Hi, I'm Eric Prystowski and welcome to a new segment of EP on EP. It's a delight to have with me Amelia Benjamin, who is the Associate Provost for Faculty Development at the campus of Boston University. And today we're going to speak about areas of atrial fibrillation. So Amelia, welcome to the show. It's truly my honor. Thank you so much for inviting me. So as a backdrop, I want to just say that I've been reading your literature from Framingham for years and you've educated us on so many areas of AFib, but I understand you're involved in kind of a new area of like, what's the next step? So why don't you educate us on that? Thank you. It's really been my great honor to participate in the National Heart, Lung, and Blood Institute research directions in atrial fibrillation. We did this about over a decade ago, trying to figure out how do we prevent atrial fibrillation and colleagues at the National Heart, Lung, and Blood Institute really felt that it was time for a refresh. What are the current burning issues that will advance the field? And we came up with multiple topics, many of them familiar, all of them familiar to you. The three that I was the most intimately involved with were screening, secondary prevention, and something that is so current and so important in 2021, social determinants of atrial fibrillation, which frankly has received so little attention. So let's, can I take it backwards? Please. Okay. So what's your third category? What do you actually mean by social determinants? Determinants of health? Yeah. What do you mean? So basically, we have taken a very, very biological perspective when it comes to most research, most epidemiology research. What are the risk factors? What are the outcomes? What, you know, blood pressure, sort of life's simple seven, correct? You know, blood pressure, obesity, et cetera. And those are very important. And I want your readers and your listeners to understand that. But over and above that, there are social factors that contribute to the onset, the detection, and the prognosis and treatment of atrial fibrillation that really haven't been studied adequately. You mean when you say social, you mean socioeconomic, gender, things like, what do you actually mean? So there are multiple. So sex slash gender, race, ethnicity, socioeconomic status, education, health literacy. That's a burgeoning field. Also rurality hasn't received enough attention. And that's probably important to you in some of the more rural states. People that are in rural America haven't had the same access to cutting edge therapies that their more metropolitan counterparts have. It's interesting you mentioned that because during this tragedy of this pandemic year, at least in the beginning, I had to do for the first month or two, totally virtual. And in the state of Indiana, in the areas that weren't the cities, it was horrible to realize how poor access they had to anything, much less even the internet sometimes. So I think you're on a good path there. Yeah. So that's very important. And then the final one that we focused on is aging and what do we do with particularly older adults. So multiple ones. But the rurality and the access to broadband, the access to tertiary care, atrial fibrillation treatments for people that need it, really, there's real disparities. You're on to a very important topic. Solving that topic is going to be hard. We couldn't even get better internet connectivity during COVID with a lot of our patients. Right. Right. Well, and then the other thing, it has implications for reimbursement. So our patient population, I work at the opposite, at an urban safety net hospital. And many, many, matter of fact, the majority of our patients didn't have smartphones and couldn't do the video. They could do a flip phone. Everybody has a phone, but they couldn't necessarily, maybe they had a smartphone, but they couldn't figure out how to do the Zoom video feature. I agree with you. I used to look and say in the beginning, maybe I have to do FaceTime, but I would always ask if they had grandkids, because I figured if they had grandkids, they had FaceTime. Exactly. Right. So I'd look and say, oh, they have grandkids, let's do FaceTime. Yeah. Yeah. But the broadband probably really crippled you when you were dealing with people in the most rural locations. It was horrible. It was usually just a phone call. I never felt good about it. And that's why, like in June of last year, I just said, I'm going back to work. I just felt I wasn't, I'm sure that was true for a lot of us. We just weren't doing what we should for our patients. Exactly. I totally agree. And I'm glad you're working. That's a huge problem. Right. Let's go back to the first one, because screening is kind of the kahuna, right? Yes. Yes. And article after article has looked at this. I've gotten involved in that actually myself. What are your thoughts on it? Because lots have been written on it. It's just hard. It's a lot of work. I mean, you need to pick up AFib, right, in a vulnerable population for stroke. Where do you think it's going? Mobile device. I mean, you know, mobile technology. Yeah. Now, where do you think it's going? Yeah. So I think we have to be intelligent about screening. And the Apple Heart Study was a brilliant study. I mean, one of their studies enrolled almost half a million people in less than a year. So that was brilliant. It was a brilliant proof of concept. The problem was that it largely was a study of the worried well. And they admit it. These are dear friends of mine. And they both acknowledge it really wasn't set up as a screening study. But the problem with screening is heretofore, it's really been people that are higher socioeconomic status, people that are largely of European ancestry, et cetera. There are huge areas of the country and the world where we need to understand more about screening where the research hasn't taken place. Yeah. And it goes back to your third point, right? Your point number one and three are really intimately connected because the way to screen that I found out is, I mean, you can do monitoring for a couple of weeks and that does give you some screening. Most studies, if you look at 75 and older, right, give you a three to five percent pickup or something. But you and I both know if you really want to screen, it has to be all the time. Those people can't afford Apple Watches. Right. They're just not, it's not on their agenda. No, no. My patients, it turns out the penetration of smartphones is actually quite high in the United States, but a lot of them are Androids, right? At least in an urban population, urban safety net population, a lot of Androids, they can't really afford an iPhone. The other piece that we really haven't thought through, and I'm interested in you as somebody who's a healthcare leader, we haven't thought through the, what's the workflow implications of this? Right. So just say you end up screening hundreds, you know, thousands, millions of people. Who's going to read all those tracings and who's going to manage all those people? And a lot of those people don't even have a risk of having a bad outcome. I think that we've got to be smarter about who we're screening, screening, you know, people that are 25 years old, probably not a good use of healthcare resources. Correct. And they're the ones who send you tracings ad nauseum. Right. Exactly. And so it's not like there's a reimbursement. And if I tell someone to please get something like an Apple watch or something like that, I consider that my responsibility to read those. Right. But how many people just send us tracings and say, what is it? It's a problem. Yeah. And what do you do with the data? So I actually have a whole talk about this, where what happens if you're somebody who has a, you know, Chad's mask of one, and you have 20 minutes detected on your Apple watch, what do you do? Right. And if you anticoagulate and they have a bleed, you're talking to lawyers. If you don't anticoagulate and they have an ischemic stroke, you're talking to lawyers. So I, this is a beautiful example of where the technology is ahead of the healthcare system and the science. Right. And one of the, you know, you're talking about missing links in research. I think the thing with most, a lot of VPs struggle with a lot is how much AFib do you actually need to be at risk of a stroke? And it's all over the board. Some articles say six minutes, some say 24 hours. I don't really know. And if you have a person at high risk, you don't really know what to do if they have three hours of AFib on an ICD check six months. Right. So I hope that that's going to be some of the areas you guys are going to get involved in. Correct. And what we're really advocating for is a lot more pragmatic trials to really, you know, we're not going to have the brilliant, large, randomized, controlled trial that's pristine. That's not what we need to do. We need to be doing more pragmatic trials to get with more diverse populations to get better answers. The other thing that we spent a lot of time paying attention to that's really important to me, I just was on the general cardiology and patient service and, you know, every other patient has heart failure, right? And virtually all of the secondary prevention research in the field of atrial fibrillation has been largely focused on stroke, stroke, stroke. And that's important. It's a very important outcome. Your patients care about it. My patients care about it. Everybody cares about it. We haven't focused enough on other outcomes like cognition, like heart failure. It turns out a lot more people get heart failure after AFib than get strokes after AFib. But what is the evidence to say how do you prevent heart failure after you get AFib? So I think that we need to be thinking about, you know, CKD, much broader outcomes in AFib as well as ischemic stroke. I'm thrilled you brought all these points up because I hope that the listeners will start thinking about these as new avenues of research. As an electrophysiologist, I've been in the field for many, many years. It's kind of like tiresome to read article after article after article in the next PBI technique. Yes. That's important. Don't get me wrong. Yes. The field will shoot me. Yeah. But we need to get to the basic questions. And I'm glad people with your intelligence are tracking those down for us. I'm hoping I can bring up one other passion project. So we didn't talk about secondary prevention. Right. So tell us about that. Okay. So that's my passion. I'm an epidemiologist. You know, I grew up with my grandma telling me an ounce of prevention is worth a pound of cure. And virtually everything in the research, if you put in ablation, there are a gazillion randomized controlled trials. If you look at some of the secondary prevention, there's really very little data. We have that beautiful study from Prash Sanders about really important weight loss, decreasing the risk of atrial fibrillation recurrence. Where are the replications of that? And how do we actually implement that in a healthcare system in diverse patient populations? What about alcohol? What about aggressive blood pressure control? What about cardiac rehab? I can send my heart failure patients to cardiac rehab if they have systolic heart failure and get that reimbursed. I can't send my atrial fibrillation patients to cardiac rehab to get it and get it reimbursed. That's a problem. Yeah. And that's a huge issue. And I will tell you, if you don't have a clinic for weight loss, after Prash published his data, I tried doing it. I had no success. Yeah. I mean, the only way you get success there is a clinic and managing and re-encouraging. You just did a routine practice, Amelia, I'm just telling you, it didn't produce his results. Exactly. It's going to be an enormous input of money to the system, or at least reimbursement for time. Right. So I know we could go on forever, but we don't have forever. Yes. Thank you. So keep doing the great work you're doing. Thanks for what you're doing for the field. It's been terrific. And I've been reading your articles for decades, so thank you very much for your work also. Thanks so much, Amelia. Take care. Thank you.

atrial fibrillation

social determinants

pragmatic trials

secondary prevention strategies

reimbursement