just to clarify, all these modifiable risk factors or

397
00:21:51.128 --> 00:21:55.088
non-modifiable affect the top chambers in a way that creates

398
00:21:55.188 --> 00:21:58.948
scarring in an erratic fashion to create irritability and spread

399
00:21:59.008 --> 00:22:02.528
it to suppress your normal rhythm and create irregular rhythm.

400
00:22:02.688 --> 00:22:03.228
Absolutely.

401
00:22:03.398 --> 00:22:03.398
Correct.

402
00:22:03.408 --> 00:22:07.368
And then on top of all this, what actually runs the

403
00:22:07.428 --> 00:22:09.608
main thing behind all this is actually your

404
00:22:10.508 --> 00:22:13.248
neurosystem, the autonomic nervous system, and the brain.

405
00:22:13.288 --> 00:22:14.968
Remember, mind over the heart always, right?

406
00:22:15.028 --> 00:22:17.908
So the brain is doing something to your heart as well.

407
00:22:17.968 --> 00:22:20.988
So it's the balance of your sympathetic and your parasympathetic.

408
00:22:21.068 --> 00:22:24.908
As we all know, humans have two different nervous system, the

409
00:22:24.928 --> 00:22:25.538
fight-flight-

410
00:22:25.728 --> 00:22:25.918
Mm-hmm

411
00:22:25.948 --> 00:22:29.097
... which is your stress, which is your adrenergic or the sympathetic nervous

412
00:22:29.108 --> 00:22:32.278
system. And then the other one is called the vagus nerve, the 10th nerve, which

413
00:22:32.588 --> 00:22:36.468
keeps things calm down. So this balance, whatever changes

414
00:22:36.508 --> 00:22:40.348
this balance can bring out AFib or promote AFib.

415
00:22:40.948 --> 00:22:44.608
And we know at a cellular level, like if you take a single

416
00:22:44.708 --> 00:22:48.548
cell and put two probes in it, and you actually look at the electricity, we

417
00:22:49.148 --> 00:22:53.088
know that too much vagal tone, too much cholinergic, they

418
00:22:53.148 --> 00:22:57.008
actually changes the electrophysiology of those tubes we talked about.

419
00:22:57.458 --> 00:23:00.988
That can trigger AFib. Too much sympathetic tone, we all know that,

420
00:23:01.568 --> 00:23:05.468
high adrenaline levels. Caffeine or too much exercise or things which

421
00:23:05.548 --> 00:23:06.078
increases the-

422
00:23:06.108 --> 00:23:06.788
Energy drinks

423
00:23:06.828 --> 00:23:10.548
... energy drinks, or stress. Whatever increases your adrenaline,

424
00:23:10.968 --> 00:23:12.808
it irritates you through the beta receptors.

425
00:23:12.988 --> 00:23:16.157
It's going to bring out, irritates the heart, and can bring out atrial fibrillation

426
00:23:16.168 --> 00:23:18.318
at the top or bad rhythm from the bottom chamber.

427
00:23:18.728 --> 00:23:20.618
So again, these two things, the balance.

428
00:23:20.688 --> 00:23:23.708
The moment that balance changes, we are predisposed to these arrhythmias.

429
00:23:23.828 --> 00:23:27.308
Just for curiosity, have you seen energy drinks cause

430
00:23:27.788 --> 00:23:29.828
significantly abnormal rhythms in young people?

431
00:23:30.808 --> 00:23:34.508
I see a lot of young peoples coming with these energy drinks or the vaping

432
00:23:34.588 --> 00:23:37.708
or drinking too much of coffee. Anything which increases,

433
00:23:38.768 --> 00:23:41.468
just common sense, it is going to bring out some kind of arrhythmias.

434
00:23:41.528 --> 00:23:42.868
Usually, the resting heart rate is high.

435
00:23:43.368 --> 00:23:46.848
Their heart rate variability changes because the heart rate is not changing too

436
00:23:46.908 --> 00:23:48.628
much. So to answer the question is yes.

437
00:23:49.228 --> 00:23:52.448
Okay. Perfect. So we're going to go through, there is

438
00:23:53.848 --> 00:23:57.468
a lot of talk about, so there is disease and there is

439
00:23:57.808 --> 00:24:01.168
cures that people talk about, whether that be medical or non-medical, and some of

440
00:24:01.208 --> 00:24:01.628
those are

441
00:24:02.588 --> 00:24:06.528
good recommendations and suggestions, and some of those are just urban legend.

442
00:24:07.128 --> 00:24:08.848
So we're going to try to myth bust a little bit here.

443
00:24:09.008 --> 00:24:09.388
Absolutely.

444
00:24:09.528 --> 00:24:11.988
So short answers, let's go through them.

445
00:24:12.208 --> 00:24:14.138
So coffee, can it cause AFib?

446
00:24:15.192 --> 00:24:18.841
So again, a lot of the answers I'm going to give you, in the world of

447
00:24:18.872 --> 00:24:20.152
electrophysiology, is cardiology.

448
00:24:20.212 --> 00:24:22.692
There is a positive and negative, and all the studies keep fighting with each

449
00:24:22.732 --> 00:24:26.652
other. But there is data, somebody did actually trial complete

450
00:24:26.752 --> 00:24:30.051
coffee abstinence versus a cup of coffee, and they look for AFib

451
00:24:30.192 --> 00:24:33.612
development. And the data shows that coffee in moderation

452
00:24:34.172 --> 00:24:36.072
does not increase the risk of AFib.

453
00:24:36.232 --> 00:24:39.412
So I don't stop my patients who have AFib to completely restrict.

454
00:24:39.612 --> 00:24:42.632
Yes, if somebody's drinking four cups or 10 cups a day, that is a problem.

455
00:24:43.072 --> 00:24:46.972
But a cup or two of a regular caffeinated coffee, there is data

456
00:24:46.992 --> 00:24:49.612
that it does not increase the risk of atrial fibrillation.

457
00:24:50.272 --> 00:24:53.692
For our listeners, just to clarify the dose in the study, like one cup, two

458
00:24:53.832 --> 00:24:54.432
cups?

459
00:24:54.472 --> 00:24:57.252
One cup. There's a trial called the Decaf Trial, 200 patients.

460
00:24:57.272 --> 00:25:00.272
Again, not a big study, but it's a randomized controlled trial, so absolute no

461
00:25:00.332 --> 00:25:04.182
coffee versus one coffee, and they showed no major change in atrial

462
00:25:04.192 --> 00:25:04.972
fibrillation risk.

463
00:25:05.492 --> 00:25:09.472
So for your patients who have either AFib or who have

464
00:25:09.532 --> 00:25:12.092
had ablation, what do you tell them typically?

465
00:25:12.332 --> 00:25:14.012
Can they drink a cup or two of coffee a day?

466
00:25:14.512 --> 00:25:18.452
I tell them, what's the point of me doing a procedure or something if I

467
00:25:18.512 --> 00:25:21.532
cannot make your life easy or don't let you enjoy your life?

468
00:25:21.592 --> 00:25:25.452
If you enjoy a cup or two of coffee a day, I'd let them allow, and actually,

469
00:25:25.492 --> 00:25:29.392
that's what the data show, that anything below three cups a day, it's okay.

470
00:25:29.912 --> 00:25:33.031
Okay. And energy drinks, would that be okay for such people?

471
00:25:33.492 --> 00:25:36.252
Stay away from those, because God knows what is there in those energy drinks.

472
00:25:36.472 --> 00:25:40.102
First of all, they're high in sugar content, and then who knows what the molecules

473
00:25:40.192 --> 00:25:44.092
are. So since these things are not FDA regulated, I tend to usually

474
00:25:44.152 --> 00:25:45.302
tell my patients to try to stay away.

475
00:25:45.352 --> 00:25:48.212
Even the reputable ones, the caffeine content may be just too high-

476
00:25:48.492 --> 00:25:48.932
Correct

477
00:25:48.952 --> 00:25:49.772
... for some people.

478
00:25:49.852 --> 00:25:51.632
Absolutely. So it all depends on the caffeine-

479
00:25:51.992 --> 00:25:52.092
Yes

480
00:25:52.112 --> 00:25:52.672
... and what the source.

481
00:25:53.092 --> 00:25:54.112
Got it. And

482
00:25:55.052 --> 00:25:57.392
magnesium is making big waves these days.

483
00:25:58.372 --> 00:26:00.642
How does that affect your AFib? Can it help?

484
00:26:00.752 --> 00:26:02.532
Can it hurt, or does it do anything much?

485
00:26:02.792 --> 00:26:04.112
So we all know that

486
00:26:05.052 --> 00:26:06.952
magnesium does help improve our sleep.

487
00:26:07.002 --> 00:26:09.132
All these

488
00:26:09.252 --> 00:26:13.232
molecules, the magnesium, potassium, sodium, they have to

489
00:26:13.252 --> 00:26:15.212
be in a certain level, and heart depends on these

490
00:26:16.312 --> 00:26:18.032
elements to stay in a normal rhythm.

491
00:26:19.632 --> 00:26:23.112
Magnesium per se, when the studies were done, especially in the ICU

492
00:26:23.172 --> 00:26:27.092
settings or dedicated magnesium supplements, did not show any

493
00:26:27.232 --> 00:26:29.792
change, worse or good, in atrial fibrillation.

494
00:26:30.532 --> 00:26:33.652
Got it. And let's go to

495
00:26:34.292 --> 00:26:37.792
something that's ubiquitous in our lives, and people talk about it,

496
00:26:37.872 --> 00:26:40.872
stress. How does that correlate to AFib risk?

497
00:26:41.372 --> 00:26:44.722
So again, and I mentioned first, right, the parasympathetic and sympathetic.

498
00:26:44.792 --> 00:26:48.382
So anything which was going to overdrive our sympathetic system, and obviously the

499
00:26:48.512 --> 00:26:52.182
stress, right? So stress, work-related stress, depression,

500
00:26:52.392 --> 00:26:53.842
anxiety, all of these,

501
00:26:55.412 --> 00:26:58.812
people have studied in population-based studies, ARIC study, the MESA study.

502
00:26:59.392 --> 00:27:01.092
People who have these

503
00:27:01.972 --> 00:27:05.942
over the normal depression, anxiety, increase your risk of AFib by anywhere from

504
00:27:05.972 --> 00:27:09.912
10% to 30%. In severely depressed patients, almost 30%

505
00:27:09.972 --> 00:27:11.792
have atrial fibrillation risk.

506
00:27:12.932 --> 00:27:16.772
And the bottom line is, right, whatever increasing your sympathetic tone, you're

507
00:27:16.812 --> 00:27:20.412
increasing inflammation. Inflammation causes changes in your

508
00:27:20.432 --> 00:27:23.712
cellular structure, more fibrosis. So all these things are connected.

509
00:27:24.752 --> 00:27:28.612
So like we talked about in the premise for the

510
00:27:28.652 --> 00:27:32.492
podcast, Next Wave Is Human, mental health is not separate from your physical

511
00:27:32.532 --> 00:27:32.812
health.

512
00:27:34.072 --> 00:27:37.892
Any imbalance in your mental health, whether that be depression or

513
00:27:37.952 --> 00:27:41.032
anxiety, will upset the balance in your body.

514
00:27:41.612 --> 00:27:45.052
So just for our listeners to clarify, sympathetic system is a system that is fight

515
00:27:45.132 --> 00:27:46.572
or flight, that helps us

516
00:27:47.512 --> 00:27:51.232
rev up the body's systems, and parasympathetic system is the rest and

517
00:27:51.292 --> 00:27:53.982
digest system, which calms the system down-

518
00:27:54.092 --> 00:27:54.152
Correct

519
00:27:54.172 --> 00:27:54.992
... in the simplest terms.

520
00:27:55.212 --> 00:27:55.392
Right.

521
00:27:57.452 --> 00:27:57.652
So

522
00:27:58.632 --> 00:28:01.492
we talked a little bit about this. Someone comes to your office, they feel

523
00:28:01.532 --> 00:28:02.312
palpitations.

524
00:28:04.032 --> 00:28:06.652
Is that mostly AFib, or is that mostly something else?

525
00:28:07.472 --> 00:28:10.532
So palpitations means the patient feel that

526
00:28:10.572 --> 00:28:14.312
they're feeling extra heartbeats or something is running fast.

527
00:28:14.372 --> 00:28:17.692
That's the definition of palpitations, right? But then you have to look into that.

528
00:28:17.752 --> 00:28:21.632
So which means we have to do some kind of monitoring to figure out what

529
00:28:21.752 --> 00:28:25.492
is their palpitation. Sometime what they feel is just your regular

530
00:28:26.012 --> 00:28:29.682
natural resting heart rate is high, and whatever they're doing is, and that's going

531
00:28:29.792 --> 00:28:31.352
faster, and they can call that a palpitation.

532
00:28:31.391 --> 00:28:35.272
So it's very important for us to actually do these, what we call diagnostic

533
00:28:35.332 --> 00:28:39.012
testing, which talks about start off in the clinic as a 12-lead

534
00:28:39.052 --> 00:28:41.292
electrocardiogram, where we hook them up those EKGs.

535
00:28:41.372 --> 00:28:43.732
If that gives you an answer right there, and then you're done.

536
00:28:44.192 --> 00:28:48.182
Otherwise, we put them in monitor called Holter monitors, event monitors from

537
00:28:48.192 --> 00:28:51.632
14 days to 30 days. There is something called a loop recorder monitor.

538
00:28:51.732 --> 00:28:55.572
People who complain of palpitations, and all other regular tests keeps coming

539
00:28:55.582 --> 00:28:59.392
normal, we implant a device. And then obviously now is the age of wearables,

540
00:28:59.432 --> 00:29:02.612
the Apple Watch, the Fitbits, and the Garmin.

541
00:29:03.332 --> 00:29:05.512
And then there's another called the Kardia App.

542
00:29:05.592 --> 00:29:08.822
You can buy this thing, and you put your fingers on it, basically doing a

543
00:29:09.132 --> 00:29:12.842
single-lead EKG. So you need to have some kind of

544
00:29:12.892 --> 00:29:16.872
information collected from your body in terms of electrocardiogram to give

545
00:29:16.912 --> 00:29:19.292
us the diagnosis, what is causing the palpitations.

546
00:29:19.912 --> 00:29:21.932
How good is Apple Watch for AFib detection?

547
00:29:22.292 --> 00:29:25.872
So the Apple Heart study almost had 400,000 patients, and

548
00:29:25.912 --> 00:29:29.852
these patients never had AFib. So these are patients who

549
00:29:29.892 --> 00:29:33.712
have not been diagnosed. And I think 2,000 of these patients

550
00:29:34.152 --> 00:29:36.802
were found to have an abnormal rhythm detected by the Apple Watch.

551
00:29:36.852 --> 00:29:40.512
This is the first study. And then those patients did the

552
00:29:40.552 --> 00:29:44.172
formal testing with the 12-lead electrocardiogram or monitors.

553
00:29:44.662 --> 00:29:48.512
The sensitivity, specificity, or the chances of how good this

554
00:29:48.532 --> 00:29:50.612
Apple Watch was all almost above 90%.

555
00:29:50.892 --> 00:29:54.762
So the Apple Watch actually is pretty good, and to the point that now,

556
00:29:55.252 --> 00:29:58.882
you won't believe this, obviously it's designed or is approved to detect atrial

557
00:29:58.882 --> 00:30:02.492
fibrillation. But I have a few patients who I've seen, they're having

558
00:30:02.552 --> 00:30:06.132
palpitations. They put their watch on, they did a 30-second

559
00:30:06.192 --> 00:30:09.832
EKG, and you believe it or not, I have discovered patients with what we call

560
00:30:10.292 --> 00:30:12.612
ventricular tachycardia, one of the most deadly rhythm.

561
00:30:13.152 --> 00:30:16.752
So I have happened to have a few patients who are actually giving us

562
00:30:16.772 --> 00:30:18.852
diagnosis. But again, remember, you have to wear it.

563
00:30:19.372 --> 00:30:20.552
You have to do the EKG,

564
00:30:21.892 --> 00:30:24.292
and then data in, garbage in, garbage out.

565
00:30:24.592 --> 00:30:28.392
If you don't put it right, if the watch is not well tied, you're going to

566
00:30:28.452 --> 00:30:32.372
create artifact. The biggest thing from all these variables is how to

567
00:30:32.432 --> 00:30:33.932
differentiate the noise from the real data.

568
00:30:34.696 --> 00:30:38.336
So just to clarify, ventricular tachycardia is a very serious rhythm,

569
00:30:38.636 --> 00:30:42.576
but you can live with AFib for a long time, but ventricular tachycardia, usually

570
00:30:42.616 --> 00:30:43.256
it's an emergency.

571
00:30:43.276 --> 00:30:43.616
Correct.

572
00:30:43.626 --> 00:30:43.626
Correct.

573
00:30:43.626 --> 00:30:46.656
Yeah. That's a total-- Anything which is happening to the bottom chambers is taken

574
00:30:46.696 --> 00:30:50.416
more seriously, even AFib is serious, but AFib doesn't have the imminent-

575
00:30:50.896 --> 00:30:50.936
Mm-hmm

576
00:30:51.056 --> 00:30:54.796
... what we call cardiac arrest or risk of death. People do die from AFib.

577
00:30:54.856 --> 00:30:56.326
It increases your mortality by

578
00:30:57.256 --> 00:31:01.096
twice. But what happens with AFib is either you end up developing a stroke, then

579
00:31:01.136 --> 00:31:04.656
you have disability, pneumonia, and so and so forth, or you develop heart failure.

580
00:31:05.056 --> 00:31:07.896
And if you don't manage the heart failure, eventually the pump will fail, and

581
00:31:07.936 --> 00:31:08.556
you'll die from it.

582
00:31:09.176 --> 00:31:12.216
So just to kind of go into why does AFib cause stroke?

583
00:31:13.316 --> 00:31:17.236
So in the beginning, remember I said the top has to beat in a synchronous

584
00:31:17.336 --> 00:31:21.316
fashion. The two top chambers beat together, the bottom follows, at 50, 60 beats

585
00:31:21.356 --> 00:31:24.376
a minute, and the heart has to squeeze and push the blood down.

586
00:31:24.856 --> 00:31:28.736
So me and you, all humans are born with a tiny chamber, just like you have an

587
00:31:28.776 --> 00:31:30.636
appendix in your gut, and we don't know why that is.

588
00:31:31.256 --> 00:31:33.416
Same way you have an appendix in your heart.

589
00:31:33.446 --> 00:31:35.396
It's called left atrial appendage.

590
00:31:35.436 --> 00:31:39.316
It's a tiny finger-like projection, where in a normal rhythm, the blood

591
00:31:39.355 --> 00:31:42.936
goes into that chamber, it squeezes and pushes the blood out.

592
00:31:43.416 --> 00:31:47.136
When somebody goes in AFib, that chamber or the left atrial appendage,

593
00:31:47.636 --> 00:31:51.276
it loses its contractile function. It starts fibrillating.

594
00:31:51.656 --> 00:31:54.436
The blood starts pooling inside the appendage.

595
00:31:55.096 --> 00:31:55.426
And

596
00:31:56.336 --> 00:31:58.756
there are other things going on, but that blood will clot.

597
00:31:58.976 --> 00:32:02.716
If the clot breaks, the left atrium is going to send to the left

598
00:32:02.736 --> 00:32:04.876
ventricle and through the aorta. It can go anywhere.

599
00:32:04.896 --> 00:32:06.896
It can go to your tip of your toe, to your kidneys.

600
00:32:07.516 --> 00:32:11.316
Usually, more or less, it goes straight up your carotid artery and goes in your

601
00:32:11.376 --> 00:32:14.176
brain and then gets lost into one of the arteries.

602
00:32:14.646 --> 00:32:18.416
And whichever part of the brain doesn't have a blood supply, you call it a

603
00:32:18.476 --> 00:32:21.976
stroke. So AFib is the most common reasons for

604
00:32:22.316 --> 00:32:23.216
disabling strokes.

605
00:32:24.596 --> 00:32:24.776
So

606
00:32:25.636 --> 00:32:28.976
to prevent it, these patients have to be on blood thinners, correct?

607
00:32:29.316 --> 00:32:33.076
Correct. That's the best we have. As I said, atrial fibrillation causes

608
00:32:33.096 --> 00:32:35.696
stasis. It makes the blood start becoming thick

609
00:32:36.516 --> 00:32:39.576
and start pooling. So obviously, the only thing we have to prevent that is to

610
00:32:39.596 --> 00:32:43.175
prevent the AFib and then to keep the blood thin by using drugs called

611
00:32:43.235 --> 00:32:44.056
anticoagulants.

612
00:32:45.116 --> 00:32:49.016
So we'll tackle more into this management part in a little bit, but I just want

613
00:32:49.056 --> 00:32:52.896
to touch up on the drinking. So alcohol is associated with

614
00:32:52.916 --> 00:32:55.156
irregular heartbeats or atrial fibrillation.

615
00:32:56.396 --> 00:32:59.956
So how big a deal is that? Can just one night of drinking

616
00:33:00.536 --> 00:33:01.136
cause AFib?

617
00:33:02.096 --> 00:33:03.546
So alcohol is an important topic.

618
00:33:04.776 --> 00:33:07.616
37 million Americans drink alcohol.

619
00:33:08.676 --> 00:33:09.956
That's the data statistics, right?

620
00:33:10.176 --> 00:33:10.186
Mm-hmm.

621
00:33:10.556 --> 00:33:14.096
With the alcohol, there is a dose. Everything has a dose and response

622
00:33:14.336 --> 00:33:17.816
curve, or if you can draw. So alcohol actually has a

623
00:33:17.956 --> 00:33:21.936
linear dose response. As you start increasing the dose of alcohol, the

624
00:33:21.976 --> 00:33:23.876
risk of AFib goes up, and other things, too.

625
00:33:26.016 --> 00:33:29.656
And so for alcohol, just like radiation, there is no

626
00:33:29.736 --> 00:33:33.476
clear safety threshold. Any amount of alcohol is bad, right?

627
00:33:33.556 --> 00:33:36.576
So there's a pooled analysis cohort of

628
00:33:37.156 --> 00:33:40.996
100,000 patients. They looked at those patients, how much were they

629
00:33:41.056 --> 00:33:44.556
drinking. One drink per day, which is 12 grams of ethanol.

630
00:33:44.876 --> 00:33:48.476
Just one drink increases the risk of atrial fibrillation by

631
00:33:48.516 --> 00:33:49.476
16%.

632
00:33:49.956 --> 00:33:49.966
Wow.

633
00:33:49.976 --> 00:33:53.556
So again, there is no safe zone. The more you drink with

634
00:33:53.616 --> 00:33:57.416
beer or cider-based alcohol, the

635
00:33:57.456 --> 00:33:59.176
dose response is absolutely clear.

636
00:33:59.556 --> 00:34:02.456
You increase the number of beers, the AFib risk is going to go up.

637
00:34:03.056 --> 00:34:06.896
With red wine and a white wine, the dose response is what we call a J

638
00:34:07.016 --> 00:34:10.897
curve. So a little bit of a certain extent, it

639
00:34:10.917 --> 00:34:14.316
protects you, but the moment you cross the limit, the risk of AFib goes up.

640
00:34:15.056 --> 00:34:18.816
So again, to my patients who drink alcohol or who come with

641
00:34:18.897 --> 00:34:22.516
AFib, we usually tell them, "Please do not drink." And alcohol, a binge

642
00:34:22.636 --> 00:34:26.296
alcohol drinking. Let's say you don't drink on a daily basis, and on a weekend you

643
00:34:26.336 --> 00:34:28.676
end up drinking four or five drinks in a short period of time.

644
00:34:29.136 --> 00:34:31.756
Alcohol, again, is going to make you diabetic, right?

645
00:34:31.836 --> 00:34:32.636
So you're losing

646
00:34:34.016 --> 00:34:37.176
fluid, you're increasing your catecholamines, you're increasing, again, the

647
00:34:37.256 --> 00:34:38.957
sympathetic and the parasympathetic comes in.

648
00:34:39.457 --> 00:34:42.576
And poor sleep, your heart rate variability goes down.

649
00:34:42.897 --> 00:34:46.136
And guess what? You're going to develop atrial fibrillation because that is

650
00:34:46.156 --> 00:34:49.196
triggering those pulmonary veins to bring out AFib.

651
00:34:50.176 --> 00:34:50.397
So

652
00:34:51.417 --> 00:34:55.256
even one night of heavy drinking can put the right person

653
00:34:55.555 --> 00:34:56.466
in AFib. Is that correct?

654
00:34:56.466 --> 00:34:59.996
Absolutely. And you don't have to be diabetic, you don't have to be obese.

655
00:35:00.556 --> 00:35:01.036
Certain

656
00:35:02.116 --> 00:35:02.676
drink or

657
00:35:03.536 --> 00:35:06.676
too much alcohol in a short period of time is usually a trigger, very well-known

658
00:35:06.856 --> 00:35:07.856
trigger for atrial fibrillation.

659
00:35:08.156 --> 00:35:10.156
So there's a term ascribed to it, holiday heart.

660
00:35:10.676 --> 00:35:10.936
Correct.

661
00:35:11.016 --> 00:35:11.596
That's a real thing?

662
00:35:11.756 --> 00:35:15.736
That's a real thing because you give rest, and you're not promoting the surges

663
00:35:15.776 --> 00:35:16.536
of sympathetic tone.

664
00:35:17.136 --> 00:35:20.916
So holiday heart mean if you're on your holidays, you drink a lot, you can have

665
00:35:20.956 --> 00:35:21.356
AFib?

666
00:35:22.236 --> 00:35:22.326
Correct.

667
00:35:22.336 --> 00:35:25.716
Potentially. Again, as I said, even one drink increases the risk by

668
00:35:25.736 --> 00:35:26.396
16%.

669
00:35:27.036 --> 00:35:30.836
So we talked about risk factors earlier, and we talked about

670
00:35:30.896 --> 00:35:33.216
sleep, weight, alcohol, exercise, stress.

671
00:35:33.576 --> 00:35:35.516
If you had to rank them, like, okay,

672
00:35:36.756 --> 00:35:38.336
I come to your office and I'm like, "You know what?

673
00:35:39.256 --> 00:35:43.156
I have stress in my life. I do like to drink every so often, a

674
00:35:43.176 --> 00:35:43.916
drink or two.

675
00:35:44.976 --> 00:35:46.356
My day starts with coffee."

676
00:35:47.396 --> 00:35:51.356
So what are the things, okay, give me top three that I must not do if I am at risk

677
00:35:51.416 --> 00:35:54.976
or if I've had AFib. Like you'll tell me, "Don't ever do these,"

678
00:35:55.356 --> 00:35:57.596
and the rest may be a little bit you can manage.

679
00:35:58.316 --> 00:36:01.716
That's a good question, but remember, it's patient specific, so when you come to my

680
00:36:01.756 --> 00:36:05.326
clinic, I have to assess all your modifiable and non-modifiable risk factors.

681
00:36:05.396 --> 00:36:09.186
But let's say you're a little bit overweight, so we know obesity,

682
00:36:09.236 --> 00:36:11.536
again, has a dose response. So

683
00:36:12.816 --> 00:36:16.748
let's talk about obesity first. Obesity or overweight, anything

684
00:36:16.788 --> 00:36:20.168
above 25 kilogram per meter squared is defined as overweight.

685
00:36:20.268 --> 00:36:24.208
Anything above 30 kilogram per meter squared is the definition of obesity,

686
00:36:24.278 --> 00:36:28.068
and above 40 is severe obesity. And in the obesity trials, so the people who have

687
00:36:28.108 --> 00:36:31.828
done trials, and then the American College of Cardiology recommends

688
00:36:31.888 --> 00:36:34.688
losing 10%. If you're overweight or obese,

689
00:36:35.568 --> 00:36:38.848
losing more than 10% has shown 30% reduction in atrial fibrillation.

690
00:36:38.968 --> 00:36:40.608
So it reduces your risk directly-

691
00:36:40.768 --> 00:36:40.778
Directly

692
00:36:40.778 --> 00:36:41.848
... correlating to weight loss.

693
00:36:42.028 --> 00:36:44.708
And again, obesity is again linked to so many things.

694
00:36:44.828 --> 00:36:45.988
Remember, everything is connected, right?

695
00:36:46.108 --> 00:36:48.888
You lose weight, you're going to have improvement in blood pressure, you sleep

696
00:36:48.908 --> 00:36:52.068
better, you changes your sleep apnea risk profile.

697
00:36:52.128 --> 00:36:56.008
Again, obesity's adipose tissue is linked to inflammation.

698
00:36:56.048 --> 00:36:58.948
And then, obesity also has a direct link with the heart.

699
00:36:59.308 --> 00:37:02.298
Your heart actually is protected. It sits in a tiny...

700
00:37:02.818 --> 00:37:05.368
It's covered by a balloon-like cover called pericardium.

701
00:37:05.408 --> 00:37:07.228
And inside there is adipose tissue.

702
00:37:07.268 --> 00:37:11.028
So people who are obese or truncal obesity have a higher

703
00:37:11.088 --> 00:37:14.768
epicardial, on the surface of the top chamber, higher the adipose

704
00:37:14.848 --> 00:37:15.148
tissue.

705
00:37:15.488 --> 00:37:16.248
The fat deposition.

706
00:37:16.257 --> 00:37:20.138
The fat deposition actually promotes inflammation, and that brings out atrial

707
00:37:20.148 --> 00:37:24.008
fibrillation as well. So there is some direct link from obesity to your heart.

708
00:37:24.528 --> 00:37:26.567
So when I look at the patient, let's say if he's...

709
00:37:27.028 --> 00:37:30.788
Again, we all live in a stressful environment, so again, the mental health needs to

710
00:37:30.848 --> 00:37:33.648
be managed first, right? Coffee, we already talked about.

711
00:37:34.048 --> 00:37:34.248
But

712
00:37:35.128 --> 00:37:38.798
the two things I would recommend is your alcohol intake, and number two is your

713
00:37:38.868 --> 00:37:42.808
sleep apnea, actually. People with AFib, almost half the patients, or

714
00:37:42.888 --> 00:37:46.668
more than actually 60% of the patients with AFib, have undiagnosed sleep apnea.

715
00:37:46.968 --> 00:37:50.858
The number is actually up to 75%. And it's bi-directional. It's both ways.

716
00:37:50.908 --> 00:37:53.778
People who have sleep apnea have AFib, and people who have AFib have actually sleep

717
00:37:53.788 --> 00:37:53.798
apnea.

718
00:37:53.848 --> 00:37:56.028
So one pulls the other and then they keep feeding off each other.

719
00:37:56.108 --> 00:38:00.078
So when patients come to me the first time for any young, old, for atrial

720
00:38:00.078 --> 00:38:04.028
fibrillation, what I'm doing simultaneously, I'm making them go do

721
00:38:04.048 --> 00:38:06.008
a sleep study in a home base or whatever you do.

722
00:38:06.088 --> 00:38:07.768
Go talk to a sleep doctor and start working.

723
00:38:08.368 --> 00:38:11.648
As we all sleep on, especially people who sleep on their back, the tongue is

724
00:38:11.668 --> 00:38:13.788
supposed to fall backwards, so we all obstruct.

725
00:38:13.978 --> 00:38:15.468
So that's called obstructive sleep apnea.

726
00:38:16.028 --> 00:38:19.908
So that is one of the most underdiagnosed modifiable risk factors for

727
00:38:19.928 --> 00:38:20.628
atrial fibrillation.

728
00:38:21.828 --> 00:38:23.308
Interesting. And

729
00:38:24.368 --> 00:38:25.028
exercise,

730
00:38:25.908 --> 00:38:29.748
and obviously exercise will cause weight loss, and we'll get into it, but one of

731
00:38:29.788 --> 00:38:33.668
the big topics that's been doing the rounds is, of course, the semaglutides,

732
00:38:33.708 --> 00:38:37.608
the Ozempic, the Wegovy, the Zepbound, and they help you

733
00:38:37.688 --> 00:38:38.388
lose weight.

734
00:38:39.488 --> 00:38:43.308
Is there any data that if you use these drugs for the

735
00:38:43.348 --> 00:38:46.448
right patients, do they have less AFib? Is there any studies on that?

736
00:38:46.568 --> 00:38:50.548
There is data now. Semaglutides, these are the, I

737
00:38:50.608 --> 00:38:53.948
call the wonder drugs now. They're changing everything, right?

738
00:38:53.978 --> 00:38:57.068
They're designed for weight loss, but we know that they reduce inflammation.

739
00:38:57.648 --> 00:39:01.428
They have cardio protective, semaglutide, liraglutide have cardio protective

740
00:39:02.468 --> 00:39:06.068
risks. And then there are studies, and there is like a

741
00:39:06.108 --> 00:39:09.808
meta-analysis where we combine all the studies together, of 26 studies.

742
00:39:09.848 --> 00:39:13.718
They show using GLP-1 agonist, semaglutide, reduces the risk of atrial

743
00:39:13.728 --> 00:39:16.628
fibrillation by 17%. So there is data getting collected.

744
00:39:16.688 --> 00:39:20.228
Again, remember, this is all new. But yes, if patients are

745
00:39:20.548 --> 00:39:24.428
having other cardiovascular, patients with heart failure, these drugs are helping.

746
00:39:24.728 --> 00:39:28.028
Invariably, it does correlate into helping with the atrial fibrillation, too.

747
00:39:30.088 --> 00:39:33.408
So say someone comes to you, he's moderately overweight,

748
00:39:34.088 --> 00:39:37.948
and you tell him, "Lose 30 pounds." Can it fix his

749
00:39:38.008 --> 00:39:38.308
AFib?

750
00:39:39.028 --> 00:39:41.088
It can, but the problem is how we're going to do that.

751
00:39:41.448 --> 00:39:45.388
Because now once you're obese, you are in a vicious cycle, right?

752
00:39:45.398 --> 00:39:48.628
These are big patients. I want them to go exercise.

753
00:39:48.888 --> 00:39:50.828
Their knees are already hurting. So again,

754
00:39:51.468 --> 00:39:55.108
the theme in atrial fibrillation used to be,

755
00:39:55.948 --> 00:39:57.368
I think we were putting Band-Aids, right?

756
00:39:57.408 --> 00:39:59.248
You're giving drugs, you're doing ablations.

757
00:39:59.328 --> 00:40:02.828
But now the new goal, even by societies from the heart rhythm from ACC, is

758
00:40:03.228 --> 00:40:07.158
AFib prevention is the new, actually, the theme that we need to prevent, nip it in

759
00:40:07.268 --> 00:40:09.988
the bud. So again, it's a challenge.

760
00:40:10.488 --> 00:40:14.368
Unfortunately, patients in persistent AFib, they're in AFib 24/7. They're obese.

761
00:40:15.028 --> 00:40:17.848
Once they exercise, they get short of breath. So you have to start somewhere.

762
00:40:17.908 --> 00:40:21.188
So in some patients, unfortunately, we have to go aggressive up front,

763
00:40:22.028 --> 00:40:25.888
treat the atrial fibrillation with catheter ablation by taking the chances of

764
00:40:25.908 --> 00:40:29.728
the obesity. But if I can maintain sinus rhythm for at least six months in

765
00:40:29.768 --> 00:40:33.767
these patients with ablation or whatever, at least I can make

766
00:40:33.788 --> 00:40:37.428
them exercise, and do all those things. So it's a continuous cycle.

767
00:40:38.728 --> 00:40:42.708
So exercise is interesting. Of course, exercise is good

768
00:40:42.728 --> 00:40:43.248
for body.

769
00:40:44.468 --> 00:40:48.428
Now, what is the relationship of exercise with AFib?

770
00:40:48.668 --> 00:40:52.428
I read some data that endurance athletes are also

771
00:40:52.508 --> 00:40:55.688
likely to get AFib. What's that? Is there any truth to that?

772
00:40:55.748 --> 00:40:59.248
Like if you're a marathon runner as they are a long-distance cyclist, which a lot

773
00:40:59.288 --> 00:41:00.308
of your patients can be,

774
00:41:01.388 --> 00:41:05.008
they are living a healthy life. Are they increasing their risk for AFib?

775
00:41:05.368 --> 00:41:09.148
It's very interesting. You will think these are thin, slim people, patients coming

776
00:41:09.688 --> 00:41:09.928
bicycling.

777
00:41:09.948 --> 00:41:11.768
These are not your prototypical AFib patients.

778
00:41:11.788 --> 00:41:13.968
These are not. And these are the patients who are very well read.

779
00:41:14.008 --> 00:41:16.668
They are good in their supplements, and you name it.

780
00:41:16.928 --> 00:41:17.838
They're doing everything right, in other words.

781
00:41:17.838 --> 00:41:21.508
They're doing everything right, but believe me, I see a lot of athletes, especially

782
00:41:21.568 --> 00:41:24.348
avid cyclists. We have this nice bike path here.

783
00:41:24.508 --> 00:41:24.708
Mm-hmm.

784
00:41:24.808 --> 00:41:27.148
A lot of cyclists are developing atrial fibrillation.

785
00:41:27.328 --> 00:41:28.008
And why is that?

786
00:41:28.128 --> 00:41:31.388
And that's interesting. So exercise, remember I talked about alcohol.

787
00:41:31.448 --> 00:41:34.748
Alcohol has a direct dose response. The more you drink, the more AFib.

788
00:41:35.148 --> 00:41:37.818
Exercise has what we call a J or a U-shaped curve.

789
00:41:38.348 --> 00:41:42.277
So if you exercise less than a certain amount, you have more disease, more

790
00:41:42.328 --> 00:41:46.158
AFib, more obesity. And there is a perfect inflection

791
00:41:46.268 --> 00:41:50.168
point. So if you start exercising more than, the number

792
00:41:50.208 --> 00:41:51.208
is 55 Mets

793
00:41:52.128 --> 00:41:54.928
per week. MET is like the metabolic equivalent, right?

794
00:41:55.028 --> 00:41:58.988
So more than 10 hours of vigorous exercise

795
00:41:59.088 --> 00:42:02.888
in a week increases the risk of AFib and other heart rhythm problems.

796
00:42:03.528 --> 00:42:06.948
So in endurance athletes. And the reason for that is many, many reasons.

797
00:42:06.988 --> 00:42:09.948
So one of the things is when somebody's athletic, remember, when they are doing

798
00:42:09.988 --> 00:42:12.788
their activity, the heart is pumping, it's racing fast.

799
00:42:13.068 --> 00:42:16.908
To compensate, first thing the heart does is, two things it does, the

800
00:42:16.968 --> 00:42:17.878
chambers will dilate

801
00:42:18.824 --> 00:42:21.504
Number two, they develop sinus bradycardia.

802
00:42:21.544 --> 00:42:24.744
It means their resting heart rate is always in 40s, so that's a compensation.

803
00:42:25.564 --> 00:42:28.464
Most of these athletes actually develop their AFib during their sleep.

804
00:42:28.534 --> 00:42:31.023
They never develop their AFib during exercise, actually.

805
00:42:31.364 --> 00:42:33.584
And that is called the vagal-mediated AFib.

806
00:42:34.104 --> 00:42:37.984
Because, again, it comes back to the sympathetic, parasympathetic, athletes have

807
00:42:38.024 --> 00:42:41.804
a very high resting vagal tone, and during sleep, that vagus

808
00:42:41.864 --> 00:42:44.574
nerve is going to promote those pulmonary veins.

809
00:42:44.624 --> 00:42:47.444
It's called the cholinergic mediated. It triggers the AFib.

810
00:42:47.504 --> 00:42:50.334
So most athletes actually develop their atrial fibrillation during their sleep,

811
00:42:50.384 --> 00:42:52.984
which is even worse. They don't even know that they have AFib.

812
00:42:53.024 --> 00:42:56.724
So that's one reason. Number two is what we call the remodeling of the whole heart.

813
00:42:56.924 --> 00:42:59.204
Their ventricles thicken. The atriums.

814
00:42:59.904 --> 00:43:03.784
There is data now that people who are endurance athletes, marathon

815
00:43:03.864 --> 00:43:06.104
runners, their atriums are dilated.

816
00:43:06.904 --> 00:43:10.444
And unfortunately, there is data shown that that dilatation never

817
00:43:10.484 --> 00:43:14.284
reverses. It stays on. Even if you stop, it stays on for years and

818
00:43:14.364 --> 00:43:18.084
years. And the bigger the upper chambers, the dilation, the

819
00:43:18.164 --> 00:43:21.044
more the risk of all these arrhythmias. And there is data, actually.

820
00:43:21.104 --> 00:43:24.083
They took rats, again, I'm not comparing humans to rats.

821
00:43:24.704 --> 00:43:28.304
They have these healthy rats, and they ran them, like

822
00:43:28.924 --> 00:43:32.904
vigorous exercise training for 16 weeks, and then they cut the heart, and they

823
00:43:32.944 --> 00:43:36.924
look under microscope. 60% of those rats, compared to the controls who

824
00:43:36.944 --> 00:43:40.844
did not, have fibrosis, which would be scarring, which you can see through an

825
00:43:40.904 --> 00:43:44.484
MRI or under the microscope. So that's the link between too much

826
00:43:44.524 --> 00:43:48.484
exercise. So the recommendation is to cut down.

827
00:43:48.704 --> 00:43:48.964
So,

828
00:43:50.084 --> 00:43:53.284
200, 240 minutes or something like that, or two to three hours.

829
00:43:53.364 --> 00:43:56.964
If you're doing 10 hours vigorous in a week, cut it down to two to three

830
00:43:57.064 --> 00:43:57.804
hours.

831
00:43:58.104 --> 00:43:59.354
So vigorous means,

832
00:44:00.244 --> 00:44:04.144
how do you define vigorous? My exercise tolerance could be very different

833
00:44:04.184 --> 00:44:07.924
than yours. In terms of heart rate, okay, if I want to tell my

834
00:44:07.964 --> 00:44:11.884
patient, "At this heart rate for this many hours," because that's how people

835
00:44:11.924 --> 00:44:12.624
want to quantify.

836
00:44:12.824 --> 00:44:14.784
Right. And again, it becomes different.

837
00:44:15.064 --> 00:44:17.524
Guidelines recommend, they give us a total timeframe.

838
00:44:17.564 --> 00:44:20.224
Okay, do these amount of minutes or, as a 240 minutes.

839
00:44:20.484 --> 00:44:20.664
Mm-hmm.

840
00:44:20.734 --> 00:44:22.894
Again, is there a limit for a particular patient?

841
00:44:22.964 --> 00:44:25.164
Okay, you're starting at 40 and you go up to 200.

842
00:44:25.784 --> 00:44:26.964
I think that's something-

843
00:44:27.484 --> 00:44:30.004
So exercise which is making you breathless and tired-

844
00:44:30.044 --> 00:44:30.333
Then you should not

845
00:44:30.333 --> 00:44:31.204
... in the simplest terms-

846
00:44:31.524 --> 00:44:31.884
You should not, correct

847
00:44:31.944 --> 00:44:32.984
... for a prolonged period.

848
00:44:33.024 --> 00:44:33.393
For a prolonged period, yeah.

849
00:44:33.404 --> 00:44:34.764
Is that simplistic?

850
00:44:34.824 --> 00:44:38.624
For my cyclist patients who are averaging 100 miles a week,

851
00:44:39.064 --> 00:44:41.824
I usually tell them, again, there is no exact limit, but I say, "At least cut it

852
00:44:41.844 --> 00:44:42.824
down by 25%."

853
00:44:43.144 --> 00:44:43.274
Mm-hmm.

854
00:44:43.294 --> 00:44:45.724
"Bring it down to 75 and see what happens."

855
00:44:46.084 --> 00:44:46.274
Mm-hmm.

856
00:44:46.924 --> 00:44:50.673
And now there is data, actually, for the athletes, and it's very difficult to tell

857
00:44:50.704 --> 00:44:53.884
them to not do what they want to like to do, so catheter

858
00:44:53.893 --> 00:44:57.184
ablation is becoming a first line for actually athletes.

859
00:44:58.244 --> 00:45:01.764
Because think about it. Their resting heart rate is slow, which means I have no

860
00:45:01.864 --> 00:45:05.504
medication, no heart rhythm medication, we call antiarrhythmics, beta

861
00:45:05.564 --> 00:45:09.284
blockers to give it to them. They're already too slow. They tend to get dehydrated.

862
00:45:09.364 --> 00:45:13.284
So I don't have much options from a medication standpoint to give to these

863
00:45:13.344 --> 00:45:16.024
patients. So ablation usually helps.

864
00:45:16.404 --> 00:45:20.204
And a good part of these ablations are we're targeting those pulmonary veins, so

865
00:45:20.244 --> 00:45:23.684
the resting heart rate does goes up a little bit post-ablation, but a lot of data

866
00:45:23.704 --> 00:45:27.264
coming out of early ablation for athletic patients.

867
00:45:27.484 --> 00:45:29.393
And they are at risk for stroke equally, too, if they have AFib.

868
00:45:29.393 --> 00:45:33.024
That exactly right. Stroke risk in atrial fibrillation is defined by

869
00:45:33.104 --> 00:45:36.904
your, there's a risk score we call the CHADS VASC risk score, which

870
00:45:36.964 --> 00:45:40.584
is C stands for congestive heart failure, H is for hypertension,

871
00:45:40.924 --> 00:45:43.284
A is for age. Age above 75 gives you two points.

872
00:45:43.524 --> 00:45:45.364
Other ones, everybody else is giving you one point.

873
00:45:46.044 --> 00:45:49.944
D is diabetes, S is stroke or any myocardial

874
00:45:49.984 --> 00:45:51.684
infarction history of peripheral artery disease.

875
00:45:51.824 --> 00:45:54.764
All these risk factors, we do a point-based system.

876
00:45:55.364 --> 00:45:59.244
So if you're a male and this CHADS VASC score is above two

877
00:45:59.324 --> 00:46:03.284
and above, the risk of having a stroke is basically two out of 100

878
00:46:03.324 --> 00:46:06.124
chances. If your score is three, three out of 100 chances.

879
00:46:06.164 --> 00:46:09.794
For a female, you have to have a CHADS VASC score of three and

880
00:46:09.864 --> 00:46:13.384
above. So that's the risk scoring used throughout the world in all

881
00:46:13.424 --> 00:46:13.904
patients,

882
00:46:15.304 --> 00:46:19.244
male or females, athlete or non-athletes, to determine the

883
00:46:19.344 --> 00:46:21.624
need for blood thinners called the anticoagulants.

884
00:46:22.684 --> 00:46:25.224
So let's dive into the day-to-day stuff, okay?

885
00:46:27.544 --> 00:46:31.094
Say one of your friends develops AFib now, okay,

886
00:46:31.404 --> 00:46:32.064
comes to you.

887
00:46:33.564 --> 00:46:34.254
As a patient,

888
00:46:35.104 --> 00:46:38.914
what are some of the questions that I should be asking my

889
00:46:39.004 --> 00:46:42.844
doctor if I am found to have AFib? Where would I start?

890
00:46:43.564 --> 00:46:45.084
So first of all, again,

891
00:46:45.904 --> 00:46:49.384
the first thing we assess is are you symptomatic or not? If you have symptoms.

892
00:46:49.824 --> 00:46:53.584
And then the other things you're going to ask me, most patients ask me, "Okay,

893
00:46:54.384 --> 00:46:58.324
should I get the ablation early on, and what are my treatment options?" Again, we

894
00:46:58.364 --> 00:47:00.224
talked about prevention is the goal.

895
00:47:00.344 --> 00:47:03.864
We want to prevent further episodes, which modify, we talked about the risk

896
00:47:03.924 --> 00:47:07.444
factors. But the question is, should we

897
00:47:07.524 --> 00:47:10.844
offer these patients an early ablation, more aggressive ablation?

898
00:47:10.864 --> 00:47:13.944
So even before we go to that, it's new onset,

899
00:47:14.444 --> 00:47:18.424
there is a procedure called shocking the heart to get people out

900
00:47:18.484 --> 00:47:18.574
of-

901
00:47:18.644 --> 00:47:18.794
Correct

902
00:47:18.844 --> 00:47:22.524
... AFib. Would that be an option for a lot of people to start with?

903
00:47:22.564 --> 00:47:25.904
Right. Because the first episode, and let's say you are staying in AFib, right?

904
00:47:25.984 --> 00:47:28.444
So which means you're developing early persistent atrial fibrillation.

905
00:47:28.564 --> 00:47:31.324
Most patients, we end up doing what we call a cardioversion.

906
00:47:31.664 --> 00:47:35.144
Before even we do that, again, my goal is to figure out why did you get into that

907
00:47:35.184 --> 00:47:38.784
AFib. Again, stress, did you not sleep well, too much alcohol, sleep

908
00:47:38.884 --> 00:47:42.484
apnea, obesity, uncontrolled diabetes, history of myocardial

909
00:47:42.504 --> 00:47:46.144
infarction. So we assess for all those, but then in terms of

910
00:47:46.184 --> 00:47:49.964
treatment-wise, step one, usually if you are in a hospital, we end up

911
00:47:50.004 --> 00:47:52.284
doing a procedure called the TE cardioversion.

912
00:47:52.414 --> 00:47:55.684
We make sure there's no clot in your heart, and then we

913
00:47:55.804 --> 00:47:59.744
manually reset your heart by putting paddles on

914
00:47:59.764 --> 00:48:02.434
your chest, and we do a procedure called cardioversion.

915
00:48:02.544 --> 00:48:04.104
That will get you back in normal rhythm.

916
00:48:04.564 --> 00:48:08.244
The problem is, it's very hard to predict which patient is going to have a

917
00:48:08.324 --> 00:48:11.924
recurrence. We know that the older you are, the poor diabetic, the

918
00:48:12.004 --> 00:48:15.668
obese you are And if you already have a heart failure, the risk of

919
00:48:15.688 --> 00:48:17.298
developing atrial fibrillation goes up.

920
00:48:17.968 --> 00:48:21.108
So the other thing we talk about in atrial fibrillation is, what is your pumping

921
00:48:21.508 --> 00:48:24.428
chambers doing? Atrial fibrillation can cause heart failure.

922
00:48:24.818 --> 00:48:28.608
And now there is lot of data and impetus

923
00:48:28.668 --> 00:48:32.148
towards what we call arrhythmia-mediated cardiomyopathy.

924
00:48:32.188 --> 00:48:36.068
We all know that atrial fibrillation causes stroke, but because your

925
00:48:36.128 --> 00:48:39.608
heart is not in a regular beat, think about your bottom chamber.

926
00:48:39.668 --> 00:48:43.438
Your bottom chamber is sometimes slow, sometimes fast, so this irregularity

927
00:48:43.948 --> 00:48:47.848
actually can itself promote what we call LV dysfunction or left

928
00:48:47.948 --> 00:48:49.947
ventricular dysfunction, or called heart failure.

929
00:48:50.528 --> 00:48:50.628
So-

930
00:48:50.708 --> 00:48:51.648
So the heart becomes weak.

931
00:48:51.688 --> 00:48:55.368
The heart becomes weak, and if you don't treat those AFib, they will

932
00:48:55.448 --> 00:48:57.308
behave just like any other heart failure patients.

933
00:48:57.868 --> 00:49:00.678
So if you treat them, the heart function can improve, it can get stronger?

934
00:49:00.968 --> 00:49:04.868
Mostly. Mostly if it's purely based on tachyarrhythmia or the fast heart

935
00:49:04.908 --> 00:49:08.228
rhythm-related heart failure. The moment you restore the rhythm normal by

936
00:49:08.288 --> 00:49:12.228
cardioversion, by shocking, or by ablation, or by medications, those

937
00:49:12.248 --> 00:49:14.008
heart failure usually reverses completely.

938
00:49:14.848 --> 00:49:16.528
So let's go step by step. So

939
00:49:17.408 --> 00:49:19.628
I came to you, AFib is diagnosed.

940
00:49:19.688 --> 00:49:19.848
Mm-hmm.

941
00:49:20.308 --> 00:49:22.968
Or even if I go a step before, I had palpitations.

942
00:49:23.888 --> 00:49:26.328
You did a monitor, now I have AFib.

943
00:49:26.428 --> 00:49:26.628
Mm-hmm.

944
00:49:27.488 --> 00:49:27.878
Now,

945
00:49:29.168 --> 00:49:32.808
you offered me cardioversion with transesophageal

946
00:49:32.868 --> 00:49:36.828
echocardiogram, which is essentially putting a probe down my mouth under sedation-

947
00:49:36.868 --> 00:49:36.908
Right

948
00:49:36.918 --> 00:49:38.058
... taking a look at the heart-

949
00:49:38.168 --> 00:49:38.198
Mm-hmm

950
00:49:38.198 --> 00:49:41.348
... make sure there is no clot, and then shocking the heart.

951
00:49:41.568 --> 00:49:41.688
Correct.

952
00:49:41.708 --> 00:49:44.798
The rhythm is restored. What would you do next with that patient?

953
00:49:45.478 --> 00:49:49.418
So usually in those patients, the fact that

954
00:49:49.418 --> 00:49:52.468
I had to go in and cardiovert you, which means you're already developing the

955
00:49:52.488 --> 00:49:54.378
persistent, that your heart wants to stay in AFib.

956
00:49:54.408 --> 00:49:58.268
So those patients should be, especially if you're in a relatively younger age,

957
00:49:58.588 --> 00:49:58.718
and

958
00:49:59.528 --> 00:50:02.308
that definition is changing, but we want to be aggressive.

959
00:50:02.468 --> 00:50:06.108
So usually the step first is we can give you a medication called an

960
00:50:06.188 --> 00:50:08.988
antiarrhythmic to prevent the next episode.

961
00:50:09.028 --> 00:50:10.178
And there are several medicines like that.

962
00:50:10.198 --> 00:50:13.628
There are several medications, and they all work on ion channels, sodium channel

963
00:50:13.648 --> 00:50:17.208
blockers, we call class I agents. There is potassium channel blockers,

964
00:50:17.548 --> 00:50:21.148
there is a beta blockers. So all these drugs are designed so that whatever

965
00:50:21.228 --> 00:50:24.648
triggers your AFib, it doesn't let you go in AFib. Okay?

966
00:50:25.138 --> 00:50:26.768
So those are the heart rhythm medications.

967
00:50:27.268 --> 00:50:31.168
Plus, simultaneously, we're also managing your stroke profile, your risk profile

968
00:50:31.208 --> 00:50:35.008
with blood thinners. But then after heart rhythm medications, usually the next

969
00:50:35.048 --> 00:50:36.788
step is what we call the catheter ablation.

970
00:50:37.388 --> 00:50:37.648
So

971
00:50:38.828 --> 00:50:41.028
the question is when to do these procedures, right?

972
00:50:41.528 --> 00:50:45.508
If you only had one episode of AFib and you're a younger person, and then I'm

973
00:50:45.588 --> 00:50:49.508
able to tell you to modify your risk factors, usually we can wait and watch

974
00:50:49.868 --> 00:50:53.568
and keep doing monitoring, by self-monitoring or by event monitoring and things

975
00:50:53.608 --> 00:50:55.528
like that. That's usually the right way to go.

976
00:50:56.188 --> 00:50:57.008
The other thing in AFib

977
00:50:57.848 --> 00:51:00.168
field is called the atrial fibrillation burden.

978
00:51:01.008 --> 00:51:04.488
All the trials of AFib to this date, if you look at any randomized trials or

979
00:51:04.508 --> 00:51:07.948
whatever we do, the definition of success is

980
00:51:08.628 --> 00:51:12.508
30 seconds or more of AFib after an intervention, which, in my

981
00:51:12.548 --> 00:51:14.128
opinion, is absolutely wrong.

982
00:51:14.308 --> 00:51:14.788
30 second

983
00:51:15.628 --> 00:51:19.438
So let's say you do an ablation. I'm doing a trial where I'm going to do half the

984
00:51:19.488 --> 00:51:22.248
patients are going to go on a drug, and the second one is going to do ablation.

985
00:51:22.308 --> 00:51:26.228
So how do we define success in the AFib world is

986
00:51:26.328 --> 00:51:30.268
after an ablation or after a procedure, are you developing episodes

987
00:51:30.308 --> 00:51:34.008
of AFib? And the definition to date has been any 30 seconds

988
00:51:34.248 --> 00:51:37.488
of atrial fibrillation documented by any monitor-

989
00:51:37.628 --> 00:51:38.228
Is a failure

990
00:51:38.508 --> 00:51:41.868
... is a failure, which my opinion is absolutely wrong. The field is changing.

991
00:51:42.128 --> 00:51:45.888
Now the goal of all these interventions is actually reduction of

992
00:51:45.928 --> 00:51:49.568
AFib burden. If you had AFib 50% of

993
00:51:49.648 --> 00:51:53.438
time before an ablation or an intervention, and now you're down to 1%,

994
00:51:54.088 --> 00:51:55.388
in theory, that should make sense that-

995
00:51:55.428 --> 00:51:55.577
Right

996
00:51:55.668 --> 00:51:57.788
... that is there. So that's where the field is going towards.

997
00:51:58.368 --> 00:52:02.308
If you come to me for the first time, my first job is to assess how much AFib

998
00:52:02.348 --> 00:52:02.827
you're having.

999
00:52:03.748 --> 00:52:07.068
If you are paroxysmal, means you come and go, how many episodes you're having in a

1000
00:52:07.128 --> 00:52:10.868
month. If you're having, let's say, three to six episodes in a month, it's pretty

1001
00:52:10.948 --> 00:52:12.708
clear that we should do more for those patients.

1002
00:52:13.388 --> 00:52:15.928
If you're going to have one or two in a year, you can argue

1003
00:52:15.938 --> 00:52:19.918
whether you can just manage them medically or procedure's

1004
00:52:19.968 --> 00:52:21.918
usually not recommended for those patients.

1005
00:52:22.748 --> 00:52:26.458
So now that we've gone through the blood thinner part you mentioned,

1006
00:52:27.228 --> 00:52:30.548
so blood thinners obviously scare people. There is risks to it.

1007
00:52:30.608 --> 00:52:34.298
It used to be warfarin, which again, people know it as rat poison-

1008
00:52:34.707 --> 00:52:34.717
Mm-hmm

1009
00:52:34.717 --> 00:52:36.188
... and people talk about it also. Now there are-

1010
00:52:36.238 --> 00:52:36.258
Right

1011
00:52:36.268 --> 00:52:40.128
... newer drugs like apixaban or rivaroxaban,

1012
00:52:40.348 --> 00:52:43.968
and we use them. But people are still scared of blood thinners.

1013
00:52:44.328 --> 00:52:47.308
Now, if I'm a patient and you tell me to take a blood thinner daily,

1014
00:52:48.688 --> 00:52:52.028
I'm worried about bleeding. If I have an accident or a cut, I can bleed a lot

1015
00:52:52.128 --> 00:52:55.287
more. What are my options? Do I have any other options to that?

1016
00:52:55.758 --> 00:52:59.368
Correct. You're right. So based on the risk factors we talked about, the

1017
00:52:59.428 --> 00:53:03.347
CHA2DS2-VASc score, if you're risk two and above for a male and above three for a

1018
00:53:03.428 --> 00:53:05.848
female, you have to be on a blood thinner lifelong.

1019
00:53:06.228 --> 00:53:08.248
That's the guidelines as of today.

1020
00:53:09.188 --> 00:53:12.988
Trials are ongoing where patients who can self-monitor their

1021
00:53:13.028 --> 00:53:16.228
AFib, when they know they're going in AFib, they can start a blood thinner.

1022
00:53:16.288 --> 00:53:17.217
But again, that's future.

1023
00:53:18.248 --> 00:53:18.968
But unfortunately-

1024
00:53:19.028 --> 00:53:20.038
And that's with Apple Watch?

1025
00:53:20.288 --> 00:53:23.248
That's where the Apple Watch or the wearables are coming, but again, those trials

1026
00:53:23.258 --> 00:53:26.958
are underway. But as of now, as we speak today in 2026, if you have

1027
00:53:27.008 --> 00:53:30.668
AFib and you have these risk scores, whether or not you had an ablation or

1028
00:53:30.708 --> 00:53:34.508
not, you're supposed to take the blood thinner lifelong. And we all know that.

1029
00:53:34.628 --> 00:53:35.768
We all scared about blood thinners.

1030
00:53:35.808 --> 00:53:37.968
You talk about reasons, you can cut yourself and things like.

1031
00:53:38.168 --> 00:53:41.228
So there are alternatives we call the left atrial appendage management.

1032
00:53:41.488 --> 00:53:43.128
We talked about 90% of the strokes

1033
00:53:43.988 --> 00:53:46.548
during atrial fibrillation come from the left atrial appendage.

1034
00:53:46.768 --> 00:53:50.378
So just to recap, that's a small out-pouching in the top chambers-

1035
00:53:50.458 --> 00:53:50.458
Top chamber

1036
00:53:50.468 --> 00:53:53.328
... which does not have a lot of other useful function as far as we know.

1037
00:53:53.388 --> 00:53:57.368
As far we know. So the surgeons can cut it during a heart surgery,

1038
00:53:57.648 --> 00:54:00.808
you can put a clip on from the outside, or we, as an interventional

1039
00:54:00.868 --> 00:54:04.288
electrophysiologist or the structural heart specialist, we can actually

1040
00:54:05.524 --> 00:54:09.184
Percutaneously go from the groin, go inside the heart, we can actually

1041
00:54:09.204 --> 00:54:12.584
plug those chambers. And there are two devices out there which are approved.

1042
00:54:12.644 --> 00:54:16.024
One is called the Watchman device, and the other one is called an Amplatzer device.

1043
00:54:16.494 --> 00:54:18.664
So these are like filters, so to speak.

1044
00:54:18.744 --> 00:54:22.604
You put them inside those appendages, and then the body's going to form a

1045
00:54:22.644 --> 00:54:26.534
layer of cardiac tissue to completely occlude those chambers,

1046
00:54:26.864 --> 00:54:30.324
so that when you go in AFib, the blood doesn't go into this appendage, and you

1047
00:54:30.364 --> 00:54:31.964
won't form a clot, and you won't get a stroke.

1048
00:54:32.624 --> 00:54:36.504
So again, for the right patient at the right time, these devices are

1049
00:54:36.544 --> 00:54:37.023
available.

1050
00:54:37.984 --> 00:54:40.744
So if my doctor suggests to me, "Okay,

1051
00:54:41.744 --> 00:54:45.554
you don't want to take blood thinner, we can do Watchman or Amplatzer

1052
00:54:45.644 --> 00:54:49.564
for you. Let's start there." Is there any particular questions that I should be

1053
00:54:49.644 --> 00:54:52.904
asking? Is one device better than the other? Is there any data to that?

1054
00:54:53.284 --> 00:54:57.164
Or is there any particular question I should be asking as

1055
00:54:57.224 --> 00:55:00.904
a patient from my perspective, being responsible

1056
00:55:01.004 --> 00:55:02.044
about these devices?

1057
00:55:02.584 --> 00:55:06.564
So again, to get these devices even approved, remember, these

1058
00:55:06.684 --> 00:55:06.924
are

1059
00:55:07.844 --> 00:55:11.494
big procedures. So to be a candidate for left atrial

1060
00:55:11.524 --> 00:55:15.064
appendage devices, you have to have a CHADS-VASc score of three and above.

1061
00:55:15.464 --> 00:55:19.444
So let's say you are a 45-year-old coming to me for AFib, and you don't have

1062
00:55:19.464 --> 00:55:22.464
high blood pressure, no diabetes, no stroke, nothing.

1063
00:55:22.924 --> 00:55:26.604
You do not qualify for this device, just to be very clear and honest.

1064
00:55:26.704 --> 00:55:29.044
But you won't qualify for blood thinner in that case also.

1065
00:55:29.184 --> 00:55:33.044
You also won't qualify for blood thinner, depending outside the ablation timeframe.

1066
00:55:33.104 --> 00:55:36.424
Remember, anytime we touch your heart or we do an ablation or a cardioversion,

1067
00:55:36.864 --> 00:55:40.724
those four to six weeks after electric shock on an ablation,

1068
00:55:41.124 --> 00:55:42.524
you are supposed to take a blood thinner.

1069
00:55:42.584 --> 00:55:44.504
So we're talking about these long-term blood thinners.

1070
00:55:44.624 --> 00:55:44.864
Mm-hmm.

1071
00:55:45.164 --> 00:55:49.104
Right. There is no

1072
00:55:49.164 --> 00:55:52.184
head-to-head comparison between the Watchman device and an Amplatzer device.

1073
00:55:52.544 --> 00:55:56.404
The endpoint is whoever does the procedure, the goal of the left atrial appendage

1074
00:55:56.504 --> 00:56:00.124
management should be complete occlusion of your chamber.

1075
00:56:00.584 --> 00:56:04.524
How you do it, that is up to who does it.

1076
00:56:04.564 --> 00:56:08.524
But we talked about in the past, we're doing these devices, and there was an

1077
00:56:08.584 --> 00:56:12.144
acceptable leak around the device at the time of implant under three millimeter.

1078
00:56:12.584 --> 00:56:16.424
Now, the data has shown that you don't want any leak after 45

1079
00:56:16.464 --> 00:56:18.524
days or after the device is completely healed.

1080
00:56:19.784 --> 00:56:22.864
Okay. So now we got past the device.

1081
00:56:23.564 --> 00:56:25.364
You decide the patient needs an ablation.

1082
00:56:26.584 --> 00:56:29.684
Can you tell our patients what the procedure,

1083
00:56:30.504 --> 00:56:33.784
or for general people to know what the procedure entails?

1084
00:56:34.964 --> 00:56:36.424
How big of a deal it is?

1085
00:56:38.224 --> 00:56:41.244
So again, catheter ablation is a first-line therapy now.

1086
00:56:41.264 --> 00:56:45.024
And in the beginning, I remember I said, ablation means to ablate or to

1087
00:56:45.084 --> 00:56:49.044
change or modify a heart tissue. In the catheter

1088
00:56:49.084 --> 00:56:52.764
ablation for AFib, we are going inside your left upper chamber,

1089
00:56:53.184 --> 00:56:56.574
and we're isolating those four pulmonary veins, those tubes where the-

1090
00:56:56.584 --> 00:56:57.674
So you go from the groin with-

1091
00:56:57.704 --> 00:57:01.504
We go from the groin. So the procedure, again, entails, right now, the procedure

1092
00:57:01.784 --> 00:57:05.664
can take anywhere from one to two hours, depending on what technology you use.

1093
00:57:06.684 --> 00:57:09.884
But the procedure is still done under general anesthesia

1094
00:57:09.984 --> 00:57:13.834
or some form of deep sedation. The access is

1095
00:57:13.884 --> 00:57:17.664
through your groin. We are going through your femoral vein, so the tubes

1096
00:57:17.764 --> 00:57:21.544
which are draining the blood, taking blood back from your leg into your

1097
00:57:21.604 --> 00:57:25.204
heart. So we're going to, under X-ray or under 3D mapping, we

1098
00:57:25.744 --> 00:57:29.544
pass these tiny wires, electrical wires, and these tubes called catheters.

1099
00:57:30.384 --> 00:57:33.284
And then the procedure, the most important part of this procedure, is what we call

1100
00:57:33.304 --> 00:57:37.064
transseptal access. To go from your right upper chamber to the

1101
00:57:37.084 --> 00:57:40.424
left upper chamber, we have to make a tiny hole in the heart.

1102
00:57:40.444 --> 00:57:44.424
It's called a transseptal access, where the needle, we cross to

1103
00:57:44.464 --> 00:57:47.964
the left side. And then we take all our equipment into the left upper chamber.

1104
00:57:48.404 --> 00:57:52.084
We create a 3D map of your heart to see how big the heart is and

1105
00:57:52.184 --> 00:57:53.864
define what the areas of scarring are.

1106
00:57:54.384 --> 00:57:57.864
And then, once we know where to go and burn or

1107
00:57:58.024 --> 00:58:01.524
freeze or electroparade, we take this catheter, and we can

1108
00:58:02.124 --> 00:58:05.824
deliver energy. So the bottom line is to deliver energy to that part of the heart

1109
00:58:05.864 --> 00:58:08.164
where the AFib triggers or starts.

1110
00:58:08.664 --> 00:58:11.104
How you do it, again, that depends on the operator.

1111
00:58:11.224 --> 00:58:15.144
But these days, pulse field ablation is becoming pretty

1112
00:58:15.204 --> 00:58:19.184
much to go the energy source. And the reason for that

1113
00:58:19.264 --> 00:58:21.954
is it's faster, the tools are much more simpler,

1114
00:58:22.723 --> 00:58:26.184
and the energy is supposed to be cardioselective.

1115
00:58:27.064 --> 00:58:30.224
When we used to use radiofrequency energy for ablation-

1116
00:58:30.264 --> 00:58:31.504
The heat energy. Mm-hmm

1117
00:58:31.524 --> 00:58:33.484
... heat energy. We use radiofrequency that generates the heat.

1118
00:58:34.964 --> 00:58:38.424
Not only you are ablating the heart tissue, you're burning the heart tissue, but

1119
00:58:38.464 --> 00:58:40.564
think about it, the heart is sitting around many other things.

1120
00:58:40.604 --> 00:58:43.824
There are arteries, there are nerves, there are other tissues in the heart.

1121
00:58:43.984 --> 00:58:47.184
The left atrium sits in front of your food pipe.

1122
00:58:47.804 --> 00:58:51.484
So the Achilles' heel of catheter ablation for atrial fibrillation

1123
00:58:51.584 --> 00:58:55.304
was actually damaging the esophagus, which can be

1124
00:58:55.344 --> 00:58:56.494
catastrophic. And

1125
00:58:57.364 --> 00:59:01.264
we don't know the exact number, but there are chances of development of what we

1126
00:59:01.324 --> 00:59:04.384
call atrioesophageal fistula. That's the worst

1127
00:59:05.684 --> 00:59:07.754
case scenario from an ablation procedure.

1128
00:59:07.794 --> 00:59:11.074
So you essentially create a hole between the food pipe and the heart.

1129
00:59:11.074 --> 00:59:11.744
Food pipe and the heart-

1130
00:59:11.864 --> 00:59:12.324
That's a problem

1131
00:59:12.364 --> 00:59:15.733
... which is pretty much catastrophic, and the mortality is above 90%.

1132
00:59:16.104 --> 00:59:17.664
Fortunately, touch wood, has never happened.

1133
00:59:17.724 --> 00:59:21.524
Again, that's where the field has moved away from radiofrequency to

1134
00:59:21.584 --> 00:59:23.944
pulse field. Pulse field ablation is cardioselective.

1135
00:59:23.964 --> 00:59:26.164
It spares the esophagus to the most part.

1136
00:59:26.754 --> 00:59:30.224
And that's why the procedure's becoming faster and much more safer now.

1137
00:59:30.804 --> 00:59:34.444
And once we do the procedure, we take all the catheters out, and then

1138
00:59:35.184 --> 00:59:38.514
we have groin management. And most patients are going home within three hours after

1139
00:59:38.544 --> 00:59:39.114
the procedure.

1140
00:59:39.404 --> 00:59:40.204
So same-day discharge.

1141
00:59:40.224 --> 00:59:42.994
Same-day discharge on pretty much 90% of the patients.

1142
00:59:43.024 --> 00:59:46.904
Unless you have a severe heart failure or you're really old or frail, then we

1143
00:59:46.964 --> 00:59:49.504
usually keep them in the hospital. And the recovery is fast.

1144
00:59:49.724 --> 00:59:53.364
Within three to four days, we tell you not to drive, not to put too much pressure

1145
00:59:53.384 --> 00:59:55.084
on your groin, and you're back to your normal lifestyle.

1146
00:59:56.476 --> 00:59:57.796
But that's what ablation entails.

1147
00:59:58.256 --> 01:00:00.016
What are some of the other risks for the procedure?

1148
01:00:00.216 --> 01:00:03.896
So again, the common risks usually are from the groin access.

1149
01:00:04.196 --> 01:00:07.336
We are accessing your veins. Even though we are using, these days we call the

1150
01:00:07.396 --> 01:00:09.936
ultrasound, we know exactly where to put the needle in.

1151
01:00:10.396 --> 01:00:12.996
But hematoma formation, blood clotting,

1152
01:00:14.396 --> 01:00:17.356
or injuring the artery is one of the risk factors.

1153
01:00:18.036 --> 01:00:21.696
During the procedure, the biggest risk is what we call thrombus

1154
01:00:21.756 --> 01:00:25.396
formation or a clot formation on these devices we are putting in your heart.

1155
01:00:26.116 --> 01:00:29.476
So when we do your procedure, your blood is absolutely thin.

1156
01:00:29.756 --> 01:00:33.736
We use a drug called heparin, so you're fully heparinized for the duration of

1157
01:00:33.776 --> 01:00:37.376
the procedure so that you don't form a blood clot and don't cause a stroke.

1158
01:00:37.416 --> 01:00:40.116
So stroke is a risk from the procedure.

1159
01:00:40.836 --> 01:00:43.896
The other risk is we are moving, heart is a beating structure, right?

1160
01:00:43.976 --> 01:00:46.856
So we are pushing these catheters inside your heart.

1161
01:00:47.436 --> 01:00:51.296
These catheters can make a hole. The upper chambers are very thin-walled structure

1162
01:00:51.376 --> 01:00:55.336
compared to the bottom chambers. So we can cause what we call bleeding

1163
01:00:55.676 --> 01:00:59.596
into the outside of the heart, which can cause pericardial tamponade,

1164
01:00:59.656 --> 01:01:03.496
which can be life-threatening and can cause much problems.

1165
01:01:03.556 --> 01:01:07.446
So those are the main risk from the procedures are vascular complications,

1166
01:01:07.996 --> 01:01:10.276
stroke during the procedure, or cardiac tamponade.

1167
01:01:10.736 --> 01:01:13.696
Are these high percentage complications or uncommon?

1168
01:01:13.956 --> 01:01:17.066
These are uncommon. The numbers in high volume centers, if you're doing a lot of

1169
01:01:17.116 --> 01:01:18.936
procedures and you're using all your

1170
01:01:20.276 --> 01:01:23.736
checks and balances, the risk is less than 2 to 3% for most of these

1171
01:01:23.756 --> 01:01:24.406
complications.

1172
01:01:25.346 --> 01:01:28.956
And you said you go home the same day for most patients.

1173
01:01:29.216 --> 01:01:29.476
Correct.

1174
01:01:30.056 --> 01:01:32.986
Any particular downsides after the ablation?

1175
01:01:34.496 --> 01:01:37.936
That's a great question. So again, it all depends on at what stage of the AFib

1176
01:01:37.996 --> 01:01:41.976
you're ablating, right? So when we are doing ablations for paroxysmal AFib

1177
01:01:42.116 --> 01:01:45.976
or when your AFib is coming and going, usually those ablations

1178
01:01:46.016 --> 01:01:48.936
we are ablating the pulmonary veins. We call pulmonary vein triggers.

1179
01:01:49.616 --> 01:01:52.756
So the ablation is very focused, and we're not creating too much scar

1180
01:01:52.856 --> 01:01:56.486
tissue. The longer you're in AFib, what we call long-standing persistent atrial

1181
01:01:56.516 --> 01:01:59.156
fibrillation, the atria, the top chambers are very enlarged.

1182
01:02:00.336 --> 01:02:04.215
Again, the data has never shown. There are a lot of trials, other than ablating the

1183
01:02:04.236 --> 01:02:08.036
pulmonary vein tissues, no other strategy has ever shown to

1184
01:02:08.096 --> 01:02:09.216
improve

1185
01:02:10.016 --> 01:02:11.276
the recurrence of atrial fibrillation.

1186
01:02:11.356 --> 01:02:15.096
But invariably, we end up ablating more tissue based on the

1187
01:02:15.136 --> 01:02:19.116
3D map we have. So the more scar you have, those scar areas

1188
01:02:19.156 --> 01:02:22.436
can harbor AFib. It can promote AFib.

1189
01:02:22.456 --> 01:02:25.936
So we end up ablating the back of the heart, called the posterior wall isolation.

1190
01:02:26.376 --> 01:02:29.606
We're ablating a lot of flutters. These patients tend to go into many different

1191
01:02:29.636 --> 01:02:33.296
fast heart circuits. So the more you ablate, you're creating more scar

1192
01:02:33.336 --> 01:02:35.926
tissue. And whatever is ablated is not going to beat.

1193
01:02:36.736 --> 01:02:40.356
So if you ablate, keep on ablating, ablating, ablating, if the whole atrium

1194
01:02:40.436 --> 01:02:43.856
is pretty much scarred and ablated, those

1195
01:02:43.896 --> 01:02:47.776
atrias do not contract. So you can develop what we call atrial

1196
01:02:47.836 --> 01:02:49.876
myopathy. They call it stiff heart syndrome.

1197
01:02:50.416 --> 01:02:52.756
The people can develop heart failure symptoms.

1198
01:02:52.826 --> 01:02:56.056
They tend to retain more fluid in their lungs, so they start developing heart

1199
01:02:56.096 --> 01:02:56.776
failure symptoms.

1200
01:02:58.956 --> 01:03:02.516
But on the flip side, if you stay in AFib, you will still scar the

1201
01:03:02.536 --> 01:03:03.056
atria.

1202
01:03:03.516 --> 01:03:03.706
Correct.

1203
01:03:03.736 --> 01:03:04.776
And you can still develop it.

1204
01:03:04.816 --> 01:03:05.606
Correct. The famous

1205
01:03:07.356 --> 01:03:07.876
statement

1206
01:03:08.896 --> 01:03:12.816
by one of the giants in the EP field is the goat model

1207
01:03:12.856 --> 01:03:16.536
of AFib. So they discovered they put goats into AFib, induced

1208
01:03:16.596 --> 01:03:19.956
AFib, and the longer these goats, this is like 30, 40 years

1209
01:03:20.016 --> 01:03:22.856
ago, they stayed in AFib, they tend to have more AFib.

1210
01:03:22.896 --> 01:03:25.816
So there's a term called AFib begets AFib.

1211
01:03:26.176 --> 01:03:30.136
So whatever starts the AFib, but once you go in AFib and you stay in, the

1212
01:03:30.196 --> 01:03:33.596
fact that your heart is in irregular rhythm starts

1213
01:03:33.636 --> 01:03:37.136
changing your own cells at a cellular level.

1214
01:03:37.916 --> 01:03:39.656
So you're right. AFib creates scar.

1215
01:03:39.736 --> 01:03:41.316
Atrial fibrillation can cause the

1216
01:03:43.036 --> 01:03:43.976
chambers can get bigger,

1217
01:03:45.876 --> 01:03:48.276
promotes more scarring. So it's all connected.

1218
01:03:49.196 --> 01:03:53.076
So let's go a step further. Someone who's had AFib for a long time or is

1219
01:03:53.116 --> 01:03:56.826
too old, is there such a thing as too sick or

1220
01:03:56.916 --> 01:03:59.856
too old for AFib ablation? Do you offer it to everyone or?

1221
01:04:00.496 --> 01:04:04.416
Again, this is per patient. When they come to my clinic, we have to

1222
01:04:04.436 --> 01:04:07.716
assess those risk factors, right? Is this patient able to lay flat?

1223
01:04:08.216 --> 01:04:10.436
Is the patient able to tolerate the sedation?

1224
01:04:10.496 --> 01:04:13.436
Remember, for me to do the procedure, I don't want you to move.

1225
01:04:13.516 --> 01:04:14.896
We have to create a map of your heart.

1226
01:04:15.255 --> 01:04:18.076
So most patients require deep sedation or anesthesia.

1227
01:04:18.736 --> 01:04:22.676
And if your heart pumping is weak, so people who have severe heart failure, usually

1228
01:04:22.696 --> 01:04:26.056
those patients will succumb to the anesthesia than the procedure itself.

1229
01:04:26.456 --> 01:04:30.236
So you have to be in a good shape, a decent shape for me to put you on the table

1230
01:04:30.436 --> 01:04:34.176
to do the procedure. In terms of age, frailty

1231
01:04:34.216 --> 01:04:38.076
index comes into if you are a thin, old, small

1232
01:04:38.136 --> 01:04:42.046
female, we know that those patients are at a higher risk of what

1233
01:04:42.116 --> 01:04:45.996
we call cardiac tamponade. So the risk of perforation becomes an issue.

1234
01:04:46.116 --> 01:04:49.896
Age is not becoming a bigger

1235
01:04:50.156 --> 01:04:53.596
impediment to the procedures. I have done ablations on patients who are 85, but

1236
01:04:53.606 --> 01:04:57.296
they're good, functional 85, have a good lifestyle.

1237
01:04:57.336 --> 01:04:58.876
They want to do more.

1238
01:04:59.916 --> 01:05:03.756
So yes, the ablation is being available to more older population.

1239
01:05:04.996 --> 01:05:06.356
Can pacemakers prevent AFib?

1240
01:05:07.516 --> 01:05:10.306
Pacemakers by itself do not prevent AFib, but there is a

1241
01:05:11.256 --> 01:05:15.096
treatment strategy we use when everything fails or patients who are very frail,

1242
01:05:15.176 --> 01:05:19.076
or especially in extremes of ages, there is a procedure we do what we call AV

1243
01:05:19.176 --> 01:05:21.796
node ablation. Remember I talked about the wire which connects the top to the

1244
01:05:21.836 --> 01:05:25.296
bottom? So in those patients, we abandon rhythm control

1245
01:05:25.396 --> 01:05:29.016
strategy. Means they will stay in AFib forever, but

1246
01:05:29.356 --> 01:05:33.276
we will make their bottom chambers, they don't race, they don't

1247
01:05:33.336 --> 01:05:37.256
go slow, they don't go fast. How you achieve is by ablating

1248
01:05:37.776 --> 01:05:41.596
or burning the AV node. But because you're burning the main wire which

1249
01:05:41.676 --> 01:05:45.446
connects the top to the bottom, the bottom chambers cannot beat on its own.

1250
01:05:45.716 --> 01:05:49.056
So to do that, you have to implant what we call a permanent pacemaker,

1251
01:05:49.676 --> 01:05:52.996
which is a wire. We have to make an incision and put this device called the

1252
01:05:53.016 --> 01:05:56.956
pacemaker. So it's called an AV node ablation pace and ablation strategy.

1253
01:05:57.596 --> 01:05:59.596
Usually, actually, is one of the most effective,

1254
01:06:01.136 --> 01:06:04.736
one of the strategies which has shown to improve the most quality of life

1255
01:06:04.756 --> 01:06:08.536
in these elderly patients post-ablation. Because their heart's never going to race.

1256
01:06:08.556 --> 01:06:10.696
They never get hospitalized for a racing heart.

1257
01:06:10.716 --> 01:06:12.116
Their heart failure improves, actually.

1258
01:06:12.446 --> 01:06:15.936
And there is something about making the ventricles or the bottom

1259
01:06:16.016 --> 01:06:19.816
chamber beat at a regular rate. That itself actually has been

1260
01:06:19.856 --> 01:06:22.456
shown to prevent fibrosis and improve heart failure.

1261
01:06:23.468 --> 01:06:26.648
So you mentioned a little while ago, I just wanted to touch up on this, that

1262
01:06:26.788 --> 01:06:30.648
treating AFib or ablation can reduce the risk of

1263
01:06:30.708 --> 01:06:31.988
dementia. Is that correct?

1264
01:06:32.508 --> 01:06:33.948
That's correct. Data is coming in.

1265
01:06:34.128 --> 01:06:35.228
The AFib itself,

1266
01:06:36.108 --> 01:06:39.988
remember it's all inflammation. We have no idea what is changing.

1267
01:06:40.148 --> 01:06:42.968
There's autonomic tone, the sympathetic tone, everything is changing.

1268
01:06:43.618 --> 01:06:47.328
This vascular stasis, atrial fibrillation causes stasis of the blood.

1269
01:06:47.928 --> 01:06:50.588
People are developing most likely microthrombi.

1270
01:06:50.628 --> 01:06:53.488
You don't have to have a full stroke, but you have silent strokes.

1271
01:06:53.858 --> 01:06:57.568
And any time a piece of a brain tissue has a stroke or doesn't

1272
01:06:57.628 --> 01:07:01.368
work, that area's gone, and that can become dementia.

1273
01:07:01.468 --> 01:07:05.408
So there is data coming on. Patients who have early an ablation done

1274
01:07:05.788 --> 01:07:09.608
actually we're changing the trajectory of developing downstream dementia.

1275
01:07:09.828 --> 01:07:11.028
Because remember, they're all connected.

1276
01:07:11.228 --> 01:07:15.008
These are the patients who have already the higher age risk. They have diabetes.

1277
01:07:15.488 --> 01:07:17.878
They have sleep apnea. All these things are promoting

1278
01:07:19.048 --> 01:07:20.268
the neurological changes.

1279
01:07:21.528 --> 01:07:25.008
Great. So AFib ablation, in your mind,

1280
01:07:25.308 --> 01:07:29.188
is it fair to say it's a first-line strategy for most patients now?

1281
01:07:29.508 --> 01:07:32.188
It is becoming first line for most patients now, absolutely.

1282
01:07:32.768 --> 01:07:35.568
Back in the day, we have to show that patient failed.

1283
01:07:35.808 --> 01:07:39.488
You have to fail one anti-arrhythmic drug before you even qualify for an

1284
01:07:39.528 --> 01:07:43.168
ablation. But now, based on the guidelines, it's a class one indications for

1285
01:07:43.708 --> 01:07:47.568
most paroxysmal atrial fibrillation, early persistent atrial fibrillation, patients

1286
01:07:47.588 --> 01:07:50.488
who have heart failure. There is a trial called

1287
01:07:50.548 --> 01:07:52.148
CASTLE-AF

1288
01:07:53.008 --> 01:07:56.848
shown that patients with advanced heart failure, actually, who end up getting

1289
01:07:56.868 --> 01:08:00.388
atrial fibrillation ablation, their changes actually, they improved heart failure.

1290
01:08:00.448 --> 01:08:03.878
In fact, time to transplant and time to ventricular assist devices.

1291
01:08:04.318 --> 01:08:08.168
So there is now randomized data coming, showing that ablation, even a sicker

1292
01:08:08.188 --> 01:08:09.998
population, is actually helping.

1293
01:08:10.628 --> 01:08:14.528
Very interesting. So let's look into the future a little bit.

1294
01:08:16.869 --> 01:08:19.288
Say we are able to look 15 years from now,

1295
01:08:21.108 --> 01:08:24.768
and you're looking back on this, "Can't believe we used to do this." What would

1296
01:08:24.779 --> 01:08:25.088
that be?

1297
01:08:26.348 --> 01:08:30.228
Two things which come to my mind is, as remember I mentioned

1298
01:08:30.248 --> 01:08:30.699
prevention.

1299
01:08:31.008 --> 01:08:31.527
Mm-hmm.

1300
01:08:31.568 --> 01:08:35.409
So can, like you sitting in front of me right now, and if I have something on you,

1301
01:08:35.438 --> 01:08:38.989
I put something on you and predict 10 years from now you're going to develop

1302
01:08:39.088 --> 01:08:41.199
AFib. If we know we can do that,

1303
01:08:42.628 --> 01:08:44.668
then we should start working on prevention.

1304
01:08:45.728 --> 01:08:48.757
So lot of artificial intelligence.

1305
01:08:49.228 --> 01:08:53.159
So AI is able to look at your EKG and actually

1306
01:08:53.168 --> 01:08:56.909
predict your downstream risk of developing myocardial infarction, heart

1307
01:08:56.949 --> 01:09:00.928
attacks, and AFib. There's a Mayo Clinic study, couple of other machine

1308
01:09:01.008 --> 01:09:01.369
language,

1309
01:09:03.208 --> 01:09:06.928
big data EKGs, millions of EKGs. They have

1310
01:09:06.989 --> 01:09:10.008
signatures, like they look at the patients who had AFib and who don't have AFib.

1311
01:09:10.748 --> 01:09:13.949
What are those EKG signatures? So apparently, there is AI-based-

1312
01:09:15.108 --> 01:09:15.529
Algorithms

1313
01:09:15.538 --> 01:09:18.768
... algorithms coming out pretty soon, which will actually predict your risk of

1314
01:09:18.788 --> 01:09:19.608
developing AFib.

1315
01:09:20.548 --> 01:09:24.449
So that's one, AI based. Number two, the AFib ablation

1316
01:09:24.508 --> 01:09:27.068
world is changing, like the therapy one is changing.

1317
01:09:27.848 --> 01:09:31.568
But for me, if I have to predict, I think what the field needs to

1318
01:09:31.648 --> 01:09:35.199
move is patient-specific atrial

1319
01:09:35.208 --> 01:09:36.168
fibrillation treatment.

1320
01:09:37.268 --> 01:09:40.008
What that means is, right now we are ablating tissue.

1321
01:09:40.048 --> 01:09:43.918
We are just basically burning or electro creating a substrate, preventing

1322
01:09:43.949 --> 01:09:47.409
triggers. But AFib is a complex,

1323
01:09:47.489 --> 01:09:51.268
nobody's targeting all the things at the same time,

1324
01:09:51.348 --> 01:09:55.278
right? Whereas the proteomics, the genomics, your genes, all those things

1325
01:09:55.308 --> 01:09:59.008
needs to come together. So the ablation, as I do a lot of persistent

1326
01:09:59.048 --> 01:10:02.148
AFib, so patients come to me who are been in AFib for years and years and

1327
01:10:02.228 --> 01:10:06.148
years. Is there a way, without me going inside

1328
01:10:06.168 --> 01:10:09.748
the heart, can I predict from outside how much ablation I need to do?

1329
01:10:10.228 --> 01:10:14.208
Where should I do an ablation? Or what areas, what nervous system

1330
01:10:14.508 --> 01:10:16.508
we need to modify? So I think that's where the field is.

1331
01:10:16.728 --> 01:10:20.588
I predict in 10, 15 years, we will have those tools that

1332
01:10:20.628 --> 01:10:24.188
this patient needs this ablation at this point in time and this location.

1333
01:10:25.268 --> 01:10:29.188
Is there a world in which we don't even create a scar with burning or pulse field?

1334
01:10:30.128 --> 01:10:33.728
That's a very interesting question, and I think that point goes back

1335
01:10:33.788 --> 01:10:36.568
to modulation of your nervous system.

1336
01:10:36.578 --> 01:10:39.988
There is something with your nervous system, because something triggers your AFib.

1337
01:10:40.028 --> 01:10:43.088
Right now, me and you are in normal rhythm, right? Think about it.

1338
01:10:43.128 --> 01:10:46.948
Your own sinus node is connected to the billions of your top

1339
01:10:46.968 --> 01:10:50.808
chamber, right? So one area in your heart is what we call

1340
01:10:50.848 --> 01:10:52.998
the orchestra. He's the master-

1341
01:10:53.268 --> 01:10:54.668
Mm-hmm. The conductor

1342
01:10:54.677 --> 01:10:58.468
... the conductor, right? So whatever changes that balance of the

1343
01:10:58.488 --> 01:11:01.298
conductor from the rest of the tissue, that promotes arrhythmias.

1344
01:11:01.908 --> 01:11:05.668
If we can figure out a way how that conductor maintains its coherence

1345
01:11:06.128 --> 01:11:09.928
with the rest of the upper chambers, we may have a chance of

1346
01:11:09.968 --> 01:11:12.608
prevention or preventing arrhythmias without burning anything.

1347
01:11:13.668 --> 01:11:13.828
So

1348
01:11:15.328 --> 01:11:17.828
my 45-year-old friend, who

1349
01:11:19.048 --> 01:11:20.188
is a business executive,

1350
01:11:21.068 --> 01:11:24.588
a little bit overweight, not crazy, does exercise two or three times a week.

1351
01:11:24.648 --> 01:11:24.808
Mm-hmm.

1352
01:11:25.788 --> 01:11:26.968
On the weekend, couple drinks.

1353
01:11:29.488 --> 01:11:32.728
Comes and asks me, "Hey, my mom had AFib,

1354
01:11:33.568 --> 01:11:37.448
so I have family history of AFib. What can

1355
01:11:37.488 --> 01:11:40.688
I do to prevent my risk of AFib?"

1356
01:11:41.548 --> 01:11:42.668
And that's a great question, right?

1357
01:11:42.718 --> 01:11:46.568
This 45 year is enjoying life, because if I stop having him drink his

1358
01:11:46.648 --> 01:11:49.628
alcohol, he's going to come to me, "Look, what's the point of living?" Right?

1359
01:11:49.748 --> 01:11:49.968
So

1360
01:11:50.788 --> 01:11:51.108
I think

1361
01:11:52.068 --> 01:11:53.748
we talked about all those risk factors.

1362
01:11:54.208 --> 01:11:54.928
So at least

1363
01:11:55.908 --> 01:11:59.408
if the guy is thinking to prevent AFib, I think that's the winning starting point

1364
01:11:59.428 --> 01:12:01.848
to begin with. At least he start thinking about his own health.

1365
01:12:01.968 --> 01:12:02.038
Mm-hmm.

1366
01:12:02.088 --> 01:12:04.348
That's the biggest thing we all need to do in all our patients.

1367
01:12:04.688 --> 01:12:08.268
Most patients who are coming to us have no clue what their underlying disease

1368
01:12:08.328 --> 01:12:12.058
processes is. So that 45-year-old at least is thinking about it. That's number one.

1369
01:12:12.608 --> 01:12:16.388
Number two, overweight. Hopefully, he start working on that.

1370
01:12:16.548 --> 01:12:20.268
If he's exercising two to three times, maybe we can work on

1371
01:12:20.408 --> 01:12:21.688
getting that weight loss a little bit.

1372
01:12:22.788 --> 01:12:26.307
Third is we talked about mind over the body, right?

1373
01:12:27.012 --> 01:12:30.692
What are his sleep patterns? Which we'll be coming into the questions of variables.

1374
01:12:30.752 --> 01:12:34.232
What are the tools available to this 45-year-old

1375
01:12:34.692 --> 01:12:38.332
who can modify his sympathetic and parasympathetic

1376
01:12:38.432 --> 01:12:41.172
tone? I think that's where I think the key is.

1377
01:12:41.432 --> 01:12:42.592
He's going to drink, he's going to drink.

1378
01:12:42.632 --> 01:12:45.992
As I said, a drink or two is not going to cause much AFib.

1379
01:12:46.682 --> 01:12:50.532
But how is this 45-year-old person

1380
01:12:50.592 --> 01:12:54.252
aging? That is where actually the key is,

1381
01:12:54.832 --> 01:12:56.192
where everything else comes to point.

1382
01:12:56.532 --> 01:13:00.052
Your supplements, your GLPs, your HRVs, your exercise.

1383
01:13:00.652 --> 01:13:03.112
That's what I think the answer to your question should be.

1384
01:13:03.572 --> 01:13:03.672
So,

1385
01:13:04.572 --> 01:13:08.372
your GLPs like Ozempic and Wegovy, they reduce

1386
01:13:08.472 --> 01:13:08.712
weight.

1387
01:13:09.372 --> 01:13:09.402
Mm-hmm.

1388
01:13:09.441 --> 01:13:11.732
And fasting can be used to reduce weight, too.

1389
01:13:11.772 --> 01:13:14.812
Is there any data on fasting and reducing the risk of AFib?

1390
01:13:15.992 --> 01:13:19.952
There is no direct data that I was able to pull up, but again, if the

1391
01:13:20.012 --> 01:13:23.832
fasting reduces your weight, reduces your inflammation, I would

1392
01:13:23.872 --> 01:13:26.952
assume that there should be some positive impact.

1393
01:13:27.612 --> 01:13:30.272
If nothing else, at least, changes your heart rate variability.

1394
01:13:30.352 --> 01:13:32.732
Again, balancing the sympathetic-parasympathetic system.

1395
01:13:33.012 --> 01:13:35.932
But I do not have the evidence directly.

1396
01:13:36.052 --> 01:13:37.542
Is there any data on meditation?

1397
01:13:38.272 --> 01:13:42.252
There is some data. There is the famous study, it's a very tiny, small

1398
01:13:42.272 --> 01:13:43.512
study on yoga.

1399
01:13:43.572 --> 01:13:43.682
Mm-hmm.

1400
01:13:43.932 --> 01:13:46.992
Which is obviously exercise, which is mind-based.

1401
01:13:47.062 --> 01:13:49.312
There is a study on cognitive behavioral therapy.

1402
01:13:49.652 --> 01:13:49.892
Mm-hmm.

1403
01:13:50.132 --> 01:13:53.702
That study did not show any big change in development of atrial

1404
01:13:53.702 --> 01:13:57.672
fibrillation. There's an ongoing yoga study, it's a randomized trial going

1405
01:13:57.732 --> 01:14:01.532
on, patients with atrial fibrillation with yoga versus just routine of

1406
01:14:01.592 --> 01:14:05.432
care. That study is ongoing. But yoga has shown, or the small

1407
01:14:05.492 --> 01:14:09.392
study has shown, the more meditative you get, you change your heart rate

1408
01:14:09.952 --> 01:14:13.652
variability. Your resting heart rate comes down, your blood pressure comes down.

1409
01:14:13.832 --> 01:14:15.792
You feel better. You change your depression.

1410
01:14:15.832 --> 01:14:17.832
Remember, depression and anxieties are all linked.

1411
01:14:17.952 --> 01:14:18.172
Mm-hmm.

1412
01:14:18.412 --> 01:14:20.272
So I think the numbers are small-

1413
01:14:20.702 --> 01:14:20.702
Mm

1414
01:14:20.702 --> 01:14:24.562
... and we don't have a good one particular

1415
01:14:24.592 --> 01:14:27.452
tool that we can prescribe to a patient, "Okay, do this kind of yoga-

1416
01:14:27.712 --> 01:14:27.952
Mm-hmm

1417
01:14:28.032 --> 01:14:29.732
... and you should benefit." But

1418
01:14:30.812 --> 01:14:34.592
in theory, it does make sense that if something makes you more meditative

1419
01:14:34.752 --> 01:14:38.552
and brings your resting heart rate down and makes you more calmer,

1420
01:14:39.152 --> 01:14:42.712
I would assume that should translate into some kind of arrhythmia

1421
01:14:42.772 --> 01:14:43.292
modulation.

1422
01:14:44.972 --> 01:14:46.912
Thank you. That was very insightful.

1423
01:14:47.032 --> 01:14:47.192
So,

1424
01:14:48.212 --> 01:14:52.012
as a part of our conversation, we want to go through

1425
01:14:52.932 --> 01:14:56.072
at least one tech device every so often to tell our

1426
01:14:56.712 --> 01:14:59.532
listeners about this. There are many.

1427
01:15:00.372 --> 01:15:01.832
Tech is coming into health in a big way.

1428
01:15:02.072 --> 01:15:02.262
Correct.

1429
01:15:02.892 --> 01:15:05.112
So, I just saw you wear Whoop.

1430
01:15:05.212 --> 01:15:05.372
Yep.

1431
01:15:05.512 --> 01:15:08.352
I wear the same. So, I just want to go through it.

1432
01:15:08.432 --> 01:15:11.152
What's your experience from a cardiologist standpoint

1433
01:15:12.972 --> 01:15:16.752
when you have Whoop database, what do you see how useful it is?

1434
01:15:17.332 --> 01:15:21.172
I think I should reverse the roles here because you are much better at

1435
01:15:21.272 --> 01:15:25.182
Whoop data, or you have a good analysis of all these variables and

1436
01:15:25.232 --> 01:15:28.872
things like that. But whatever, these devices are helping,

1437
01:15:29.032 --> 01:15:32.552
giving some insight. Remember, all these devices are a

1438
01:15:32.692 --> 01:15:33.272
window

1439
01:15:34.652 --> 01:15:36.312
to your autonomic nervous system.

1440
01:15:36.752 --> 01:15:40.632
And how do we measure that? One of the things I keep saying is the heart rate

1441
01:15:40.672 --> 01:15:42.212
variability, and we talk about it, which is-

1442
01:15:42.352 --> 01:15:44.042
So can we tell people what heart rate variability is?

1443
01:15:44.072 --> 01:15:47.812
It basically is how fast or slow

1444
01:15:48.232 --> 01:15:52.132
each and every heartbeat will change to your body's external

1445
01:15:52.192 --> 01:15:56.082
environment. So, if you're in fight or flight, your heart rate's

1446
01:15:56.092 --> 01:15:58.772
supposed to go up. When you're resting, your heart rate is slowing down, when

1447
01:15:58.792 --> 01:16:02.012
you're sleeping. So how fast that beat-to-beat

1448
01:16:02.052 --> 01:16:05.292
variation can occur is a term called heart rate variability.

1449
01:16:05.352 --> 01:16:09.272
So just to clarify, even when your heart rate is regular,

1450
01:16:09.952 --> 01:16:12.212
every beat is not equally spaced.

1451
01:16:12.221 --> 01:16:12.221
Exactly.

1452
01:16:12.252 --> 01:16:13.612
There is always that variation.

1453
01:16:13.672 --> 01:16:16.152
Variation. Now, that variation is in milliseconds.

1454
01:16:16.332 --> 01:16:18.612
We talk about one-thousandths and thousandths of a second.

1455
01:16:18.912 --> 01:16:22.472
But for each heartbeat, that matters. And there is mathematic tools.

1456
01:16:22.512 --> 01:16:26.332
These devices, they're called SD and N, standard deviation, and root

1457
01:16:26.372 --> 01:16:30.312
mean squares. All these are tools to actually figure out that variability.

1458
01:16:30.372 --> 01:16:33.532
So Apple Watch generates a number, Whoop generates a number.

1459
01:16:33.612 --> 01:16:35.362
Most variables are generating that number.

1460
01:16:35.402 --> 01:16:39.232
Again, they're looking at your variation in every pulse, and that creates the heart

1461
01:16:39.272 --> 01:16:39.992
rate variability.

1462
01:16:40.872 --> 01:16:44.852
So coming back to the point, any of these tools are giving

1463
01:16:44.872 --> 01:16:45.571
you insights.

1464
01:16:46.472 --> 01:16:50.312
Whoop gives you sleep data. We talk about the various

1465
01:16:50.352 --> 01:16:52.612
phases of sleep. Are we focusing on the sleep?

1466
01:16:52.652 --> 01:16:56.452
So at least now you have a tool which tells you how good your sleep is, how deep

1467
01:16:56.492 --> 01:16:59.932
your REM sleep versus non-REM sleep is.

1468
01:17:01.072 --> 01:17:03.532
But the second question is how are we going to use the data?

1469
01:17:04.032 --> 01:17:04.212
Mm-hmm.

1470
01:17:04.532 --> 01:17:07.372
That's even more important than just getting a variable.

1471
01:17:08.332 --> 01:17:12.092
So, in terms of sleep, I feel knowing

1472
01:17:12.292 --> 01:17:14.312
is half the job, sleep or exercise.

1473
01:17:14.382 --> 01:17:18.232
So Whoop gives you calculated variables on strain and recovery.

1474
01:17:18.772 --> 01:17:22.632
Strain is their kind of algorithmic calculation, which takes into account

1475
01:17:22.672 --> 01:17:26.552
your heart rate, your activity, your respiratory rate,

1476
01:17:26.612 --> 01:17:27.442
your body temperature-

1477
01:17:27.442 --> 01:17:27.452
Temperature

1478
01:17:27.492 --> 01:17:28.992
... the whole thing, how well you recover.

1479
01:17:29.112 --> 01:17:29.352
Correct.

1480
01:17:29.392 --> 01:17:30.092
So it's more for

1481
01:17:31.012 --> 01:17:34.112
athletic sort of performance, but your day-to-day as well.

1482
01:17:34.782 --> 01:17:38.292
And I particularly like the idea of total strain

1483
01:17:38.352 --> 01:17:42.072
because even when you're sitting in a busy boardroom

1484
01:17:42.112 --> 01:17:42.802
conversation,

1485
01:17:44.052 --> 01:17:48.012
you are under a certain amount of strain, and if that's high, that still puts

1486
01:17:48.072 --> 01:17:48.992
a toll on your body.

1487
01:17:49.532 --> 01:17:53.252
Correct. I agree with your point because Apple Watch has all the data, too.

1488
01:17:53.532 --> 01:17:57.472
But then you have to use individual-- You have to piece them together.

1489
01:17:57.492 --> 01:17:57.772
Mm-hmm.

1490
01:17:57.912 --> 01:18:00.812
If we're all busy, who has time to look into all these things?

1491
01:18:00.852 --> 01:18:04.012
So if that tool gives you, "Okay, today was my strain full.

1492
01:18:04.052 --> 01:18:07.302
This is a strain day, this is not a strain day." And you can pinpoint what caused.

1493
01:18:07.792 --> 01:18:11.032
For me, I don't drink alcohol, but every time I

1494
01:18:11.072 --> 01:18:14.932
do, even a glass of wine, my sleep is gone.

1495
01:18:15.152 --> 01:18:16.772
My heart rate variability is

1496
01:18:17.652 --> 01:18:18.732
down the drain. So

1497
01:18:19.832 --> 01:18:21.592
to me, it's definitely helping me.

1498
01:18:21.652 --> 01:18:25.612
Even what tiny things I'm doing is making big changes to my health.

1499
01:18:25.712 --> 01:18:28.112
And over time, remember, it's not one day.

1500
01:18:28.272 --> 01:18:31.512
This is going to collectively, if I keep getting data again and again and again,

1501
01:18:31.592 --> 01:18:35.012
hopefully, I'll have enough impact on my behavior.

1502
01:18:35.102 --> 01:18:36.292
And that's what we want for our patients.

1503
01:18:36.652 --> 01:18:36.872
Mm-hmm.

1504
01:18:37.172 --> 01:18:40.012
These are devices which are easily accessible for most patients now.

1505
01:18:41.372 --> 01:18:43.752
So I think variables are here to stay.

1506
01:18:43.882 --> 01:18:47.772
And then the key is, one, to know the data, and number two is how can we

1507
01:18:47.812 --> 01:18:49.272
tell our patients how to use the data.

1508
01:18:49.932 --> 01:18:50.472
Exactly.

1509
01:18:51.432 --> 01:18:55.272
As far as accuracy is concerned, you're talking about mid to

1510
01:18:55.332 --> 01:18:58.732
high 80s in terms of accuracy in sleep detection for Whoop-

1511
01:18:58.752 --> 01:18:58.852
Correct

1512
01:18:58.872 --> 01:18:59.792
... from what I understand.

1513
01:19:01.192 --> 01:19:01.452
And

1514
01:19:02.412 --> 01:19:06.152
it's good for broad sleep stages compared to the gold standard, which is the sleep

1515
01:19:06.192 --> 01:19:06.512
study.

1516
01:19:06.672 --> 01:19:06.812
Right.

1517
01:19:07.332 --> 01:19:11.172
But from what I could find as more accurate for REM sleep, it may overestimate the

1518
01:19:11.212 --> 01:19:12.192
deep sleep a little bit.

1519
01:19:12.332 --> 01:19:12.932
The Whoop, you mean?

1520
01:19:12.972 --> 01:19:16.772
Yes, the Whoop. But coming to that, of

1521
01:19:16.832 --> 01:19:17.132
course,

1522
01:19:18.352 --> 01:19:20.882
I don't think you want to use these as

1523
01:19:22.912 --> 01:19:26.472
the dictum, "Okay, I got this much today." I think this is consistency of

1524
01:19:26.552 --> 01:19:29.732
wearing and seeing which way your data is tracking day-to-day-

1525
01:19:29.742 --> 01:19:29.792
Right

1526
01:19:29.812 --> 01:19:31.152
... as opposed to an isolated data.

1527
01:19:31.252 --> 01:19:32.512
Right. It's the trend.

1528
01:19:32.652 --> 01:19:32.842
Exactly.

1529
01:19:32.912 --> 01:19:35.732
Are you hitting the right trends? That's what more important is.

1530
01:19:36.312 --> 01:19:40.252
And the other reason I particularly like this is, of course, there is no screen,

1531
01:19:40.332 --> 01:19:41.172
so no distraction.

1532
01:19:41.352 --> 01:19:41.612
Correct.

1533
01:19:41.732 --> 01:19:42.482
The data goes straight to-

1534
01:19:42.532 --> 01:19:44.102
And it's easy to wear. You can sleep with it at night.

1535
01:19:44.452 --> 01:19:47.492
I could not sleep with an Apple Watch, believe me. I tried.

1536
01:19:47.532 --> 01:19:49.632
Well, nothing against that. We use Apple products, but-

1537
01:19:50.652 --> 01:19:50.732
Yeah

1538
01:19:50.752 --> 01:19:53.012
... I particularly like this in terms of fitness tracker.

1539
01:19:53.392 --> 01:19:55.272
We'll talk in our future episode about

1540
01:19:56.332 --> 01:19:59.892
other variables like Oura Ring and see how these two compare.

1541
01:19:59.932 --> 01:20:00.072
Right.

1542
01:20:00.632 --> 01:20:03.132
But all in all, it was a great conversation.

1543
01:20:03.552 --> 01:20:06.572
Thank you so much for taking the time, and

1544
01:20:07.632 --> 01:20:09.912
hope to talk to you soon. Next time we'll talk about pacemakers.

1545
01:20:10.072 --> 01:20:11.252
Thank you for having me. Appreciate it.