Video Overview of Atrial Fibrillation — John D. Day, MD, FHRS
Afib Overview from the 2015 Atrial Fibrillation Patient Conference
September 2, 2015
At the 2015 Get in Rhythm. Stay in Rhythm.TM Atrial Fibrillation Patient Conference, Dr. John D. Day covered:
- What afib is
- What are the symptoms
- How it is diagnosed
- Why it is dangerous
- How widespread it is
- What are the risk factors for it
- How lifestyle affects afib
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About John D. Day, MD, FHRS
Dr. John Day graduated from medical school at Johns Hopkins University. He did his residency in internal medicine, cardiology fellowship and cardiac electrophysiology fellowship training at Stanford University.
Dr. Day started the atrial fibrillation ablation program at LDS Hospital/Intermountain Medical Center. The atrial fibrillation ablation program at Intermountain Medical Center has now become one of the largest atrial fibrillation ablation programs in the world. Dr. Day performs more than 300 atrial fibrillation procedures each year and has personally performed nearly 4,000 atrial fibrillation ablation procedures. Dr. Day currently serves as Director of Heart Rhythm Services at the Intermountain Healthcare.
Dr. Day is board certified in cardiology, and cardiac electrophysiology. He has published more than 100 manuscripts, abstracts, and book chapters and regularly lectures both nationally and internationally on heart rhythm disorders. He is recognized as an international thought leader on atrial fibrillation ablation as well as implantable defibrillators/cardiac resynchronization device therapy. He currently serves as the president of the Heart Rhythm Society.
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Twenty years ago — at the time I was on call and still doing my cardiology training — I was at Stanford University at the time, and it was the middle of the night. And typically, when you're on call, you hope to make it through the night without your pager going off. But in the middle of the night my pager went off. And I looked at it and the telephone number was from my father. You don't ever want to get those calls in the middle of the night.
And as I called my father, he shared with me that my grandmother, Grandma Day as we called her, we had just found her down on the floor unconscious. They had taken her to the hospital and she had had a massive stroke and was diagnosed with atrial fibrillation.
[00:01:00] She had never been in atrial fibrillation before. She was in excellent health, other than a little bit of arthritis and high blood pressure. She was currently serving on the city council, she was very active in politics, the community, and service. But one little stroke, actually it was a big stroke from atrial fibrillation, changed everything.
She didn't ever make it; two days later she passed away. Since that experience, it's changed the way I've approached things. I always knew I wanted to go into cardiology, but atrial fibrillation was something that I knew that there was something we had to do about this, something to try to change this so that other people didn't have to go through the same thing.
[00:02:00] And so as I'm talking with you today and sharing with you some of these thoughts and new ways of looking at things, there are better ways that perhaps we don't have to experience this. Or, if we do have atrial fibrillation, that it can be reversed. And so let me take you on a journey as we go through ways atrial fibrillation can either be prevented or reversed.
But before we get there, first of all I want to disclose, as Mellanie had mentioned, and thanks to Mellanie for inviting me here, I have performed more than 4,000 atrial fibrillation ablation procedures. I've been doing these for the last 16 years since it began. But the thing that I've learned about all of this is that how we live, our lifestyles, our day-to-day choices, have every bit as much to do as to whether or not we can overcome our atrial fibrillation as any high-tech, whiz-bang procedure that we could perform.
[00:03:00] So what is atrial fibrillation? And it doesn't look like it's going to play here. There we go, fantastic. Atrial fibrillation represents total electrical chaos of the upper chambers of the heart, as you can see here. Also, over time as people have atrial fibrillation you will see areas of scarring that develop. This electrical chaos results in the upper chambers of the heart not being able to beat properly. When that happens, strokes can form, blood clots can form. And then if that blood clot happens to make its way out of the heart and to the brain, that's a stroke.
[00:04:00] Also, when the upper chambers of the heart are quivering and beating at very rapid rates, it can cause the lower chambers of the heart to beat very fast, as well. If you've ever taken your pulse through an episode of atrial fibrillation, you'll typically note that it's very fast and very irregular.
What symptoms can this cause? Atrial fibrillation can cause a lot of symptoms. Probably the number one symptom that I hear is fatigue, "I'm tired. I just don't have the energy that I used to have." Number two would be shortness of breath, especially if trying to do something: walking upstairs, trying to move. You just don't have the stamina that you once had. Other common symptoms of atrial fibrillation include chest discomfort or palpitations. Some patients may even pass out or be dizzy or lightheaded. But fatigue and shortness of breath, especially with exertion, these are the symptoms that I hear every day in my practice.
[00:05:00] How do we diagnose atrial fibrillation? Atrial fibrillation is diagnosed by EKG. That could be in your doctor's office, that could be while wearing a heart monitor, that could be even now with some of our smartphone apps. There are several companies that have smartphone apps, and with those smartphone apps you can put your fingers on your smartphone and take your own EKG. But that is how we diagnose it.
Now, with the technology that's available, even implantable, continuously-recording EKG monitors, we can make the diagnosis. In the past there were so many cases of strokes that we didn't know what were the causes. Now with better EKG recording equipment, even on our own phones, we can make these diagnoses much easier.
Why is it dangerous? Why do we even worry about atrial fibrillation?
[00:06:00] The number one fear, like with my grandmother, was the fear of a stroke. And, in fact, atrial fibrillation increases the risk of a stroke five times — this is what we fear more than anything — is to be able to prevent these strokes. Also, atrial fibrillation increases the risk of heart failure by threefold. It doubles your risk of a heart attack. It doubles your risk of kidney failure. Also, atrial fibrillation can cause premature death. So clearly this is something that we want to try and avoid.
Now if you've asked around, and you've probably talked to some of your neighbors, maybe some of your coworkers, family members, it seems like everybody, everyone you talk to, somebody knows someone with atrial fibrillation. Why is this the case?
[00:07:00] We know now from studies that one in every four American adults now, that's one in every four American adults, will have at least one episode of atrial fibrillation over the course of their life.
As doctors, we are seeing more and more cases of atrial fibrillation. I'm seeing younger and younger patients with atrial fibrillation every day in my clinical practice. I'm seeing teenagers now with atrial fibrillation. Why is it so common? We used to think that it was just part of our aging society. That as we're getting older as a country, we're seeing more and more cases of atrial fibrillation. But that's not the case, there's something even more profound going on than just the aging of our population. We are truly seeing an epidemic of atrial fibrillation, and it's not just from age alone.
Now this is a study, you're looking at this, this is a map of the world. And this was by my good friend Dr. Sumeet Chugh at Cedars Sinai in Los Angeles.
[00:08:00] And this was a study that he published within the last year in the most prestigious cardiac medical journal, called Circulation. This work was done as a grant from the Bill & Melinda Gates Foundation. And what you're looking at is a graph of the world. But fascinatingly, you'll look, North America is here in red. Nowhere else in the world is in red. This is the prevalence or this is how many people have atrial fibrillation according to the population.
You'll notice that the prevalence of atrial fibrillation in North America, and especially the United States, is more than double that of Western Europe. It's higher than South America, Africa, and it's much higher than Asia. Why? Why is the United States or why is North America the atrial fibrillation capital of the world?
[00:09:00] We are a melting pot, people come from all over the world, they immigrate to the United States. What happens when they come to the United States that makes their risk of atrial fibrillation go so high?
If we look at the rising incidence of atrial fibrillation in developed countries versus developing countries over the last 20 years, we'll note that the incidence of atrial fibrillation has increased 71% in the developed world. While it's also happening in the developing world, it's only at 11%, at a much lower rate. Why is it that atrial fibrillation is so common in the United States? Why is it that the developed world seems to be cursed with atrial fibrillation? What is it that makes it so common?
It gets even more striking when we look at Asia compared to the United States.
[00:10:00] And this is from the same manuscript from Sumeet Chugh from the Bill & Melinda Gates Foundation grant looking at the incidence of atrial fibrillation, comparing Asia versus North America. And what is quite striking as you look at this is, for men, atrial fibrillation is eight times more common in the U.S. than it is in Asia. For women, it is ten times more common. How can you explain a tenfold difference? What is going on here?
Now these data are quite interesting. This is from the University of California at San Francisco, from my friend Greg Marcus, from data that he did. And this was a fascinating study. They gathered everyone in the state of California in the Medicare population, looked at every case of atrial fibrillation. They had nearly 14 million people that they looked at, 375,000 new cases of atrial fibrillation, and they broke these out by race.
[00:11:00] Now when you look at these, whether you're Asian, Hispanic, black, your risk of atrial fibrillation in California is about the same. Caucasians are a little bit higher, and we know that. Caucasians are genetically predisposed to have a little bit higher rates of atrial fibrillation. But my point is, when people are living in their original country, for example Asia, compared to the United States, there's a tenfold difference. But once they move to California, they lose that protective effect. And it's not just California, it's anywhere in the United States.
So why is it that when people are in their native countries their risk of atrial fibrillation is so much lower, and then once they immigrate to the United States they become like every other American with high rates of atrial fibrillation? What is it? Is it something in our water; is it something in the air? Is it something about the way we live? How do you explain a tenfold difference?
[00:12:00] Now certainly you could argue that there is a condition called reporting bias. What this means is maybe in Sub-Sahara Africa we're not counting up every single person who has atrial fibrillation. There are so many other things we're worried about in Africa: Ebola, HIV. Maybe we're missing a few cases of atrial fibrillation. And I'll give you that. But in the developed world, whether that be in Western Europe, Japan, some of these others, you have fantastic public health programs. We aren't seeing that same reporting bias that you might see in Sub-Sahara Africa, for example.
What I'm going to argue is that there is a different lifestyle. That our lifestyles, the decisions that we make each and every day may have more to do with atrial fibrillation than we had previously imagined.
[00:13:00] Well, one way to try to get out this issue of reporting bias is to do an EKG study. In other words, gather everybody in a population, do an EKG, and then count up how many cases of atrial fibrillation that you have. And, in fact, these studies have been done. We know that atrial fibrillation increases with age. So if we gather our oldest citizens, and in that case that would be our centenarians, and we do an EKG on every centenarian, we can easily add up how many cases of atrial fibrillation. And, in fact, those studies have been done. And when those studies have been done, you see results similar to what we have here on the screen.
In a U.S. population, if you gather up (and these are actually published medical studies) all the centenarians in an area and do an EKG, in this study you can see that 27% of these centenarians in the U.S. had atrial fibrillation.
[00:14:00] When you repeat this study with a Danish population, you see 12%. And you know what, that goes right in line with the studies that I presented when we looked at the global burden of atrial fibrillation. Rates of atrial fibrillation are about twice that in the United States and Europe. However, in Bama, China...
Now Bama, China is a county in China, and I'm going to talk with you a little bit about this. It's a small, rural county in China near the Vietnam border in Southwest China. When they repeated this study in a centenarian population, they only had three centenarians with atrial fibrillation. Once again, roughly about a tenfold difference. And so these data would argue that maybe it wasn't so much of a reporting bias, maybe our way of life has more to do with atrial fibrillation than we realize.
[00:15:00] So could it be our lifestyle? I'm going to take you, just digress here for a moment. For the last few years... In fact, I hit one of my own health crisis a few years ago. At the age of 44, I found myself on multiple medications with an autoimmune disease, high blood pressure, high cholesterol, a number of other problems. Fortunately I have not had atrial fibrillation, but I was certainly heading down that pathway, and as I was searching for answers.
I speak fluent Chinese and travel to China regularly. I think they like me in China because I'm one of the few Caucasian doctors that can give his cardiac lectures in Chinese. But while traveling there, I heard of this small village where people don't seem to get sick. That they can live these remarkably long and healthy lives free of chronic diseases, free of medications, free of surgeries, free of having to see the doctor's office.
[00:16:00] And, in fact, they're often out working in the fields until their 90s or their 100s. And this was an area that I had to see it.
And so we put together a research team and for the last nearly four years we've been researching this small, remote mountainous community in Southwest China near the Vietnam border. And in this community you don't see atrial fibrillation, among many other conditions.
This is in the community, this is their daily commute. They're not hopping in their cars, getting stressed out in traffic, breathing the potential fumes coming from all the traffic. But this is their morning commute. This is an older women carrying a 70-pound load of vegetables on her back going up and down the mountain. This is the way they have fished the river in this village for millennia catching these small fish that they'll eat the same day that are very oily fish, high in the good, healthy fish oils.
[00:17:00] Here they are with the daily catch. Here's a woman collecting vegetables that day. All the vegetables that they eat, it's primarily a plant-based diet. On the day they pick their vegetables is the day that they eat them, naturally organic. A much peaceful, slower, more harmonious way of life, if I can use that term.
This is a typical meal there. All of the people will gather together — four or five generations all living in the same home. Fellow neighbors will come over to dinner, everybody knows everyone, and it's a very tight-knit community. Could all of these factors be at play as to why we don't see atrial fibrillation in a village like this? Well, this village led us on a journey.
[00:18:00] And, in fact, I do have a book that's going to be coming out in the next year or so from HarperCollins going through our experiences here in this village, my own personal health turnaround, and the lessons that we learn from this village that can help us. Not only with atrial fibrillation, but to help us in preventing other forms of heart disease, cancer, autoimmune diseases, etc.
So, getting back to my question, can atrial fibrillation be eliminated? And I'm going to run through these ten items and make the argument that 90% of atrial fibrillation can be prevented. Or, if you already have atrial fibrillation, if changes are made fast enough, that it can be reversed before it becomes permanent or irreversible. And these ten factors are: number one, genetics; smoking; hypertension; alcohol; stimulants; sleep deprivation; diabetes; stress; physical activity; or obesity. And I'm going to run through each of those right now.
[00:19:00] Number one, genetic factors. I love this photo. This photo shows, as you can see, a pencil eraser erasing away our genome. While we cannot actually change our genes, we can change which genes are turned on and which genes are turned off. This is a process called epigenetics. This is the number one determinant of our health and our longevity: which genes we turn on, which ones we turn off.
Now as you might imagine, with my grandmother having suffered atrial fibrillation and it took her life, I was quite concerned, "Am I going to develop atrial fibrillation, as well?" And so I had my genome sequenced through 23andMe. Fortunately, while I did have a lot of bad genes — and if you follow me on my blog, I keep revealing over time the number of bad genes that I have — but fortunately, when it comes to atrial fibrillation, I did get a good deal in life.
[00:20:00] And this is one, the Gs273 gene. And there are two genes for atrial fibrillation that are identified on this $99 consumer genetic test through 23andMe, and fortunately I got the two good ones.
And so with this, even though I am Caucasian, my risk of atrial fibrillation is 18% lower. I also discovered, through this test, that I'm 97% European and, as we know, Caucasians are more likely to develop atrial fibrillation. However, I also discovered that I'm 3% Neanderthal. So if you think that I'm a little bit strange or have some weird quirks here today, it must be from that 3% Neanderthal genes that I have.
And according to 23andMe, I am an outlier; I have a lot more of the Neanderthal genes than is typical.
[00:21:00] But based on my genetic analysis with the two genes that they screen for atrial fibrillation with 23andMe, I'm at an 18% lower risk of developing atrial fibrillation. But the key is, whether you have the afib genes or not, the number one factor of whether those genes will cause atrial fibrillation is our lifestyles. Our lifestyles determine which genes are turned on and which genes are turned off.
Number two, smoking. Now I'm not going to dwell a whole lot here. Anyone who cares enough about their health, and I know you care about your health because you are here with us today, this is not an issue for you. But perhaps there are people in your life that are still struggling with this addiction. We do know from the data that smoking is a powerful risk factor for atrial fibrillation.
[00:22:00] Smoking causes what we call oxidative stress, or rusting, throughout our body. Rusting of the brain is Alzheimer's disease; rusting of the heart is atherosclerosis, or plaque build-up; and that same rusting can also cause atrial fibrillation.
From this large study that was published a few years ago, we know that active smokers are more than twice as likely to develop atrial fibrillation. If you are a smoker, quit now. If you stop smoking, you can significantly reduce that risk. And, in fact, from this study you can see that you can get a 36% risk reduction of developing atrial fibrillation by stopping smoking and stopping it now.
Number three, hypertension or high blood pressure. This is common. I had this, as well. Before I hit my health turnaround, my blood pressure was very high. I was actually on medications for high blood pressure.
[00:23:00] Fortunately, through changing my lifestyle, I was able to drop my blood pressure more than 30 points and I'm now totally medication-free of everything. But high blood pressure is a powerful [trigger for atrial fibrillation.
Studies show that high blood pressure increases your risk of atrial fibrillation by 56%. Personally, I am concerned with the current health guidelines. And, in fact, if you suffer from atrial fibrillation, with the most recent guidelines that have gone out to doctors, especially primary care physicians, even if you have high blood pressure, your doctor may now ignore your high blood pressure. This is not right when it comes to atrial fibrillation. That stress, having your heart pump against that stress hour after hour, day after day, wears out the heart and can cause atrial fibrillation.
[00:24:00] The current guidelines don't report that you don't need to treat high blood pressure unless your blood pressure is higher than 150 over 90 in people over age 60. This is too high if you have atrial fibrillation. This is just going to cause more wear and tear, and potentially scarring, on the heart.
Number four, alcohol. Now we all know that if you drink too much, your heart may go out of rhythm, it's even called holiday heart. Where, especially young people, go out drinking, partying, and then the next day they go into atrial fibrillation. But there's more to it than just this.
[00:25:00] In the most recent study that was published in the Journal of the American College of Cardiology — and in this study they gathered all the studies that had been published on alcohol and atrial fibrillation — they found that even just one drink a day increased your risk of atrial fibrillation by about 10%. So any alcohol may be a risk factor for atrial fibrillation.
Now certainly, for those of you with atrial fibrillation, you know whether that one drink, two drinks, might trigger afib for you the next day. If it is a trigger for you, it may be something you want to look at. If it doesn't seem to be a trigger, then keeping it in moderation may be just fine.
Number five, stimulants. You've probably seen the news, all these reports of energy drinks in young kids and what it's doing to their hearts. There are actually even cases of “Red Bull atrial fibrillation.” If you look through case reports, you are seeing more of these published.
[00:26:00] There are actually ongoing studies to look at whether Red Bull, in particular, is a potential risk factor for atrial fibrillation. So stay tuned.
What I can tell you in my own practice is I've seen a number of young people, especially young men. It's often combining a few things together: they have their energy drinks; then maybe they're on ADHD medications, which are stimulants; maybe they're not getting enough sleep; they're stressed out. And I am seeing a number of cases of atrial fibrillation in young otherwise healthy men who like their sports drinks. Now, whether it's the sugar load in these sports drinks, whether it's the taurine, whether it's the caffeine, we don't know for sure.
When it comes to coffee, there have been a lot of studies looking at it. Fortunately, the data seems to be mixed; we don't see a strong signal with coffee.
[00:27:00] There are some studies that suggest that perhaps it increases the risk of atrial fibrillation; other studies don't suggest any correlation. So I would say look at yourself — if the caffeine in chocolate or that cup of coffee triggers afib, then that might be an important trigger for you and something to look at. If it doesn't seem to play a role, then as long as it's in moderation, it seems to be okay.
Number six, sleep deprivation. Now how many of you have heard of sleep apnea? Good, I'm seeing most of your hands go up. If you have atrial fibrillation, you should be screened for sleep apnea. What is sleep apnea? Sleep apnea is where you stop breathing in the middle of the night. What happens when you stop breathing? The oxygen levels plummet, it puts a stress on the heart, and it can cause heart failure, high blood pressure, and atrial fibrillation.
[00:28:00] You really don't need anything high-tech to make the diagnosis. The sleeping partner can make the diagnosis 99% of the time. Why is that? Typically, these patients snore like a train and they stop breathing in the middle of the night. So, if your spouse or loved one tells you that you snore, you stop breathing, then you gasp in the middle of the night, you probably have sleep apnea.
Sleep apnea increases your risk of atrial fibrillation four- to fivefold. If you have atrial fibrillation, get screened for sleep apnea. If you have sleep apnea, get it treated. The good news is, oftentimes with weight loss, sleep apnea is reversible, or learning to sleep on your side. There are also ways of dealing with this. We do know that if you choose to have an ablation, that if you have sleep apnea, getting it treated can double the chances of a successful procedure.
[00:29:00] So if you have atrial fibrillation, get screened. If you have sleep apnea, don't ignore it.
What about sleep deprivation in general? Now, you may be wondering, what's the link here between the Kennedys and Marilyn Monroe. Well, I don't need to tell you what the link might have been, who was sleeping with whom, but what I can tell you is that we sleep, on average, two hours less than we slept in the 1960s. In the 1960s, the average American slept eight and a half hours. Today, the average American sleeps six and a half hours. Acute sleep deprivation increases your risk of developing atrial fibrillation by more than threefold.
What we don't know yet, the studies haven't been done, if we can get more sleep, can we reverse atrial fibrillation. So sleep apnea, not sleeping enough, these are all risk factors for atrial fibrillation.
[00:30:00] So if you want to stay healthy and get your afib under control, make sure you are getting rejuvenating, restorative sleep each night.
Number seven, diabetes. Now, in addition to atrial fibrillation, we are also seeing a diabetes epidemic over the last 20 years in the U.S. In fact, the rates of diabetes have gone up 75%. With diabetes, if you have a diagnosis of diabetes, your risk of atrial fibrillation has just gone up 40%.
From studies, we also know hemoglobin A1C — that is a blood test your doctor can do that measures how much sugar particles are on your red blood cells, so it gives you roughly a three-month average of what your average blood sugar levels are — we know from this study that the higher your hemoglobin A1C, the more sugar you have in your blood, the higher your risk of atrial fibrillation.
[00:31:00] Also, the more years you are diabetic, the greater your risk. So if you have diabetes, get it treated. You may even be able to reverse it with lifestyle changes. Get it under control. That could also be a factor of what's causing atrial fibrillation.
How many of you have ever wondered if stress causes afib? I'm seeing most of the hands go up. What happened when you asked your doctor that? Did they shrug their shoulders? Did they blow it off? Well, it turns out stress is more important than we know it is. In fact, stress in many studies has been reported to be the cause of 75% of all doctor visits in the U.S. Let me repeat that. 75% of all doctor visits in the U.S. are felt to be due to stress. We are the most stressed out nation in the world. What's going on here?
[00:32:00] How does that affect us? So let me talk about stress.
In Sweden, they looked at what is the risk of job stress in Sweden. Now you're looking at this photo and you're probably saying, "What kind of stress can you have if you live in a beautiful place like this?" Well, they actually looked at it and they defined a high-stress job as one where you have a lot of pressure and low decision latitude. Kind of sounds like being a doctor now with all the regulations that are put upon us — lots of pressure and insurance companies and government and everything don't allow us to practice the way we feel that may be the best for our patient.
So people who reported a high-stress job — they randomly selected about 7,500 men and followed them for seven years — those who reported a high-stress job were 32% more likely to go into atrial fibrillation over the next seven years.
[00:33:00] My good friend Rachel Lampert at Yale University recently published a study in the Journal of the American College of Cardiology where they looked at daily emotions and the risk of going into atrial fibrillation. So they had an electronic diary where people would report how they were feeling — whether they were feeling happy, sad, depressed, anxious, etc. — and then looked at whether they would go into atrial fibrillation as recorded by a monitor that day.
Interestingly, if you look at this, if people reported sadness, so if you woke up feeling sad, you were five and a half times more likely to go into afib that day. If you woke up feeling angry, stressed, impatient, or anxious, you were three to four times more likely to go into afib that day. Interestingly, if you woke up feeling happy, it was highly unlikely that you would have afib that day.
[00:34:00] So our daily emotions can determine whether or not we have an afib episode.
So, learning to manage stress, anger, these are all critically important. Fascinatingly, hunger did not seem to be a trigger for atrial fibrillation. So if you're feeling hungry, that seems to be okay. But if you're feeling sad, angry, stressed, impatient, or anxious, that's not a good sign.
Now what happens the day after? Now this is fascinating. If, say, you reported feeling angry or stressed on a Monday, does that increase your risk, say, on Tuesday, the following day? And, in fact, from the same study it does. And that was especially the case with anger and stress.
[00:35:00] So if you are feeling stressed out today, not only are you highly likely to go into afib today, your risk of going into afib is even higher tomorrow, even if you're not feeling stress tomorrow. So there's a residual effect. Whether it's all the cortisol, all of the adrenaline, there is a residual effect. So learning to control our emotions, having a healthy mindset can help us to get afib under control.
Along these same lines, my good friend D.J. Lakkireddy at the University of Kansas published a study showing that yoga can be very, very powerful in treating atrial fibrillation. And this was a well done clinical study where they showed that yoga was able to decrease your atrial fibrillation burden by 24%. For many of these patients, yoga was able to put their afib into remission. Yoga is a powerful treatment strategy. This is every bit as powerful as any medication for atrial fibrillation.
[00:36:00] Learning to control our emotions is important if we're going to get afib under control.
Number nine, physical activity. Now, looking at this photo, it seems a bit crazy. And, when in these small, rural villages in China, when I talk with them about exercise, none of them report exercise. They think, "Why would you get in your car, drive to the gym, and then take the escalators up, do your workout, and then get in your car and drive back home? It seems crazy." And so, with this, there's something there — we need to be more active throughout the day. And this is a study showing that if we can go from couch potato to even minimal activity, that we can decrease the atrial fibrillation burden in this study by about 50%.
[00:37:00] Now, on the other end of this spectrum, extreme levels of exercise —Ironman, ultramarathons — actually increase our risk of atrial fibrillation. And this was a study looking at long-distance, cross-country ski racers in Sweden. What they found is, the faster your times, the more races you do, the more likely you are to go into afib. And it's the same thing with long-distance cycling, marathon running, etc. So we know that couch potato is not good for afib and ultra-athlete is not good for afib. The sweet spot seems to be somewhere in between.
Number ten, obesity. Now I showed you this graph at the beginning looking at the global afib burden, and it seems to be centered right here in North America. If I show you a similar map from the World Health Organization looking at the global obesity burden, you'll see that North America is still at the center.
[00:38:00] The Framingham Heart Study was the most famous heart study, where they followed everybody in Framingham, Massachusetts, and now they're even following the next generations. And with regards to atrial fibrillation, and this was a study that was published more than ten years ago in the Journal of the American Medical Association, they found that being overweight increased your risk of atrial fibrillation by 52%. And how this is, and I used a little abbreviation here — sorry, LA stands for left atrium — is that being overweight causes enlargement of the left atrium. This being overweight is a powerful risk factor for atrial fibrillation.
We know that, for every one point your body mass index goes up, which is a function of your height and weight, your risk of atrial fibrillation goes up by 4%. Most recent studies from the Framingham Heart Study tell us that pericardial fat — that we can also develop fat accumulation around the outsides of our heart — this fat can secrete hormones and inflammatory substances which can also push the heart into atrial fibrillation.
[00:39:00] This was a study that was just recently presented at one of our big meetings from Mayo Clinic looking at the role of gastric bypass surgery for atrial fibrillation — a Mayo Clinic study of what is the effect of gastric bypass surgery on atrial fibrillation. And skipping to the chase, you can see here that in the patients who opted for surgery, they had a 12-point reduction in their body mass index. So this is huge, we're talking 100-plus-pounds of weight loss. You can see that their risk of atrial fibrillation didn't change over seven years. Those who did not opt for surgery, their atrial fibrillation rates went up more than fourfold over the next seven years.
[00:40:00] Now these data are the most recent data. This study was just recently published in the last couple of weeks in the Journal of the American College of Cardiology by my good friend Prash Sanders from Australia looking at the role of weight management in atrial fibrillation. Now these data are truly remarkable. In the LEGACY study, they had 355 overweight afib patients. Now I'm going to focus on the 38%. They enrolled these patients in a weight loss program — 38% of these people were successful, they lost an average of 36 pounds. Now their average weight was about 220. These 38% of the patients lost an average of 36 pounds, and they kept that weight off for one to two years.
What would happen if you're overweight and you lose 36 pounds and you can keep it off for one to two years? Let me show you.
[00:41:00] How important is losing 36 pounds? 46% of the afib patients went into remission — no drugs, no procedures — half of the AF patients went into remission with losing 36 pounds. Their blood pressure dropped 18 points, that's huge. The average blood pressure medicine only reduces your blood pressure by about five to ten points. Their levels of inflammation, which is measured by C-reactive protein, went down 76%. 88% of the diabetics went into remission. Their LDL, which is bad cholesterol, went down 16%, triglycerides 31%. And even heart disease, an enlarged heart and thickened heart reverse. This is huge. With just 36 pounds, getting it off and keeping it off, all of these things can happen.
Does lifestyle matter if you choose an ablation?
[00:42:00] This is a photo of us doing one of our procedures. And, in fact, it does. From that same group, they showed that adopting healthy lifestyles after an ablation can double your chances of success. Many of you may have talked with friends, "Oh, the ablation didn't work; I had to have it done two times, three times." Well, maybe it's because lifestyle changes weren't implemented.
You can see that in this study, one ablation, if you refuse to make lifestyle changes, only 26% of the cases will be successful. If you make lifestyle changes, 62% chance of a successful ablation on the first try. With two ablations, you can get it better. But still, if you are unwilling to make lifestyle changes, in this study there's only about a 26% chance that a procedure is going to work. So clearly it is important.
[00:43:00] This is something that we've looked at in our own practice and I'll quickly go through this. We enrolled 59 patients, 54 completed the program. The average weight loss was about 30 pounds; we found that we were able to eliminate medications in 63%. CRP, which is that measure of inflammation, markedly reduced. And we were able to significantly reduce their AF symptoms, as well. So lifestyle changes do matter. It's a two-way street. If you were thinking about an ablation, you need a skilled physician and you have to be willing to make these changes, as well.
What's happening to China today? This is that same village. When I was first there, there was no Coca-Cola, there were none of these other things. But you can see this was actually the home of one of the centenarians, her son has a shop. And if you'll look closely there, what do you see? Red Bull, HóngNiú.
[00:44:00] So, Coca-Cola, even Red Bull, has found this remote village of 500 people in these mountains near the Vietnam border. Unfortunately this health miracle that we've seen in this small village is going away. They want our Western lifestyle. And in turn they're going to see a lot of the same conditions that we see in ours, like atrial fibrillation.
So the choice really is up to us. We have the power to make the changes now. Our DNA is not our destiny. The choices that we make each and every day can determine whether or not we get atrial fibrillation.
Thank you for your attention.
Mellanie: Let's open it up. I think we probably have a couple of minutes that we could take questions. And let me ask you, if you can, to please come to these microphone stands.
[00:45:00] We have one here and one over there. This is really hard, we have so many. Let me ask this lady right here. And if you can't get to the microphone, let us know and we'll bring a microphone to you. But we'd like to have you on camera asking your question.
Dr. Day: All right, you're up.
Evie: Okay. What if you have a perfect lifestyle?
Dr. Day: So, excellent question, "What if you have a perfect lifestyle?" Now this does not work for everyone. As I mention, there are people that may have a perfect lifestyle. They have zero, they've been able to completely manage their stress, the healthy diet, perfect weight, they're exercising the right amount, they're doing everything right. We know that even if you do everything right, it can still happen. It can still happen.
Evie: It did.
Dr. Day: And it can happen in 10% to 20% of the people. And, it's the same with all heart conditions. We know that lifestyles can prevent about 80% of all heart conditions, but there are cases when it can still happen. And if you do have a perfect lifestyle, then you may have to look for other treatment options. Whether that be medications, ablations, and those things, yeah.
Evie: I take medication. I'm thinking of having an ablation, but I keep putting it off because I hear that if it doesn't work, one has to do it again. And it's eight hours under anesthetic, I believe something like that?
Dr. Day: What was that?
Evie: Eight hours under an anesthetic?
Dr. Day: Eight hours is a little bit extreme; our typical case is a little over two hours under general anesthesia.
Dr. Day: But it is a lengthy procedure. And certainly, if you do opt to go that way — you're going to hear a lot about ablation, there's actually a whole session on it later today — having a skilled physician at a skilled center is critical.
Evie: I did go and see Dr. Natale, and spoke with him about it. And, we had to travel so I didn't go and do it, but I'm thinking, "Should I?" Because the medication is working. But, as you said, tired, the fatigue is awful.
Dr. Day: It is, it can be.
Dr. Day: And even fatigue from the medications.
Evie: And the disinterest in doing things, that's the other thing; it puts you off doing anything.
Dr. Day: Exactly.
Evie: So, that's the one problem for me.
Dr. Day: Yeah.
Mellanie: And we'll have a couple hours this afternoon on catheter ablation, so we'll talk more about those kinds of things.
Evie: Okay. Thank you very much.
Mellanie: Thank you very much. I'll tell you what, we probably have time for one more quick question. I hate to be the one to choose.
Dr. Day: Now at the break — I will be here over the break, and then I've got to jump on a plane. I'm actually on call this weekend at my hospital.
Dr. Day: So I've got to jump on a plane and get back, but I will be here through the break. If you have any questions, I'd be happy to answer your questions through the break.
Man: You spoke mostly about people going in and out of afib. I think there are probably a lot of people like me who stay in rhythm for long periods of time, years, and then something sets off the afib and nothing reverses it except a cardioversion or something like that. And then, with medication, and sometimes even without medication, it will stay in rhythm for long periods of time. What is the difference between those two kinds of afib?
Dr. Day: So, excellent question. And what he's asking is, what is the difference between what we call paroxysmal atrial fibrillation and persistent atrial fibrillation? Paroxysmal atrial fibrillation is where somebody may go in and out of rhythm and they self-correct. Persistent atrial fibrillation is where you go out of rhythm [00:48:45] — you're stuck out of rhythm unless a medication or a cardioversion or ablation or something is done to restore normal rhythm.
[00:49:00] Patients with paroxysmal atrial fibrillation, the in and the out, those patients have a mild — in general, not always, but in general, it's a milder form of atrial fibrillation — and so in those patients our therapies are often more successful, lifestyle changes are often more successful. For the people who have persistent atrial fibrillation, that represents, in general, a more advanced form. And so it may require more advanced treatment.
Fortunately, in your case, it sounds like you hold rhythm well for a year or two at a time, and then go out. So that is actually something that's very good. Fortunately, it's very infrequent for you.