Treating Atrial Fibrillation with Medications and Preventing Strokes — Video of Eric Prystowsky, MD, FHRS
December 12, 2013
In this video from the Get in Rhythm. Stay in Rhythm.™ Atrial Fibrillation Patient Conference, world-renowned electrophysiologist Eric N. Prystowsky talked about treatments for atrial fibrillation, including rate control and rhythm control, as well as use of anticoagulants to prevent afib-related strokes.
At the conclusion of his presentation, StopAfib.org founder Mellanie True Hills bestowed upon Dr. Prystowsky the first ever “Advocate for Patients” Award for his work in bringing afib patients to the table where decisions are made about our care and his ongoing quest to “Preserve the Brain” through educating doctors and patients.
Video watching time is approximately 36 minutes.
About Eric N. Prystowsky, MD, FHRS
Dr. Prystowsky is a graduate of Pennsylvania State University and the Mt. Sinai School of Medicine. He completed his internal medicine training at Mt. Sinai Hospital, New York City, and his training in cardiology and clinical electrophysiology at Duke University Medical Center, Durham, North Carolina.
From 1979 to 1986, Dr. Prystowsky was a full-time faculty member at the Indiana University School of Medicine, where he was Director of the Electrophysiology Laboratory. In 1986, he returned to Duke University as Professor of Medicine and Director of the Cardiac Arrhythmia Center. He joined The Care Group in 1988.
In addition to co-authoring two textbooks, Cardiac Arrhythmias: An Integrated Approach for the Clinician and Clinical Electrophysiology Review, Dr. Prystowsky has also authored over 700 publications concerning cardiac arrhythmias. He is the Editor-in-Chief of The Journal of Cardiovascular Electrophysiology and is also on the editorial board of 16 journals, including Circulation.
Additionally, he is past chairman of the American Heart Association’s Committee on Electrocardiography and Electrophysiology, past president of the Heart Rhythm Society, and past chairman of the Test Writing Committee for Clinical Electrophysiology for the American Board of Internal Medicine. He was given the Distinguished Alumni Award from Pennsylvania State University in 2007.
Knowing how important this information would be to those living with atrial fibrillation, we committed to do a two-camera video shoot of the entire conference—a very expensive undertaking—in hopes that you, the afib community, will be willing to help us defray those costs through a donation (instead of us charging you for these videos, which many of you said you were willing to pay for). You can make a secure tax-deductible donation here, or click on the red Donate Now button.
Mellanie: Our next presenter this morning is Dr. Eric N. Prystowsky. He’s an electrophysiologist at St. Vincent’s in Indianapolis. He has co-authored two textbooks, has 700+ publications, has been on numerous guidelines committees and think tanks, is on the editorial board of 16 journals, and is the editor-in-chief of the highly prestigious Journal of Cardiac Electrophysiology. He is the most sought out afib expert at medical conferences around the globe, and it’s an immense honor for us to have Dr. Prystowsky with us from Indianapolis to speak today. Dr. Prystowsky will talk about treating afib with medications and avoiding strokes.
Dr. Eric Prystowsky: Thank you so much, Mellanie. It’s a delight to be here. I come here for a rather circuitous course. I was just in Venice at a very large arrhythmia meeting there, I think two days ago. I came home, my wife said, “Well, at least you’re going to stay around for a while.” I said, “I’ll be here a day.” Anyway, she has abandoned me now. Anybody who has grandkids will understand this. My son and daughter-in-law, it’s their tenth anniversary, so they’re off on a trip today. My wife reminded me that she won’t be there for a week when I get home because she’s up watching the grandkids in Chicago. This should be an interesting week.
I’m delighted to be here though. Let me just say a little about Mellanie and her organization. I guess it’s close to ten years ago, Mellanie, seven years ago, we bumped into each other at something. I had an intense interest in afib in trying to reduce burdens of afib since almost the mid-nineties when we wrote our first guideline suggestions on how to treat patients with it, and Mellanie was doing her website. [2:22] We got together. I’m sort of connected in the Heart Rhythm Society, and our alliance started there. I think her site is wonderful. I’ve enjoyed reading things on it, and I think it’s one of the best things that we have out there for patient education. I think the field owes Mellanie True Hills and her organization a lot for that. So, thank you for all of the work that you’re doing.
Let me go into what I’m going to try to do today. I’d like to give you a bit of a run through. [2:52] These are my conflicts of interest, and these are important to put up there. It’s interesting—in Europe, they go through things; they often don’t put these slides up, and I’m thinking, “Don’t you guys have conflicts?” They view things very differently there.
First of all, some of the things will be slightly repeated from the previous speaker. There are four categories, and patients get a little confused with this because they aren’t really as segregated as you might think. What they’re based on is how long you’re in afib. So, for example, if your episode stops on its own, we call that paroxysmal. It’s a word that can be used for anything—you have paroxysms of something. All it means is it stops on its own. But how long stopping on its own? And we’re doing some research now looking at this. You get the feeling that “oh, my afib lasted two hours.” Okay, I have patients with paroxysmal afib where it lasts three days; it still stops on its own. But what if it lasts five days? The same disease, same category, but I don’t think the risks are the same, and I’ll explain that to you in a little bit.
Persistent afib means simply you’re in it until someone stops it. So honestly, somebody doesn’t like how they feel, they come in after a day of afib and they get cardioverted, they get shocked back into normal rhythm. Well, maybe if you waited a day it would stop on its own. If you waited a day, you’d get called paroxysmal afib. If you get shocked in the first five hours, even if it was going to stop on its own, technically you become persistent afib. So, people say, “Oh, you have persistent afib. I’m not sure there’s much we can do for that.” It becomes a problem on how you look at these things. These terms aren’t sort of as sliced up as nicely as you might think.
Longstanding is a term that came in actually from an article that we published in our journal. Some French authors were looking at a new way to ablate certain kinds of afib, and they used some funny term that they came up with. I said, “No one is going to understand this.” So, we sat down together, and I said “Isn’t this really just the same thing as longstanding persistent if it lasts for a year or more?” They said, “Yeah, we like that.” The term came into the literature. Their manuscript said if persistent lasts for a year, now it’s longstanding.
And then permanent really is in the eyes of the beholder. It really means you can’t get back out of afib. But then you go to somebody who does ablations or surgery, and they say, “Oh, we can get you back to normal.” So, you went from permanent afib—really, permanent—to cured?
So, that’s why these terms are a bit confusing for patients as well as doctors, as well as trials, and it’s very hard to figure it out. What if you have one cardioversion out of five years and every other episode stops on its own? Are you persistent, or are you mostly paroxysmal? So, when I say this—the reason why I dwell on this a little bit is you need to know when some doctor gives you a “you’re persistent”—this isn’t quite as crystal clear as the doctor may say, and maybe the doctor is confused. Believe me, there is a lot of confusion out there over these terms.
So, we don’t use the term chronic afib anymore because afib is basically a chronic disease. In a sense, we dropped that one when we wrote the guideline. That’s at least a run through of these terms.
[6:03] This is what I use in the office. I developed this with my artist because I find it very useful for teaching patients on their first visit. There are three cardinal things that you must get out there right from the beginning about your afib, as far as treatment goes, and one of them has to deal with stroke prevention. We’re going to talk about that. The next is the issue with rhythm control and rate control, and they’re all important. And they’re not segregated that I only do one of those.
[6:32] So, this is a slide that I made up probably 15 or 20 years ago. I still believe it to my core. The prime directive in the management of afib is to preserve the brain. Preventing strokes is the key to managing this disease. I’ve yet to meet a patient in my office who said, “You know, doc, I don’t care if I get a stroke, just get me back in sinus rhythm.” Not at all.
Mellanie was involved with me on a national project with the famous basketball player, Jerry West. I’m sure you’ve all heard of Mr. NBA. It was great fun for me because he and I appeared on a bunch of things together, and we were trying to raise public awareness about afib. He has it, and he tells his story in a very poignant way. He was the general manager of the Lakers. He couldn’t even watch the last game. He went on the highway, as he tells the story, and he just drove around, and he came back, because he would get into afib if he got rattled too much. I asked him once, I said “What bothers you the most, Jerry?” and he said, “A stroke.” Stroke is a fear to him.
He’s a very trained athlete. His whole life was spent doing things athletically. He said, “I’m not going to be in a wheelchair, Eric,” or “Doc,” as he likes to call me. It’s funny, he was my idol. So, for me to just sit down and have dinner with Jerry West was a thrill, plus being involved in this national program with him. I said, “Well you know, I’m Eric,” and he said, “Okay Doc.” I said, “You can call me Eric,” and he said, “No.” He’s like one of these old time guys. “You’re a doctor.” I said, “Well, I wish the rest of my patients felt that way.” But most of them are like where is that Prystowsky guy.
[8:10] So anyway, ‘preserve the brain’ is key. You’ve seen this before, and I will tell you, this is going to create some problems. I was just in Europe talking about this and this CHA2DS2-VASc. The reason it came about is, we’ve always known, even in the original guidelines, that it wasn’t only about five things. These are acronyms, as you’ve heard already, and these are stroke-risk scores, and in the CHADS2scoring system, if you had a score of one, we felt that you should have, for that woman out there, the pricey stuff. Actually, warfarin is very cheap, but I understand what you mean. So, we feel there you probably need full blood thinners.
So, they refined this and called it a CHA2DS2-VASc scoring system, and here is the problem with this. The problem is that it’s taken from a different database, and I’ll show you why that becomes important. Let’s look at your actual risks side-by-side. So, if you have a CHADS score system—let’s just take a person who has hypertension, he is a man who is 55 years old. You have one risk, you just have hypertension. [9:16] But I will tell you from my own experience, hypertension is a major risk for stroke. None of these scoring systems have teased out individual components. The people who wrote this system were at the meeting in Venice, and I challenged them to go back to the database and look at each item and see how that added to risk, because you can do that, but it hasn’t been done yet. In my own personal experience with patients, hypertension is a major risk for stroke. I think it’s more of a risk personally, but I can’t prove this yet, than just simply the fact that you’re a woman.
If you’re a 28 year old woman, I mean really, you have the same risk do you really think if you have afib as a 59 year old man with hypertension? I personally don’t think so. I haven’t proved it yet, but I think that’s something that we have to look at. Because here, if you have hypertension, you would be considered a 2.8% risk of stroke. Here, if you have just hypertension, you’re 1.3%. Well, that’s a big difference because your stroke risk is only slightly more than the population. Do you really want to take a drug that can cause a 1% risk of bleeding? That is where this issue becomes important. I think it’s going to raise a lot of concern among clinicians when they start to have to use this, and I think this will become the standard.
I do have some problems with it. On the other hand I will tell you, I am a really crazy guy about trying to reduce stroke. It’s the first thing that I talk about, and I spend an enormous amount of time on it. I want to make sure patients really get this because I don’t care how well I do with the rest of my therapy, if I get that call that Mrs. Smith is in the emergency room and she can’t move the right side of her body, I’m devastated along with her. I’ve had that happen to my father. I understand that from a family member. I’ve been involved in this for almost two decades now trying to wrestle with this problem. I will personally still, even if you’re a one, I will probably be giving you anticoagulants, the pricey type of anticoagulants, or you can take Coumadin.
[11:15] So anyway, let’s go through some of the trials. I don’t expect you, you’re not scientists—some of you may be, so I should not have said that—but don’t worry about that, I just want to show you a concept from these slides. Three drugs are out there now, what they call the new, or the novel, oral anticoagulants. I consider them the new oral anticoagulants, but the people who developed them consider them the novel oral anticoagulants, and you’ll hear these terms NOAC. That’s what it stands for.
[11:43] They are the new drugs that are out there, and they are all very useful. I want to show you that in the trials. I don’t know that you can really parse them that carefully, and in fact, one of the guys who was involved in each of these trials presented it at these recent meetings, and he was pushed by me as the chair of the meeting to tell us which one you want to use, and he refused. He said, “You know, it’s your choice.” There is not one of these that is so far above the others.
Now, let me walk through the trials with you. Basically, what you do in these, they’re called Kaplan-Meier curves—they’re named after the two people, Kaplan and Meier, who developed these decades ago for any kind of trials. What you do in any of these trials is you have two therapies, and you enroll thousands of people in these trials – 15 to 20,000 in some of these trials – and you compare the results. The major results for most of these trials are things like either mortality or stroke, or heart failure —things like that. Then, what you do is you see how they do overtime, and that is how you develop a curve. In this case, it’s the cumulative ratio on here of outcome of stroke or systemic embolism.
This is with the drug that’s called dabigatran, and it’s trade name is Pradaxa. In the United States, we only allow 150 milligram dose, so don’t even worry about this line. Basically, here are the events that you can see with warfarin, which is Coumadin. Here are the events with the 150 milligrams of dabigatran—its trade name is Pradaxa—the drug did much better. In other words, over time, there were many more strokes or emboli in the Coumadin group than the dabigatran group, and that’s why this became a very popular drug. It’s more effective than warfarin. It also reduces bleeds in the brain much more effectively. This whole group does. Unfortunately, there is about a 1% to a 1.5% increase in gastrointestinal bleeding. It’s been looked into further—it’s more related to age. If you’re 75 or greater, you have to be very cautious. These are the nuances that I, as a clinician, would use when I discuss these in the office. They are all very good drugs, but you look at the patient in front of you, and make a decision of which is best for that patient.
[13:51] This was the second one to come out. This is the drug rivaroxaban, or Xarelto is its name. You can see here is the warfarin line for number of events; less events in rivaroxaban. The nice part about rivaroxaban is it’s once a day. It’s the only one that’s once a day. It works by a slightly different mechanism, but none of these drugs require all of that INR testing and stuff, but they are more expensive. They’ve only been out a couple of years so we don’t know ten-year follow up, and that’s something that we always worry about with any drug. It does have a slight increase in gastrointestinal bleeding. I don’t know if it’s the same as dabigatran, but it has a slight increase. It also reduces bleeds in the brain. The advantage here is that it’s once a day. So, that’s a nice thing.
[14:39] The latest of the released drugs is apixaban, or Eliquis, and this was in another trial, and you can see, again, the same sort of thing. You can see here’s the warfarin line; here is the apixaban. Now, here was a major difference, and this is a very important major difference for me as a clinician. It also showed a reduction in major bleeding, and it is the only one that had that sort of major reduction. I’m not sure why, but it was a very nice outcome, so it’s also twice a day. Pradaxa and Eliquis are the trade names, they’re twice a day drugs. Xarelto is a once a day. Eliquis has an advantage of reducing major bleeds. They have advantages and disadvantages, and you need to individualize with your patients.
I will tell you something that I found out, at least in the Indianapolis area—I don’t know if this is across the country—depending on your insurance plan. I’m looking at people out here in the audience; many of you may be on Medicare plans. It doesn’t matter; I’ve had patients who tell me. I give them all three names before we start. I’ll start them in the office with a sample, if we need to, but I give them the names and tell them to go back and check. And sometimes they’ll say, “You know, my plan pays for Eliquis, and it won’t pay for the others,” or “It will take care of Pradaxa, but not this one.” I have no idea why that is. I have no idea whether the Affordable Care Act, so-called Obamacare, is going to change that. I have no idea. But I can tell you, there are differences. What I do before putting the patient at economic risk is, because these drugs are expensive, I say, “Here are the drugs—you go back and check, and give me a call. I can start you on any one of them, and let me know which after we have that discussion, and that way you don’t get yourself in an economic bind.”
[16:24] The funny thing is, this is an expensive process for those people who get INR testing. You just don’t see it. I asked a patient once, “Well, I don’t understand. I checked into costs at our hospital. It’s $231 if you do an INR test.” That’s a lot of bucks, and I’m thinking, “If you do 12 of those a year, one a month, and you bought into $2700.” I asked one of my patients one day in the office, I said “Why are you resisting starting a new drug? I don’t get it. You’re spending all of this money.” “Not me, Doc.” I said “What do you mean, not you, Doc?” He said, “I don’t pay anything. That’s picked up.” I said, “So, I get it now. It costs you pennies for the warfarin, and you don’t pay for the testing. So, that’s a great deal for you.” But for the medical system—we don’t look at it that way in the United States; Europe and the rest of the world does, they look at the macro economics of the system—for the medical system, I doubt if there’s that much difference. I mean, if you got in, and the government got serious about lowering prices with pharmaceuticals, and you added it all together, I’m not sure these new drugs wouldn’t be the same price, or cheaper. The difference is, and I understand this, you don’t have to pay for the INR testing. So for you, out of your pocket, it’s much cheaper using warfarin. There is no one size fits all. This is a very long discussion in the office. This is what takes most of my time in the initial office visit. We walk though this carefully, and we decide what’s best for each patient.
[17:53] Okay, there is also this thing which I’m not going to belabor because frankly, I think it’s, I won’t use the word silly because this thing will be seen around the world, and I have all of my friends in Europe who put this together and say, “How can you call my HAS-BLED scoring system silly?” I’m not saying it’s silly—I’m just saying it’s almost not worth doing because all of the risk factors mainly that cause you to be at risk for a stroke also increase your bleeding risk, hypertension, stroke history. I mean, not all of them, but maybe elderly age. The point is most people who really need a blood thinner also, unfortunately, fall into risk, usually people who are more at risk for bleeding.
The fact is, I can replace your gastrointestinal cells a lot easier than I can replace your brain cells. Okay, if you bleed in the brain, the game might be over. I’ll take the bleeding risk versus the stroke risk as a trade-off any day of the week.
[18:45] Okay, so now we go into rhythm control. [18:49] To talk about that, I want to show you a slide that you’re not going to bother looking at and please don’t. This is in here mainly to remind you in case your doctor forgets. All of these rules that we mentioned about scoring systems for keeping you out of stroke risks and blood thinners, they fall apart when you talk about cardioversion. Everybody who has been in afib for at least 48 hours is at risk for a stroke after cardioversion even if your score is zero.
Those rules only apply to long-term blood thinning. Around the cardioversion time, different rules are there, and it’s because when the heart has been in afib for a while, like more than at least two to three days, the top chamber becomes a bit dysfunctional. It doesn’t contract as well, and when you cardiovert that patient, there is actually, believe it or not, even less contractility on the top chamber, and it’s a great time for there to be low flow in the top chamber and clots to develop. That has taken years of research to figure out. The reason that I bring it up is not to let you know about going through this algorithm. Just remember that even though you may have been a person who never was taking a blood thinner, your doctor may say to you, “Oh, I’m sorry, you’ve been in afib for over 48 hours. We now have to talk about a different strategy,” and that’s appropriate. That’s a strategy that has to do with cardioversion.
[20:02] When we talk about this rate versus rhythm, there’s a famous trial called the AFFIRM Trial. Again, Kaplan-Meier curve. I’m not going to go through the details. I just want to use it as a setup because it’s looking at mortality, and people who we’ve tried to keep in rhythm—in other words, stay in normal rhythm all of the time—versus people who say, “Don’t worry about that, let’s just leave you in afib and control your rate, and we’ll look at you after a period of time and see how well you did.”
I found that this is a strategy now. There was no difference in the strategy. [20:41] People did the same. But I want to remind you that the follow up in this study was two-and-a-half to three years, okay? So, what do we really know about these strategies? This is something that’s becoming, for me, very important. We really know that I’ll give you a period of time in here. Most people enrolled were in their late 60s, and that’s okay there, but [21:04] for people who were younger than that, there is really no data on the safety of long-term afib. People who are older, still, there’s a lot of question marks. So, why do I bring it up? Because there are some new data coming out suggesting people who are at risk of stroke. I mean, people who keep in afib long periods of time. Over time, now you’re talking four, or five, six years later, they’re starting to show increased mortality in some studies, and that’s very worrisome to me. See, that was never looked at.
[21:36] Also, a very complicated slide, but it’s in your book—I’m just bringing it up. There is also data out there now saying, and this really worries me, that there is increased risk when you stay in afib for long periods of time. There’s increased risk in Alzheimer’s, in senile dementia, and several other things. We recently wrote an editorial on this in one of the journals. There are these things that they called silent cerebral infarcts. In other words, if you put yourself through a MRI machine, even though you’ve never had a stroke, but they’re finding out in people with afib who’ve been in it for a long time, they have these little areas there that are silent infarcts. People are worried as they accumulate over time, they may be causing decrease in mental alertness. Again, new research, not nailed down, but for me, enough of a worry that I like to keep people in sinus rhythm.
[22:26] Again, I won’t go through all the drugs, and there is a very big algorithm you have in your book. Suffice it to say that there are a lot of choices with drugs, and it’s individualized to you. What kind of disease you have, what kind of safety risk, it’s individualized to you. The choices are here. You should at least know about them so you can discuss them with your doctor.
[22:47] Last of all is controlling your rate. So, let’s say you are a person that I make a decision, you can stay in afib. I think it perfectly reasonable. You’ve been in it for ten years. It’s going to be crazy to try to get you out of it. It’s critically important to keep your rate under control. [23:06] I’m sort of a nut on this, too. I do it by all out-patient monitoring. I hardly ever bring anyone into the hospital with afib. The vast majority of afib care can be done totally as an outpatient. I give them these monitors, the mobile outpatient telemetry systems, and then I give them a drug, and I look at a heart-rate plot. You can see that much of the day, this person’s heart rate is above a hundred. To me, that’s not good rate control.
Then we give them a drug, and we ask them to send in another one, and now they are controlled, and we do this as an outpatient until the heart rate is controlled, and then when it’s under good control, I tell them to send the monitor back, and we stop there.
Now, if they’re still having symptoms, even with excellent control, it’s time to move on to sinus rhythm. I’ll stop at this point, and I’m happy to answer any questions. Thank you for your time.
Mellanie: Can I join you on the stage? I want to kick off the questions, if I might. What I’d like to ask you is, we know that the guidelines say, and you and I have had this conversation many times, that if a patient is asymptomatic—in other words, they’re not experiencing any symptoms—then you start with rate control and you really only consider rhythm control if they have symptoms. But we know that, in many cases, patients have symptoms that they haven’t expressed to their doctors. Would you address this whole thing about the symptoms and rhythm control?
Dr. Prystowsky: Yes. Thank you for bringing that up. That’s a very critical point. Doctors, especially nowadays, honestly, we’re all being squeezed. If you haven’t seen it in your doctor’s office, you’re going to see it. There are just so many people out there and not enough doctors, and you’re trying to move through quickly.
It’s easy to say, “How are you doing? Do you have any symptoms?” “I feel pretty good, Doc.” “Really, okay. We’re going to leave you in afib.” You take a little time, and you put your pen down, and you say, “I want to talk to you a little bit more.” It’s really important if the spouse is there, and it’s usually the guy. I teach this all of the time. You’ve heard me say this before. I’ve been training people in my field for over three decades, and I tell them, and I tell audiences, if you get a new patient, and it’s a man, and they don’t come with their wife, send them home because you get no useful information. I have yet to see a guy in my office say, “Yeah, I’m really feeling bad, doc.” In fact, the typical scenario is they say, “I’m doing okay” and you see the wife.
You just have to kind of glance over and the wife, you can see, is starting to fidget. I know what’s going to happen, so I tell the guy “Let’s go into a little more detail. I mean, are you a little fatigued? Are there things that you can’t do anymore? Do you feel generally the same?” “I feel good, Doc.”
The wife explodes, “You’ve been telling me for six months you don’t feel good. You don’t do this,” and then finally the poor guy, he breaks down and tells you all of the things. There are subtle things. You just don’t have the same energy level. There are things that you can’t do that you used to be able to do. You sort of don’t have the pep that you used to have.
Then what you do is you cardiovert them, and you say “How do you feel now?” Not all of them, but most of them say, “I don’t understand. I didn’t think I had any problems. I feel good.” If you’re having a lot of palpitations, or shortness of breath, or dizziness, that’s easy. It’s all of these subtle things of afib that become insidious, and you learn to live with them, and you forget how it was six months ago or a year ago. I always, if I have any shot at giving someone at least one chance at sinus, I’ll do it, because it’s not infrequent that they’ll say, “Wow, I feel so much better. I mean I’m getting a better sleep. I can get to do my things.”
I’m a pretty big guy on sinus rhythm, but there are some times when the journey is too hard, and you’ve been in afib for ten years, your left atrium is a huge size. And there you have to take a deep breath and you say, “You know, I wish I had seen you nine-and-a-half years ago.” But, for most people, I try to give them that one shot. Like you and I have discussed, many times people say “Wow, I forgot I felt this good at one time.” There are a lot of subtle symptoms, and it’s up to you. If you don’t want to tell the doc, it’s up to me to figure them out, or for sure, it’s up to your wife to beat you up a little bit in the office so they come out.
Mellanie: Awesome. Any questions? We have one here.
Question: Yes, my husband has been diagnosed with PSVT, and I was just wondering is that a form of afib or something totally different? It sounds like the symptoms are very similar.
Dr. Prystowsky: Yeah, that’s a really good point. Actually, I’ll repeat the question if you didn’t hear it. It’s a condition called PSVT. That actually stands for paroxysmal supraventricular tachycardia. The truth of the matter is, any atrial rhythm that comes and goes on its own is technically under that category. Paroxysmal, comes and goes. Supraventricular means it’s from the top chambers. Tachycardia, fast heart rate. That’s where it comes from. Many years ago, somebody made that in a paper, like this was a specific thing for a certain group of rhythms. So, usually when an electrophysiologist talks about that, we mean it’s a different group other than afib, but technically, afib would fit under there. So, I think what you’re talking about these kinds of rhythms, there’s a syndrome called WPW. There’s a thing call AV node reentry. Usually it refers to those, and symptoms can be the same, but they’re usually easily treated with ablation. Usually, one day in the lab and they’re gone. So I’d have to know, and often I’ll get sent patients with that diagnosis, and you have to pick it apart. Afib could be called that by some people—it shouldn’t be, because it has a different connotation—but symptoms can be the same, yes.
Question: Hi. Have you done any studies in regards to aspirin?
Dr. Prystowsky: Aspirin? Personally done them, no. The studies on aspirin are, let me just tell you, aspirin is grossly overrated. I’ll just start by saying that. Aspirin does have side effects. That’s one of the reasons why we don’t routinely, some of us, give aspirin to someone over 65 like we did 20 years ago, because risk-benefit ratio is really not necessarily there anymore after you’ve looked at all of those studies. There is a lot of bleeding, eye problems. Aspirin is not a benign drug. Having said that, if you look at the whole world of studies on looking at aspirin, Coumadin, and everything else, aspirin was a very, very, very weak drug for preventing strokes.
When we wrote the guidelines, I raged against my committee, but I lost on putting some of the things they did. There is really only one study that really substantially supported aspirin. I would tell you that I think aspirin is not to be used on anybody you’re serious about reducing stroke risk. If you want to give it to someone who is sort of on the margin, that’s fine, but if someone is really at stroke risk, aspirin is not going to cut it.
Mellanie: Okay. And this gentleman here?
Question: Yes, I have had five cardioversions, none worked, had an ablation, stayed out for about two years, and now I am back in. So, can I just kind of look to do that same procedure over again? How many times can you have a cardioversion, or how many times can you have an ablation?
Dr. Prystowsky: Those are two different questions. Cardioversion you can have as many as you want, if you are a masochist, but I would highly recommend against. I mean, there are people who do that. They say come back every three months and be cardioverted. I personally, think that is not the best thing to do. I don’t think it’s hurting your heart, by the way. I just think it’s crazy, just from a doctor’s viewpoint, but I would go back and talk to your doctor about another ablation. It’s not uncommon that, you’ll hear talks later today about ablation. I’ll just make a general comment for a guy who has been in this field a long time. I’d done my first ablation for afib in the 1990s.
There is a lot of confusion about ablation, and there are camps. There are some people who feel, “Oh my God, you have to have this method.” Other camps say, “Oh, no, no. That method doesn’t work, you have to have this.” They are usually people who are doing research in the area who are personally having good results. Let me tell you from a 30,000 foot view of somebody who runs a journal, who’s been in this whole area for decades – it isn’t that simple. We have multiple things we use in our own group, and we try to target the kind of ablation to the kind of patient we are dealing with. There is no one size fits all, no matter what anyone tells you. That’s really just not true.
I think that you should go back to whoever your doctor is and rethink another ablation, or a drug. We have these hybrid successes. You know, sometimes you’ll have a terrible time with a drug, then you get an ablation, and unfortunately, you get a recurrence, but then a drug sort of cleans up the mess. I always tell patients, “Imagine that you had to lift 200 pounds, and you couldn’t do it.” But if I told you, “Could you lift 50 pounds,” you go “Sure.” Well, you sort of change the anatomy of the top chamber with the initial ablation, and sometimes, drugs can come in now and basically take care of business for you where they couldn’t before. A savvy clinician has to use all of those things.
You don’t necessarily have to have another ablation. Maybe what you have to do is retry a drug, and if you can tolerate the drug, maybe you don’t have to go a second ablation. These are not simple decisions. You have to really sit down, but I wouldn’t have a two–three months cardioversion. First of all, it’s just not convenient, if nothing else. I mean, you have to go in and do all of that stuff. That, to me, is sort of not your best approach. Yeah, you could do it, but it’s not your best approach. I would go sit down, and either have another ablation, or maybe now reintroduce a drug that didn’t work before, and you may find that you have a really good lifestyle.
Mellanie: Thank you. We’ll have time for more questions a little bit later. We need to move on. I want you to stay. We have a special surprise this morning. We have an award that we would like to bestow to Dr. Prystowsky. It is the 2013 Advocate for Patients Award.
Dr. Eric Prystowsky: Wow, that’s very kind.
Mellanie: Dr. Prystowsky has been instrumental in bringing patients to the table with their doctors, with think tanks, and really engaging the patient community with the professional community, and helping us to get involved in places where decisions are being made about our care. In addition to that, he has started this quest on Preserve the Brain to help raise awareness of some of the issues that are not widely known, particularly among the general practitioner-family practice community, so that we can educate patients as well as doctors about what some of the issues are, and how stroke is a significant risk, and staying in afib long term puts people at more risk.
Dr. Prystowsky, on behalf of StopAfib.org and the atrial fibrillation patient community, I’d like to give you this award, The Advocate for Patients Award.
Dr. Eric Prystowsky: Wow, thank you.
Mellanie: Thank you. So, Jessica, why don’t we do a photo here.
Dr. Prystowsky: I normally leave the stage, but let me say this one thing. I’ve been privileged in my career to receive several awards from different venues. As a physician, the reason I went into medicine was to help patients. Mom and Dad were doctors. I saw what they did, and I can tell you that no award means more to me than one that’s given for patient care. I really thank you, your organization, and I thank my patients for teaching me so much over the years. Thank you all.
Mellanie: Thank you, Dr. Prystowsky.