So I'm going to present a case and I have some questions that I'll ask the panel. So the patient is a 65 year old male with hypertension. He had palpitations. He bought a smartwatch and he recorded his ECG during those palpitations which showed this, which is atrial fibrillation with rapid ventricular response. So my first question is, do we need to do more monitoring? These people who come in to us with a store-bought monitor, is there any reason that you would do more monitoring? Because I'll tell you that many people would say, well yeah, do another monitor to confirm the diagnosis. Well I would argue you have the diagnosis, but is there more information that one could gain? Are you interested in AF burden from a patch technology? Do you want to see the sinus rate during periods of sinus rhythm to help you decide how much rate control? Or do you want to look for post-conversion pauses that are going to have you thinking about a pacemaker? So that's my first question to the panel. Even before addressing that, he's 65 and has hypertension. I'm convinced, I agree, this is AFib. From my standpoint, he has AFib. If you want to call it clinical or subclinical, I mean he had symptoms and you documented the rhythm at the time. So the one first thing is you don't want to have a stroke while you're figuring all the rest of that out. So anticoagulation to me would be an important first step. You know, he is fast and I assume it was at rest. He's having rapid rates. I don't, I would do more monitoring, just more to see, is he going, I don't know if he's always or how long his palpitations last, but if he's going in and out and having, you know, short episodes and how fast it is and is he at risk of developing a tachycardia-induced cardiomyopathy. So I would do more monitoring. And again, depending on how often, it might just be 24 hours if he just has a few seconds and he recorded this as opposed to, you know, hours worth of at least a 24-hour monitor. Look at his rates and look at his burden if he's having just a few brief symptoms. But I think more monitoring, yes, but use the watch. So what I do for these patients and say, okay, over the next week I want you to, you know, do two or three recordings every day and find out is he having asymptomatic AF episodes or are most or all of his asymptomatic time periods, normal sinus, and, you know, just get some random pickups during the day. I think that's good enough for the typical patient. So having to record with and without symptoms. Yeah, yeah. I think that's a reasonable way to approach it. And then you talk about the deluge of data. I, you know, I love that terminology, but that is, that is. I let these patients curate their own data, too. And they don't email them to you at all times of day? I don't encourage that, no. Actually, I don't give out my email address to my patients. They can find it, and they do, but I don't hand it out. I think it might also depend on what their substrate is. If he, if you do an echo and it shows that his EF is down, you might want to have, you know, a little bit of sort of, I guess you might want that monitoring to get a better sense of where he is 24 hours a day. If his EF is normal, his LA is fine, you know, maybe just the spot monitoring is going to be good enough. I wouldn't do any more monitoring. It would be enough data for me to actually make a decision of what my next strategy would be. After I implemented the next strategy, I would then do robust monitoring to make sure I'm not missing AFib even he's back in normal sinus rhythm. So it's good for diagnosing. It's sensitive when you have it, but when you don't have it doesn't mean that he does not have AFib. So I would use monitoring to really quantify what the effect of my intervention on this particular patient is or has, you know, how it manifests after that. Yeah, I think you could go either way. I mean, clearly as Andrea pointed out, he has a Chad's Vascular O2. We're going to start him on anticoagulation. Could this be a single 31-second episode of AFib and maybe that's overkill? Well, right now the guidelines don't distinguish duration, right, for initiation of anticoagulation. They base it on Chad's Vascular. I do agree, given the burden of basic amount of AFib, that if I was going to intervention and he still had symptoms, there may not be a correlation. I don't want to see the efficacy. But I think the thing you really point out out here is the patient had palpitations and he had a positive EKG. So I would now begin to trust the patient's symptoms also. And if the patient said that, oh, that was the only isolated palpitation I had, then I would take a step back and then decide if I wanted to do monitoring. But if the patient says, I have palpitations, I have them quite often, and every time I've had palpitations, I've had an EKG that shows AFib, chapter closed for moving anticoagulation. I think I agree with that, actually, is to use the monitor in that regard. The only thing is when he gets the drugs to him, he's on a beta blocker, he may not feel it as much, he may not be having it. He's on anticoagulation, so he's safe. So the next question, I think we're going to, I mean, you know, this, you know, we all agree that this patient should be on anticoagulation, although again, you know, what happens if this is a 30-second episode? We don't have data that 30 seconds of AFib predisposed to stroke, but currently the state of our knowledge is that we can base our decisions about anticoagulation from the patient's underlying risk factors for stroke. And based on his age and history of hypertension, our guidelines say that he has two risk factors and should be on anticoagulation. And whether he gets ablation or antiarrhythmic drugs is really part of a shared decision-making decision or discussion. Our guidelines say that we often may go to antiarrhythmic drugs first, but in someone with a structurally normal heart who doesn't have a lot of other comorbidities, that more and more ablation is a first-line therapy. And we wouldn't just offer this patient rate control necessarily because he's young and otherwise healthy, although truthfully, you know, if you gave him a beta blocker and his heart rate in AFib was 70 instead of probably 130 and he felt better, well, one might argue that's a reasonable approach too. After some discussion, this patient started on an antiarrhythmic drug and then he emails me because, unlike David Haynes, the world seems to have my email address. And I must tell you the situation that he emailed me, I was having root canal that day. So I come out of, you know, a two-hour procedure, unable to speak, bewildered. The first email I check is from him and the email says, hey doc, I'm having palpitations and lightheadedness and this is the ECG he sends me. So again, even if you're not an expert, this is something bad. It's a wide complex tachycardia given the fact that he's conscious and emailing me and I gave him a 1C drug. More likely than not, this is a what's called atrial flutter with one-to-one conduction. These medications can slow the atrial rate. Let's say normally you're going at a rate of 300, well luckily the AV node can transmit one-to-one at 300. But you give a drug like flecainide and now you slow the atrial rate to 220 and lo and behold, the AV node can transmit one-to-one at 220. So more likely than not, this is atrial flutter, one-to-one conduction as a result of his antiretroviral drugs. So my question to the panel is, do you call 911, right, and tell them to go, I don't know where because I don't know where he is. Do you call him and go to the emergency department and tell him don't take this drug until you do that? Do you do all of the above? What do you do? I'll tell you, I called him because I went through his records and he didn't answer. So now what do you do? Where is he? So now I'm unable to use my mouth, sedated in my dentist's office trying to manage this remotely. I did know from his email address where he worked, so I called that number. Again, sort of out of the purvey of your normal responsibilities as an electrophysiologist. And they said, hold on, he's in a meeting. I'm like, what do you mean he's in a meeting? His heart rate's 240 beats per minute. So it actually turned out that it had terminated and he was just going about his daily routine. But this is the kind of information that we are now exposing ourselves to. And again, what is my responsibility? What happens if this was at 1am? And what happens if he lost consciousness? Or what happens if he were driving? So let me ask you, what would you do? Would you tell him don't ever email me again? Would you change your email address? Would you give him David Haynes' email address? So was it a mistake to give access to you, to your patients in the first place? I think you're happy to have this information, right? It's better than just sort of this nonspecific, I'm lightheaded, you know, once in a while. Is it because your heart rate's too slow? You know what's going on? So the data piece is useful, but you're right. It opens up this whole new space of never being able to leave your work. I can tell you one of the really attractive features of the patch monitors that drives my decision making is that you don't get any data until they peel that patch off, mail it in, and you get the report sent to you. You're insulated from this scenario. Now that sounds harsh. Fortunately, I, you know, patients don't usually drop dead. I mean, that has happened in people's careers. It hasn't happened to me, knock on wood. You want to be responsible, but you can't be exposed 24-7, and you need to have, you know, processes and people in place to do that, and we have talked about information flow and management of information. We are drinking from the fire hose right now, and there's dropout all over the place, and this would be one example. I mean, I suppose one potential option is to route people through the system in some way, right? I mean, that system protects us in some way in that, you know, that data goes through the phone room. Someone triages it at that moment, you know, and if you're not available, then someone else will, you know, kind of respond and triage it, but it's, you know, the problem with that system is sometimes this comes through, and no one looks at it for 48 hours. Right, or it's a big responsibility on your colleagues to now, you know, adjudicate this information on someone they have no knowledge of. Andrew, do you give your patients access to you like that? Yeah, so they do have a lot of access to me, but this is a tough situation because it depends on your infrastructure at your center, and I think if you do set up a call center, it's where does this data go right now. It's a little easier with ICDs. We see the same thing with, you know, implantable loop recorders, right, because they don't get called, so you don't have that extra layer. You know, ICDs, they go, you can get an alert, an ICD, and that goes through a, you know, the company system too, but with this data, it's raw, right? I mean, I'm glad you get, we get the data, but you want to get it in a timely manner, and you want it to be acted on, so right now, I think really there's a gap. We have a gap in this whole system of where people come in and how they get to us and get this information to us, and so the technology is amazing. We're all wearing these watches and, you know, using it to get that information rather than to give them, you know, sometimes you're giving these patients three or four monitors, and you still can't get the information you need, but it's right there, but we need some better way to fill in those gaps, either a call center at your own center or some central, or you guys can help us to create this central call center. So the first part of your question, access. I give every patient I've done an ablation on my cell phone number. Post-procedurally, I take a picture of their CARDO or NAVIX image, and I actually show them what I've done, and I text that to them for their own personal, so they have a pictorial representation of what exactly has happened. Speaks better than saying I drew circles and did a line, so they have cell phone access to me, and I'd rather they have cell phone access to me, at least for the immediate post-procedural period for the next month or so, because we looked at this. It drives down any visit to the ER or calls, just the fact that they know they have access to you is calming enough, so I give 100% access post-ablation. Pre-ablation, not everybody gets my cell phone number, and not everybody gets my email access unless they ask for it, and I certainly give it, and I think nobody really abuses it too. I've never seen a patient abuse their access, and they only get in touch with you when something is really problematic where they're having a huge issue. I find a mechanism if I'm awake and willing to triage it to my support structure, but I think this is the brave new world. You know, there's going to be an uberization of health care. People are going to demand it when they need it, where they need it, and at any point in time, we don't have the logistical structures to be able to deliver the care that way, but I think it has to happen. There is no going backwards. There is no siloing ourselves and trying to protect our domain. I think we just need to figure out how we're going to do it. So, you know, as I emphasize the term that he emailed to me, right, so without having any idea of when I would be able to respond to that, by giving them your phone number, they can now text it to you. What if you're scrubbed in a case or on an airplane? You know, what is the expectation of the time frame that you're going to respond? Are you a 24-7, 365 days a year emergency department? So, I make it very clear to them when I give myself a number that I don't carry my phone on me. I may not have access to my phone at four to six hours at a time if I'm in a procedure or if I'm traveling, and that's, I set the expectation immediately at that point in time when I give them cell phone access. Emails, I tell them I look at it, but I don't always have access again to it for long periods of time. So, if you have anything urgent, urgent, call the office, call the ER, but if you have something semi-urgent or so, and that's again, you know, you leave it to their understanding, but you lay the expectations out to them as clearly as possible. But, I hear you, and that sounds great, but I think that that leaves gaps, leaves exposure, leaves expectations that you might not be able to fulfill. I mean, you know, again, talking personally, my process is all queries, concerns get routed through the office number and get bounced directly to me if I'm available, but if I'm not available on a plane out of the country, just maybe a weekend of entertaining where I don't want to be, you know, having to field complex issues, it gets signed out to a competent person, and then that person, if it's a specialized thing regarding my patient, they all have my cell phone number, and yeah, I do have lots of conversations with cross-covering physicians, but, you know, having that direct access I don't think is the right system. I don't think that gives patient adequate protection. Now, the problem is, again, this fire hose of data coming at us, the conventional call system breaks down when that system gets overloaded, and so we're still back to the same problem. I couldn't agree with you more. I think there needs to be a system that can operate better, but at the same time provide rapid individualized care, and it should not have to be the provider or the physician per se, and we need to figure that out, but I think at this point in time also, you know, I've had patients on Zyopatches who passed out on a Zyopatch, landed up in the ER, got a pacemaker, and I get the results of the Zyopatch two weeks later saying patient had a heart block with an eight-second pause. Now, the patient survived, but that could have been a disaster, and we still use Zyopatches, but I think, you know, so there are issues on both ends, and I don't think there's, we don't have the right answer, and I think having the industry out here trying to really understand this unmet need in providing, you know, fast individualized care for real sick patients is an important one. So, can we send Siri to medical school? That's the question. We need to move on. Thank you very much. That was a good discussion.

hypertension

palpitations

electrocardiogram

atrial fibrillation

rapid ventricular response