Western AF Symposium 2023: Session 18 Roundtable

#ASKWAF

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Featured is the Session 18 #ASKWAF Roundtable from WAFib 2023. 

Moderator: Edward J. Schloss, MD – The Christ Hospital

Moderator: Janet K. Han, MD, FACC, FHRS – UCLA / VA Greater Los Angeles Healthcare System

Bassam Wanna, MD

Mellanie True Hills

Leslie Li, MD

T. Jared Bunch, MD

Gaston Vergara, MD

Edward J. Schloss, MD: We’re going to get started. This is the end of Western AF 2023. We're going to do the annual “Ask WAF” session. Nassir has flattered us by saying this is his favorite session. I will say it is also my favorite session. I also think it's a rare privilege to be given 40 minutes with no agenda and I could say anything I want. Janet and I have total control over the agenda for 40 minutes. When does that ever happen at any other meeting of this stature? So, thank you very much for this. Again, I will say, as many have, thank you for all the arrangements, Nassir, and the folks from EP Lab Digest. This has really been remarkable. So, digital devices and AF. Social media is pretty much still Twitter. If you're on Twitter, I hope you know Ethan Weiss (@ethanjweiss). Ethan is a preventative cardiologist and one of the great minds on Twitter, and just as luck would have it, midafternoon today he put up a vignette and we thought this is perfect. So, here we are leading off “Ask WAF” with a vignette¹ from Ethan Weiss. So, I'll read this, it will take a minute or two: “A story for a Friday afternoon. Spoiler, I really don't know what to do with it. So, I have this patient. He is mid-50s and healthy. Aside from an ACS event a few years ago for which he was stented and is on all the right secondary prevention things. He is also very active. He wears an Apple Watch, and a couple of years ago the watch was telling him he had AF. Given his CAD, this was important as it would mean adding a DOAC to his regimen, which of course does not come without risk. The watch continued to trigger frequent AF alerts and we did a Zio. He kept careful notes and the Zio was on for a week. There was no AF at all. And the events the watch were calling AF were clearly not AF. We felt better about blowing off the watch, but it kept saying he was having AF. A few weeks ago, he called me from a local ED, where he was being treated for an acute stroke. Again, no documented AF. In fact, while on telemetry, he had zero AF despite several warnings from the watch. So, after a bunch of conversations with him and great neurologists, we all decided to treat him with Plavix and not DOAC, but we also decided to repeat the Zio. So, he wore the Zio for 2 weeks and guess what it showed? Yes, AF. Lots of it. He is now on a DOAC, but of course this case has me thinking. I am confident that what the watch was calling AF a couple of years ago was not AF. But when was the watch actually right? Could we have prevented the stroke? I am also confident we would have picked up on the AF (he is having lots) as we would have done a Zio post-stroke. But did the watch make us look harder? Anyway, I thought this case was super interesting, so I thought I'd share. Again, no real agenda in doing so. So, this is an interesting one. The phone call from the patient under your watch, who has a stroke.” I think that's a nightmare. We all think about. I think about it. So, thoughts? You know, I just realized I haven't done the introductions yet. So, hold that thought. I'm going to work my way down the line and start with you, Janet. Tell us who you are and then we'll come back to this case. 

Janet K. Han, MD, FACC, FHRS: Sure, I'm Janet Han, associate professor of medicine at UCLA and a cardiac electrophysiologist.

Bassam Wanna, MD: I am Bassam Wanna, MD, assistant professor of medicine/EP at Tulane University in New Orleans.

Mellanie True Hills: I'm Melanie True Hills. I am an AF patient, 17 years AF-free now, and I am the founder and CEO of a patient advocacy organization called StopAFib.org.

Leslie Li, MD: My name is Leslie Li. I'm a second-year EP fellow at Tulane University.

T. Jared Bunch, MD: I'm Jared Bunch, a clinical electrophysiologist that does work with Will Cho, who you met during the last session, as well as Brent Wilson.

Gaston Vergara, MD: My name is Gaston Vergara. I am a cardiac electrophysiologist in private practice in Las Vegas. I used to be a fellow of Nassir’s at one point a long time ago.

Edward J. Schloss, MD: Since you've got the mic, you start first. Along the way, would you have done anything differently?

Gaston Vergara, MD: Not really with the information that you had. The watch didn't show AF. Now by the time he had the stroke, he has vascular disease, or something related to the carotid arteries and the aorta, and I think that dual antiplatelet therapy is a reasonable approach.

Edward J. Schloss, MD: Anybody else said would've done anything—any of the other clinicians? I'll get to Mellanie in a second.

Bassam Wanna, MD: Sometimes I would think, to take the guesswork out of it, maybe putting in a loop recorder if the patient has lots of concerns with the Apple Watch recording. I'm not convinced about it. Sometimes I might offer them that. But I don't know. 

Edward J. Schloss, MD: I asked Ethan. He said he was they were PACs. So, if you got a loop recorder in this patient, you're going to get a boatload of PVC transmissions, aren't you? So, you hold your breath when you put a loop recorder in somebody like this. I do, at least. 

Bassam Wanna, MD: Yes, I would. 

Edward J. Schloss, MD: Would anybody else? I'm going to ask Mellanie her take here in a second. But Leslie or Jared? 

Leslie Li, MD: Yes, I definitely agree this is fascinating case. So, I have friends who are medical doctors and cardiologists in practice. They say the Apple Watch and smartwatches definitely pick up a lot of AF, and you'll be surprised that a lot of times the watch is actually correct. In this case, apparently, 2 years ago the patient was having triggers from the watch, but it was then reviewed by physicians as not AF. But I'm kind of more curious to know, like later on, because he got frequent alerts, are all these episodes frequent PACs, maybe one or multiple actually showed AF but somehow either missed or if the patient didn't transmit it to the physician because he was previously told that it was not AF? That could be a possibility. The other possibility and details that will be helpful to understand a little about the case that as Dr Vergara has mentioned that because he has cardiovascular disease, and oftentimes people who have CAD also have carotid disease or cerebrovascular disease. So, they're also having an increased risk of having vascular nature that could be a reason of stroke. So, I think neurologists and some imaging studies would tell us better what's the etiology of that stroke per se. Maybe AF is just another phenotype of his cardiovascular risk factors. I honestly don't know if we really didn't misinterpret any of the AF episodes and mistake them as PACs or other noise during the previous 2 years before he had a stroke. I don't have a better idea what we could have done to otherwise prevent a stroke potentially caused by AF, which we don't know. 

Edward J. Schloss, MD: So, I want to hear Mellanie's take now. We talk to patients as physicians and clinicians. She talks to them as colleagues and peers, and she's going to hear things that we don't hear because people are different when they come to their doctor's offices. So, this is an interesting scenario. This person says I've been pushing this button forever, and my doctor says everything's fine. But then you have a stroke. 

Mellanie True Hills: This is unfortunately not an uncommon situation. I hear stories like this a lot. So, with the patient having coronary disease, there's possibly more likelihood of having some AF, and then even after the Zio patch, and sometimes you can wear a device for a couple of weeks and really not get something definitive. But with the watch continuing to alert, I like the idea of an ILR to check longer term to see if there's something going on. Patients will do just about anything to prevent a stroke. So, an ILR is something that might be preferred by patients than continuing to try a 2-week monitor, because if they can pick up what's going on and avoid a stroke, then that's really important for patients. 

Edward J. Schloss, MD: You think this fellow was thinking about stroke even before he showed up in the ER with a stroke? Do most of your AF-aware patients think about stroke? I guess you’ve already told me that's true, right? 

Mellanie True Hills: Research has shown there's a disconnect between patients and doctors as far as preferences. Doctors fear bleeds, but patients fear strokes, because there is a fate worse than death, and that's a debilitating stroke. So, patients will do just about anything to avoid a stroke in general.

Edward J. Schloss, MD: I think that's a good time to segue. I think Janet's going to take it from here. We're going to talk about what would be your diagnostic options. 

Janet K. Han, MD, FACC, FHRS: Yes, I think this is a tough case. Because I feel like when we looked at what Ethan had wrote in the Twitter messages, what we're describing is false-positives. So, I have a hard time sort of connecting that to wanting to put in an ILR for what we're really deeming false-positives from these devices. I think that's what I have a hard time thinking about. So, the other people that have been reading Ethan's tweets seem to think that perhaps people are starting to use watches that it should be fine and that is enough data to be able to start people on therapy. So, somebody replied “This discussion seems quaint thanks to Apple Watch. Isn't everyone who already wears a watch being screened? Wouldn’t it be a more interesting discussion as to how has consumer health tracking affected AF treatment and care?” Dr Adrian, I don't have his last name, said “Is there any data on the sensitivity/specificity of alerts or ECGs from Apple Watches? I've had cardiologists recommend them over a Zio when we haven't had them in the ED to discharge patients.” Another person said “Seems like if a device is claiming to identify AF, the manufacturer should be required to demonstrate in the report minimum specificity and sensitivity. The use of this device muddied or muddled the waters, and may have contributed to delayed recognition and treatment of this AF.” So, it's interesting. I always find it fascinating. There was a slide that was shown earlier today about if people understand which devices are FDA cleared. Mellanie and I talk about that a lot. I find it fascinating that the latter 2 tweets that were put on here talk about not knowing the sensitivity and specificity of these devices. When really, in the FDA clearance of the second iteration of the rhythm notification for Apple does talk about sensitivity and specifically being in the upwards of the 80s to high 90s. Real life is probably not like that. There's a study that just came out in JACC EP that shows the sensitivity and specificity of 5 head-to-head ECGs are not really what was put into the FDA clearance—more sort of near the 50%-80% range. So, I think that the other thing we have to remember is that these watches are not really measuring burden 100% of the time. It's measuring when the patient or consumer is still. I think we have to be able to understand that these watches are not going to be the end all be all as it is right now. So, in Ethan's case, what would you have done differently? I would love to hear from the audience. I don't know that I would have done much differently. I don't know that I would have even necessarily put in an ILR. I would love to have known if the patient was symptomatic. Was he having palpitations at any time that this was happening at all? Then, maybe if it was still saying false-positive, was he doing tracings? That'd be interesting to know as well. Thoughts from anybody else?

Rod Tung, MD: Is it possible that the stroke is not attributable to AF at all? I don't know where carotid artery disease went when we start talking about AF. Is it supposed to be zero? Is there any extra intracranial/extracranial disease? He's got CAD. This is run in the mill, artery to artery stuff that can happen. It's not all cardiometabolic. So, through this lens we think we can prevent every single thing with AF, but this may have nothing to do with anything. So, I'd like to know further workup about what happened with his carotid Dopplers, intracranial MRA, etc. But I think we should never expect it to be zero and think everything is related to AF. The number keeps getting higher and higher in terms of what strokes are attributable to AF. I'm not certain that's biologically accurate.

Janet K. Han, MD, FACC, FHRS: Yes, to dovetail on that a little, there's this guilt that we probably feel if we're asking some of our patients to use these devices. There are also legal ramifications that I always worry about too, with patients sending all these tracing to you. You're telling them all the Zios are negative, and then they come back with a stroke. What are they going to say? What's the legal stuff around this?

Tina Baykaner, MD: I think it's tricky, right? Because I'm assuming from Ethan's tweets that the AF alerts are for PPG-detected pulse irregularity alerts. It says AF and then I'm assuming the patient again records an ECG on the Apple Watch, and Ethan looks at those tracings which are, I assume, later than the PPG-alerted AF alert, and it could have been at the time and short episodes. But maybe I live in a bubble in Palo Alto, where everyone has a watch and they come to clinic with these AF alerts. I think I would have been a little crazier about more frequent Zios if someone is having AF alerts over and over. I wouldn't say, one Zio was normal, so I think you have nothing. I would have probably done another Zio in 2 months until I figure out what the heck is going on, because it's really weird for the watch to give that many alerts, and for an entire year.

Janet K. Han, MD, FACC, FHRS: I think the key is to ask why is the watch giving so many alerts? If you're really going to hang your hat on false-positives, you’d better be sure. 

Bassam Wanna, MD: If he was indeed having AF, wouldn't at least one of the tracings have shown true AF if the PPG was picking up the irregularity?

Janet K. Han, MD, FACC, FHRS: I think it just depends on if the patient ever did tracings, because remember, you have to do the tracing. It takes you a second to sit down, get still, and wait 30 seconds. 

Audience Question: I want to echo this sentiment about what this person needed. Again, I firmly agree with Rod that we don't even know if the stroke was from AF. But the bottom line is this guy is having lots of AF alerts. He is probably having PACs—somebody had already mentioned that. There's plenty of Holter data out there saying that patients with a high burden of PACs have a higher risk of stroke, probably because it is pre-AF. So, one week of the Zio monitor was not nearly enough. This guy should have been monitored repeatedly because he is getting all these alerts and to make sure, again, if it would have made a difference. It gets back to that screening of what to do with somebody who has AF that you find out of the blue. Whether it is an ILR or repeated Zio patches, if he is having that many PACs that he is using his Apple Watch that frequently and there are PACs on that Zio, he needed more monitoring to make sure he does not have AF. 

Janet K. Han, MD, FACC, FHRS: Yes, that's my mistake. I am not sure if they did one or more monthly Zios. I do not remember, but I think that segues us into symptoms.

David Haines, MD: I would like to follow up on Rod's comment that this is an anecdotal, isolated event. You cannot throw out lots of carefully thought-out data and processes for managing patients based on one outlier, albeit a horrible case, right? One practice thing, and I think somebody sort of mentioned it, but I always tell my patients when they do their ECG, I say, “If it says AF, repeat it in a minute, repeat it in a minute, repeat it in another minute. If you have 4 in a row, it probably is AF.” But we know that these things overread and they are designed to maximize sensitivity and they lose out on specificity for that. Also, things do change over time and obviously they did with this guy, and frequent PACs do portend a worse prognosis. But rewrite this guy's history: frequent PACs. We are going to start apixaban, and a year later he shows up with an intracranial hemorrhage. Then, we would be having a totally different conversation. So, I think you need to take this terrible case as it is, as an outlier, but I do not think you need to completely rewrite how you practice.

Edward J. Schloss, MD: Yes, when we look at outcomes, what really matters was the decision analysis up to the outcome, not what the outcome was, because we can all be unlucky, right? It does not maybe help us in court, but the ones where I have trouble sleeping at night was would I have done it any differently if the answer is no? Then, you chalk it up to fate. So, we are moving on. Jared, you have not talked yet, so I am going to pick on you. We talk a lot about asymptomatic AF, and then a lot of people say that nobody is asymptomatic, and or other people challenge that. But if you have somebody, let's say it is a persistent AF patient, a primary care doctor sent you a patient whose ECG randomly showed 60 beats per minute AF, and they come to you in the office for first evaluation, and he says he is asymptomatic. What is your history there? What actions do you do to define asymptomatic?

T. Jared Bunch, MD: I think that is a great question. Recent data has changed my practice. So, the first aspect I would want to know is when he went into AF, because we now have the EAST AFNET trial that showed an equal benefit as far as hard endpoints with AF with early rhythm control, whether they were symptomatic or not. So, we have randomized trial data to suggest that asymptomatic patients benefit particularly early on if we treat them more aggressively. Of course, EAST AFNET was a trial of rhythm control plus comprehensive medical treatment. I think the second aspect, and Ben Steinberg has done a lot of this work at the University of Utah, is how we define asymptomatic. That evolves with the person and their station in life and what they are doing. We will send these scores out: are you short of breath? Do you feel palpitations? That may be relevant for somebody younger, but somebody who is 90 and not going up and down stairs and pushing themselves, their symptoms may be something different. We must be careful with how we label symptomatic with broad questions. We clearly see this in the cognitive realm where we are just not asking people the right questions about how they are processing and feeling. We are asking more specific questions about palpitations. So, I do think, first, we need to ask better questions, we need to get evolve our questions, we need to understand our patients when we ask the questions. But second, I think we are learning that we have to treat this rhythm independently. Some of the work we are seeing with kidney function, brain function, brain reserve, and heart failure that has been done by a lot of people here suggest that we can now make a difference, because we have better treatments, not only for AF but it’s comorbidities.

Edward J. Schloss, MD: Bassam, would you do anything more? I think Jared is making a case for treatment, regardless of whether they are symptomatic or not. Would you do anything more? Let's say the guy is a little reluctant.

Nassir Marrouche, MD: [Inaudible comment presented off mic]

Bassam Wanna, MD: Sometimes it is difficult going back to the patient-level care. They show up in my clinic and tell me they feel okay. I give them a trial of cardioversion, and they come back to me and still say they feel okay. So, then it becomes hard to convince them, even with all the data for early intervention and better outcomes with that, it is a bit hard to convince them at that level.

Gaston Vergara, MD: Cardioversion for sure, but my threshold to take these patients to the lab is lower and lower. I take them earlier and earlier. And I do not wait. It has been discussed before in the meeting, a lot of these patients have been in AF for say, 6 months to a year. They may not have symptoms today. But 4 or 5 years down the road we are going to have a permanent patient. The success rate of an ablation is going to be a lot less. Now we have a symptomatic patient and we have no way of getting them back in sinus. So, I think early seems to be better.

Edward J. Schloss, MD: I am going bring in Mellanie again. We know about the folks who come in and say they are fine and they look askance at you when you start talking about all these things you are going to do to them. How should we approach that crowd? 

Mellanie True Hills: So, we hear from a lot of patients that they are asymptomatic. But Dr Eric Prystowsky and I talk a lot about this at our patient conference and discuss it with a lot of the patients. Many of them have been labeled as being asymptomatic. Maybe it was because when they were first diagnosed, the doctor said, “Are you having any of these symptoms?” They said, “No, I really do not notice any symptoms.” Maybe they think they are just getting old with the shortness of breath and slower when they are walking up stairs—those kinds of things associated with getting older. I hear Dr Prystowsky say over and over to patients, “If you think you are asymptomatic or you have been labeled asymptomatic, ask your doctor to cardiovert you and see if you feel better, and if you feel better, you were not asymptomatic.”

Edward J. Schloss, MD: I am just going to quickly jump in. There is data that it doesn't really change anything when you cardiovert them and talk to them later. Janet can speak to this in a little more detail. She shared this data with me, which I am less versed with, but they all say that the good quality scores stay the same post cardioversion. 

Janet K. Han, MD, FACC, FHRS: I do the same as Bassam and many others. I have tended to cardiovert people to see, just like Mellanie said, if people feel better. What is interesting is when this study came out of Reddit, and it pretty much shows that they cardiovert people, in a month follow-up, people kind of cannot tell if they felt poorly, they either still felt poorly, or if they felt good, they still felt good. They could not really tell, which I thought was interesting. So, I am not really quite sure. 

Mellanie True Hills: It is quite possible that they do not remember what it was like before and they do not think they are really different. Also, AF patients often are on beta blockers, which cause brain fog and confusion, and maybe they are not really sensing a difference. But maybe they really are different. So, I think sometimes it is that they really do not notice that they are different. 

Janet K. Han, MD, FACC, FHRS: I want to make sure that Bassam speaks up because I think he wanted to say something. 

Bassam Wanna, MD: It is also important to know how long they stayed in rhythm unless you have a monitor on them, so maybe they did not stay in rhythm enough to feel a difference as well. 

Janet K. Han, MD, FACC, FHRS: What about the patient who is truly asymptomatic? For example, I have a patient who is in his 70s. He is fitter than anyone I know that is in their 20s. He is a bodyguard, he lifts, he runs miles, but he has been in persistent AF forever. I walk with him up and down the stairs, take a jog with him around the clinic, and he can run faster than me, but he has it in his head that he wants to be in sinus rhythm because he thinks it is better. So, what do you do? I want to hear from the patient perspective and I want to hear from all the other panelists. 

Mellanie True Hills: I hear from a lot of patients who are exactly like that. Typically, they are athletes, so, their doctors have said, “You are asymptomatic, so stay in AF.” They have gotten so used to it that they have increased their fitness level to compensate for it. So, we do see a lot of them.

Edward J. Schloss, MD: Can I jump in? I will move to the next topic in a second. Otherwise, we will run out of time. Jared, and feel free to chime in as well, Nassir, but what about heart block patients? I am a device guy, so I see a ton of this. I will tell it very quickly. I had a male patient who I inherited as an AV junction ablation pacer and he has been in sinus rhythm for the last 2 years, but 100% RV paced. Sure enough, he goes into AF for about a month, we pick it up on a remote and now he's symptomatic, but interestingly, on history, he was symptomatic a month before he went into AF. But once he knows he is in AF, he wants to get out of AF, because he was conditioned through his 2 ablations and his multiple antiarrhythmic drug trials several years ago that he has to get out of AF. I cardioverted him and he spent about 6 hours in sinus, and then he came back and feels exactly the same. So, I am kind of stuck right now. I do not think I can get this guy back into sinus. But let's suppose somebody who does have salvageable atrium, Jared, should I go after these folks if they're in heart block and they are in AF, and they are not symptomatic? They almost never are. 

T. Jared Bunch, MD: Yes, that's a great question. I think it will be really interesting. Rod and I were talking about this in Arizona. We really need a trial of ablation in these patients who do not quite do as well with ablation in some of the randomized trials. A trial of AV node ablation plus physiologic pacing versus AF versus rate control, and that will really start to answer the question that you're alluding to, which is, what's the value of the atrial kick and how important is that? Now we know back from the Ozcan data that AV node ablation in the New England Journal of Medicine clearly led to an improved quality of life. We know from PABA-CHF that they experienced improvement, not as much as ablation, but that atrial kick question is more challenging. I do have some of these patients and then we end up doing additional testing. We look at how they perform on an exercise test and things like that, trying to understand them a little better. I think you have seen this, yours will be similar where you have these people who are asymptomatic for 4 or 5 years, and then all of a sudden, they come back symptomatic and something has changed. Some of the things we have found more recently is AF changes the vascular compensation and how our body responds to that stress and the adaptation of the vessels is altered. So, you start to lose your ability to compensate and recover from other hemodynamic stresses. Again, it has changed my approach a little. But I really like that trial, and I have to give Rod the credit because he suggested it. That will answer the trial of the role of atrial kick in these patients, which I think is the essence of your question. 

Edward J. Schloss, MD: Leslie, I think you are the last one who has not spoken on this topic, and then we will move on if you have anything more to add.

Leslie Li, MD: I have a question. Do those patients include heart failure patients or everybody? 

Edward J. Schloss, MD: My scenario would be a CRT patient with native heart block who has been doing fine. Let's say they are a super responder and they show up now with AF. We cardiovert and it comes back. He is still 25. So, I have amio and maybe a PVI. Do I want to do either one of those? There is no answer, so we are going to move on. We will ask it again next year.

Janet K. Han, MD, FACC, FHRS: So, I think there is always a theme with every Western AF at the end. I feel like this year, it’s time for a nomenclature in classification. So, I put this slide together pretty quickly, but I feel it is almost out of date now or almost obsolete, because we talk about AF being this progressive disease, which is true. But we also learned more during these sessions these last couple of days that there's so much more that goes into this, that what's important is that maybe substrate and timelines are not really the same for everybody. Other stuff has come from Jason as well talking about how we should get people early, so they don't progress to AF. Nassir put out this nice tweet asking if it was time for a new classification system. We’ve seen that theme go on and on. During our meeting this year, a congenital doctor also said that maybe we need a different word for AF that goes on continuously until it's interrupted vs AF that lasts for over a certain threshold, and then comes and goes sort of spontaneously. Then, Jay wrote a nice tweet. Why don't you talk about what you wrote?

Edward J. Schloss, MD: Yes, I'll jump in. So, this is from Eric Prystowsky in a panel discussion: “Is it okay to delay ablation as long as it’s paroxysmal? So, this is the scenario. Somebody is well monitored. They've got a pacemaker, and you watch them every year, they've got 5% AF burden, episodes are all 6 hours or less, they're minimally symptomatic. Year after year goes by. Can you sit on those folks? When do you ablate? Do you ablate the first time they sustain over 24 hours? Do you ablate when they need their first cardioversion, or do you go after them when they're in that 6% burden range? Anybody want to jump in on that?

Gaston Vergara, MD: This was the case that I had a week ago. He's a physician, he comes to see me, and he has had 4 episodes of AF over the last 15 years that were all paroxysmal. Then he finally needed a cardioversion. Him and I talk about what to do. Let's say I decide to ablate him, because now he needed a cardioversion. But he needed a cardioversion because he was symptomatic and went to the ED, and since he’s a physician, they got him in right away, but maybe he would have converted 6 hours later. So, let's say I ablate this patient. What's my endpoint for that ablation? How do I know that that ablation did anything? Because the episodes are so far apart? So, I don't know that we know. With a pacemaker it is easier.

Edward J. Schloss, MD: But if he still comes back with short episodes, you don't know if you actually accomplished anything. 

T. Jared Bunch, MD: There's really interesting data, and I think it went against what I learned, that AF in a fairly substantial number of patients gets worse over time and there's this spectrum of disease that we see in the community. But there's now 3 contemporary trials that all align, the ORBIT AF trial, the large Merlin database, and then also from University Health, and what they found is most people with fibrillation stay on the extremes. They're in the paroxysmal or persistent camp, and there is hardly anybody in the middle. It's aligned now in 3 large prospective trials, so I think we have to really focus on keeping people on the left side—paroxysmal and infrequent. It may not be a failure if you keep somebody from the persistent side. I do think 24 hours is where you see people slip and they move to persistent from that paroxysmal leftward side. But it's really fascinating data and it went against what I anticipated to find out where people really reside, and they don't reside hardly ever in the middle. They reside on the 2 extremes.

Janet K. Han, MD, FACC, FHRS: How do you monitor for that? Jason brought up a good idea of putting in an ILR. Should we be popping in ILRs to all our paroxysmals? How are we going to watch for progression or conversion? I should maybe say conversion vs persistent. 

T. Jared Bunch, MD: We're not quite like other populations where everybody has an Apple Watch. It’s about 30 percent of our patients, and a lot of that is Nassir’s legacy that really pushed for people to be more technologically involved. But we have a lot of people with Apple Watches. We have an active system for those to be reviewed. I don't do a lot of ILRs as well, but the Apple Watch in this spot checking, this SMURDEN concept that was presented, is a great work. If you're going in and out, you're in that leftward side. So, it is helpful to do some spot checking. But I haven't moved to frequent ILRs.

Leslie Li, MD: I think monitoring is definitely the key issue here because we’ve already talked about despite so many devices being available, for example, for really low burden AF patients, it is really hard to put in a loop recorder. Even for an Apple Watch, we're discussing the potential pitfalls of this device. Also, I don't think we have data currently in terms of the best timing of ablation. Is it more of looking at the phenotype change or maybe the cellular and molecular level? If you're already seeing the patient starting to have more AF burden, maybe something that is not visually already happening there might affect your future ablation success. So, at this point, we just don't have data in terms of super low rate burden AF patients. But I feel like my experiences with 2 patients led me to think about other things. I had a couple of patients tell me they had incidental findings of AF, but really paroxysmal a couple of times, and that really changed their lifestyle. They started to do lifestyle modification, low salt diet, lose weight, bariatric surgery, and curing their hypertension and diabetes. This still needs to be proven by more monitoring, but they told me basically they were “cured” of AF, at least they didn't really have further AF episodes. So, this really made me think, especially nowadays with the wearable devices, that we're detecting a lot of subclinical AF. A lot of patients would have a few episodes in 10 years or really short runs of just 1 or 2 minutes, and then if you put a 30-day Holter or 30-day MCT on, they will be having 1% of AF burden. So, is it potentially useful or valuable at this point for lifestyle modification intervention at those super low burden, early AF patients, and see if we can then follow them long term?

Janet K. Han, MD, FACC, FHRS: I think that’s a good point. But I want to give Mellanie the last word on lifestyle. Mellanie, do you think it's going to push us towards lifestyle, like Leslie said?

Mellanie True Hills: On this particular scenario, I keep fixating on the phrase “if PAF is well controlled by drugs.” How long is that going to last, and are they going to have enough fibrosis by the time the drugs no longer work that it makes it difficult to ablate? So, for patient quality of life, we used to say that there was maybe a window of opportunity of say, 1-3 years, to have an ablation and have it be really successful and that it would be less successful after that window of opportunity. But we've heard data here that has said that may be a year to have the best results. So, that phrase just keeps concerning me. Lifestyle changes are definitely important, but part of the problem that we have as patients is that if you're struggling with AF, and maybe it's symptomatic, maybe it's asymptomatic, you may not feel up to doing a lot of exercise. Dieting may not be that easy. So, lifestyle modification is a lot more difficult when you have AF than it is when you don't.

Janet K. Han, MD, FACC, FHRS: So, maybe then we do both in concert. With that, I think we will close our session. Thank you very much.

The transcripts have been edited for clarity and length.

Reference

1.     @ethanjweiss. Twitter/X. February 24, 2023. Accessed November 16, 2023. https://twitter.com/ethanjweiss/status/1629264720871190528