All right, so this is a 62-year-old Spanish male, he's actually a diplomat living in Chicago, who has hyperlipidemia and he presents with newly diagnosed persistent atrial fibrillation. So he was presented for a routine physical examination five months before he saw me and he was just incidentally found to be in atrial fibrillation. My next question to the patients are always, well, now that you know, you know, has there been some change over the last, you know, few months? And even in retrospect, if he thinks very hard, he says, I have no symptoms, I have no palpitations, I'm, you know, exerting myself without limitation. He actually swims, I mean, I want to be a diplomat, he swims one to two hours daily and he consumes three alcoholic beverages per day. So that is a good life. Those medications that he's taking at that time are aspirin, 81 milligrams daily and atorvastatin, 10 milligrams daily. So he comes to me and always have to verify atrial fibrillation, it's the most misdiagnosed arrhythmia, but his ECG confirms rate-controlled AFib here. So he has an echocardiogram performed and actually his heart looks very normal structurally except for a little bit mild enlargement of his left atrium, not surprising in someone with AFib. And he has a stress test, he exercises well, he has no ischemia, and he has a seven-day monitor to try to figure out, are you someone who's going in and out, are you in it all the time? And he has 100% atrial fibrillation, he's persistent, well rate-controlled actually on no meds, 69 beats per minute is his average rate, probably part of why he's so asymptomatic. So the question is, now what do we do and why? Should we start with David? So you know, this is not uncommon and it's the dilemma because we know that as we discussed yesterday, AFib is associated with, yes, increased risk of stroke, but also heart failure, cognitive decline, and increased risk of death. Now, again, association does not prove causality and using those adverse outcomes as sole justification for taking a guy like this in for ablation is a little bit, you're on a little bit of thin ice, I think, but he's a young guy, otherwise healthy, and so I at least have the discussion and lay things out. If it was me, and patients often ask, what would you do if it was you? I would have the ablation. I would reiterate what was said yesterday, I'd cardiovert him first, hopefully get him up to about three hours of swimming a day, because he's clearly a slacker, but... He's probably a very good diplomat. Because, you know, I think that, as you mentioned yesterday, there are subtle changes that occur that people don't realize until you juxtapose sinus rhythm. I think it's going to be a problem trying a drug on him because his rate is going to be slow because his high vagal tone, and I wouldn't be surprised if his resting heart rate was, you know, in the 40s and you popped him back into sinus, so your options for drug treatment are going to be limited. So if he has an improvement in symptoms and sinus rhythm and he went back into AFib, then I would certainly offer an ablation, and I think that I would have a careful discussion with him, offering him even potentially PVI in the absence of symptoms, but if everyone yelled and screamed at me, I would accept that. And I forgot to mention, alcohol may be a big factor in this guy, so abstinence, you'll at least take a run at that, whether he'll be open to that or not, you know, will be dependent on him. It's occupational hazard for them, they're exposed to it every day. I would definitely go with cardioverting him first. I think, you know, a lot of times, you know, he doesn't have symptoms, but sometimes you can recognize that you feel a little bit better, although he's obviously pretty active as it is, and I was going to make the comment about the alcohol. He does have some left atrial enlargement, so it's not just a single, it's probably been there a while, it didn't develop overnight most likely, but I would definitely try to cardiovert him before, you know, going for ablation. I would do the same, and I would actually empirically put him on defedolide, bring him in for a cardioversion, knowing that he's not going to stay out with the remodeled left atrium, and give him a try, see how he feels, whether he feels different or not. And if he does, then obviously at that initial conversation, talk about the downstream strategies of an ablation, and then revisit it, because he might be more open to that discussion later on too. Can the panel make a comment on if they pick cardioversion plus drug, what would be your choice? How do you pick dofedolide versus a different agent? And it may be good for the audience to hear that. So in this particular patient, exactly what Rod alluded to, has already a fairly slow heart rate, indicating that the conduction system may not be overtly optimal, and therefore I think defedolide, which is a selective potassium channel blocker, which doesn't cause as much as bradycardia as Sotalol or one of the class 1C agents do. So that would be my drug of choice initially for this particular patient, probably without beta blockers, see what his intrinsic sinus node looks like after a cardioversion, and then see if you want additional beta blockers on it. Yeah, and I actually favor, I like defedolide for that reason, for the lack of bradycardia promotion effect, but also it's actually very well tolerated. The only problem lately, and I don't know if other people are having it, it's harder to get, certainly if they don't have insurance, the manufacturing has been, you know, down a bit, at least from the brand name, and I think there's even one or two of the generics there. But right now we still, you know, it's still available, and I think it's very well tolerated. One, I would just push back on one item. I would actually just cardiovert him alone, because you don't know whether he's going to stay in a normal rhythm on his own. And defedolide is a three and a half day hospital stay, and I would tell him to buy an Apple Watch and try to see when he slipped back into Afib, because, you know, if he goes six months, is it the drug, or is it the cardioversion alone, and then if he recurs, then I would argue maybe to bring him in. That's just my practice. And I would echo that, and I would certainly cardiovert this guy and wait for him to recur before I would take him to the ablation suite. I would not do that without at least doing the cardioversion. Great. So I guess the main point was our strongest justification for intervention, whether it's cardioversion or ablation, is symptom control. And what do we do with someone with no symptoms, but who's someone very young? So it seems like we're pretty uniform in that we would do something to try to restore sinus rhythm. So in this case, we stopped the aspirin. We started him on Apixaban, and he underwent TEE-guided cardioversion. Also counseled him on alcohol use, and I usually have these people come back in a week for a follow-up ECG just to see where they're at. And indeed, he was back in atrial fibrillation. We asked him to kind of keep going with the abstention from alcohol use. He stopped alcohol. He actually lost 20 pounds, and the plan was for a repeat cardioversion at two to three months. Can I ask? Yes. Why did you do a TEE echo as opposed to anticoagulating him for a month and just bringing him in? That is a really good question. We could have chosen to do that. I guess I think I was feeling the clock ticking. He had been diagnosed five months before already. Who knows how long he had been in it? And I wanted to sort of, there's the A-fib begets A-fib, and it's a good point, and maybe it wouldn't have made a difference, but he also was low risk for complication from a TEE. TEEs are fun. I mean, yeah. So I don't do them. But anyway, so he came back at two to three months, and we cardioverted him again. And here's his follow-up one week post-cardioversion number two. My question was going to be next steps, but it seems like we've kind of answered that. I actually ended up putting him on a little bit of flecainide, recardioverting him, and he maintained sinus rhythm for a while, but now has reverted back to A-fib. I mean, he continues to swim two hours a day, and it's just completely asymptomatic. So the question is, what are the next steps? So we'll see. It sounds like, well, actually, yeah. So what are the next steps? What would you do? He's already tried a drug. He's failed. So can I ask you a question? Yes. So did he feel any different when you cardioverted him? Zero percent different. I try so hard to get him to tell me that he just, yeah, he felt much better, but I can't get it out of him. Yeah. So I'm going to go with the way David approached this. What would I do if it was me? I would actually go down the path of then getting myself on defetalide, getting cardioverted with a medication that I know could be there for a longer period of time at an adequate dose rather than a whiff of a class 1C, keep myself in normal sinus rhythm for a little bit, and then go down the ablation route to preserve normal sinus rhythm. Let me ask you. Do you think, you know, this is such a rapidly evolving field, right, and there's going to be great technologies coming out. Would you tell this patient, hey, sit tight for six months, 12 months, you know, 18 months. There's great things coming out that if we can buy time with a drug and then do ablation, do you think that we're at a time and place now to say, we're good enough to go? Oh, totally. If the medication is holding him in normal sinus rhythm, I would stave off the AF ablation until a time that I felt it was absolutely necessary. The main thing is to get him out of AFib so that there are no further remodeling. There's no further fibrotic changes and irreversibility on the substrate end of things and the microarchitecture end of things. I would 100% try to get the patient to wait if he's stable and feeling fine in normal sinus rhythm for newer technologies that we talked about yesterday. And then just one last question if I have a minute. What is your age threshold at which you will kind of say, a little fibrosis won't be too bad for this asymptomatic person with rate controlled AFib? I don't think I would use age as a cutoff. I would just think that if I intend to get this patient back in normal sinus rhythm at some point in time, I would actually aggressively try to keep the patient in normal sinus rhythm with medication so that there is no adverse remodeling. Whether the patient's 70 years old or 75 or 80, if I've decided that I'm going down the route of a catheter ablation, then I think trying to keep the patient in normal sinus rhythm prior to that is not a bad thing unless you're going for the ablation within a short period of time. At what age, we're honing in on these younger people that were being presented because we could argue that we don't know the 30-year impact of being in AFib. But if that, we're all presented with patients who are in their mid-70s who come for their yearly routine exam and are found in AFib. What is the age group where we say, hey, we don't need to be aggressive anymore and rate control and anticoagulation is just as good as rhythm control? For me, it seems to be changing as I get older, right? But I'm interested to hear what's the threshold? Is 75? Is 65? Is 85? I can attempt an answer. I can say it depends on how well the patient chose their parents. So there are many 90-year-olds who look like 60-year-olds, especially from my part of the country. Even the ones who have not been touched up. So again, more seriously, again, each patient has a biological age and what you think is their physiologic age. And we definitely factor that in. There's no objective criteria, which is one of the reasons why an in-person visit and the interaction with patients I think becomes an important issue, especially to extend the point that Dr. Russo made, which is how do you gauge symptoms, right? How do you really walk along the same road with your patient to understand, especially in arrhythmia like AFib where its quality of life becomes a big consideration for subjecting someone to an invasive procedure? And the other factor that I think is important, again, is is it a myopathic atrium? So someone who has relatively normal atrial size, mild enlargement, if you want to do an MRI and look for evidence of delayed enhancement scar in the atrial wall and you see low scar burden, the likelihood of them responding to PBI is significantly better. And so the threshold to send them for invasive therapy is lower, whereas if you see significant atrial enlargement, even in a 70-year-old person, I'm less enthusiastic about pushing forward. Great. Thanks. Thank you.

persistent atrial fibrillation

62-year-old male

symptoms

cardioversion

ablation