Ask The Heart Doctor: Women's Heart Health-Part 5- Atrial Fibrillation

In part five of this panel discussion, our heart doctors talk about risk factors and treatment options for atrial fibrillation.

Meet our panelists:

Leslie Cho, MD, Cardiologist, Director, Cleveland Clinic’s Women’s Cardiovascular Center
https://my.clevelandclinic.org/staff/6638-leslie-cho

Christine Jellis, MD, PhD, Cardiologist, Vice Chair, Heart Vascular & Thoracic Institute – Patient Experience & Physician Engagement
https://my.clevelandclinic.org/staff/19994-christine-jellis

Donna Kimmaliardjuk, MD, FRCSC, Cardiac Surgeon
https://my.clevelandclinic.org/staff/30663-donna-kimmaliardjuk

Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Leslie Cho, MD:

Welcome, everyone to a session on Ask Your Heart Doctor. Today our focus is on women and heart disease, and we're joined by our surgeon as well as our cardiologist colleagues, and we're going to go around and introduce ourselves. First, my name is Leslie Cho. I'm the Director of Women's Cardiovascular Center at the Cleveland Clinic.

Donna Kimmaliardjuk, MD:

I'm Dr. Donna Kimmaliardjuk and I'm a cardiac surgeon with a special interest and focus on coronary artery disease and bypass grafting.

Christine Jellis, MD, PhD, MBA:

I'm Christine Jellis. I'm an imaging cardiologist with a special interest in advanced imaging. I'm one of the detectives and we use this imaging to figure out how bad heart disease is.

Leslie Cho, MD:

Okay, let's talk about AFib. And there is surgical ways to treat AFib. There's catheter ways to treat AFib, and there are medical ways to treat AFib. So there's a lot of questions about what are the risk factors for AFib. Christine, what are the risk factors?

Christine Jellis, MD, PhD, MBA:

So although some people will have isolated AFib, I think oftentimes what we'll find is that they've got other cardiac issues. For me, I often see patients who have valve disease and then have structural changes to the heart and develop AFib. I think we also see people with a lot of cardiovascular risk factors. So diabetes, obesity, sleep apnea, other things like that that create the perfect storm, if you like, for AFib to be initiated. And then it becomes a vicious cycle. Once someone starts having AFib, oftentimes that leads to atrial enlargement, which can then lead to ongoing AFib, and we go round and round, so.

Leslie Cho, MD:

And valve disease.

Christine Jellis, MD, PhD, MBA:

And valve disease is the big ticket one. But I think all of those things we need to take into consideration. Sometimes if we treat those things so we intervene on the mitral valve or we get on top of their sleep apnea, then that may be enough to try and reduce the incidence of AFib. But we always have to be wary that AFib also increases, the likelihood increases as people get older anyway. So I think oftentimes, even if someone thankfully goes out of AFib, it might be something that comes back again later in their history. So treating the problem. And then as you said, there's all these different options around, okay, if someone does have AFib, firstly what are we going to do about the AFib? But then anticoagulation as well, because we know that atrial fibrillation does increase the risk for stroke, particularly in certain groups of patients. So we have to be mindful that even if we've got the AFib under control, the last thing we want is someone to have a stroke.

Leslie Cho, MD:

Is there a difference in terms of how you give medicines? Is there a certain medicine that's better for women than others for AFib?

Christine Jellis, MD, PhD, MBA:

It's interesting. I think, again, you look at all the different factors. So if someone has got left ventricular dysfunction, then they may not be suitable for certain medications that we use for AFib. I think if someone is very symptomatic and perhaps younger and has a lot of life still to live, we might be more proactive about going with an interventional approach such as a catheter ablation. If that person has got valve disease and they're going for surgery, I would be asking Donna to say, well, Donna, what can we do in the OR that's going to help those patients from a surgical perspective?

Donna Kimmaliardjuk, MD:

Absolutely. I actually have a question for both of you, because I sometimes get asked this by my patients post operatively. Is there any, or what is the evidence to say, oh, no, don't be drinking coffee or don't drink alcohol or certain foods or things that you should avoid that might make you more likely to go into AFib. And then also commonly after surgery, I'm telling my patients, we got to get you up walking. I want you walking, walking, walking. But then they'll be told, oh, you went for a walk and you flipped into AFib. No more walking.

Leslie Cho, MD:

No, but you're right. The alcohol for sure is a risk factor for AFib, 100%. Caffeine, eh. I always say caffeine never caused anything except overachievement, which I think is 100% true, but caffeine really, no. Although caffeine can make you have more PVCs [premature ventricular contractions] and PACs [premature atrial contractions], but it doesn't, I don't think have any role in AFib. Some people are super sensitive to it though. For sure, alcohol. So that's very unpopular to say, don't drink alcohol. But alcohol really is one of the risk factors for hypertension, AFib, obviously gaining weight, so we really try to limit that.

I don't know about food. Some people do say certain acidic food makes them very sensitive. What I can say I think, especially for women, is that so much of AFib is related to risk factors, and so controlling risk factors makes a difference. For valve disease, that's very problematic because sometimes you go a little bit too far in your valve disease and unfortunately the AFib is permanent. Yeah. 

People ask us about maze procedure, which is a surgical thing. In your opinion, what are some of the risk factors and how difficult is it to get surgery for AFib, the recovery process?

Donna Kimmaliardjuk, MD:

Yeah, great question. So most of us surgeons, when we do an ablation at the time of surgery, it's because they're coming for something else. So they either need a valve repaired or replaced, or they need bypasses. And so often it's going to be still through that sternotomy approach where we go through the middle of the breastbone. We do have one of our surgeons though, that does these ablation procedures in select patients not through this big cut through the chest and just with little incisions just either below or from the side to try to ablate or burn those electrical circuits that we think are causing the atrial fibrillation.

So again, without the incision of or having to go through the breastbone, that recovery process is going to be a little bit easier, a little bit faster. But when we see it, it's most often in concomitant surgery. I think it's quite rare to have standalone ablation or maze procedure. But again, the beauty of being at Cleveland Clinic is we can offer, again, in properly selected patients surgical ablation with small incisions if they're not able to go for a catheter ablation approach with our electrophysiology colleagues.

Christine Jellis, MD, PhD, MBA:

Can I add too, when we think about stroke prevention, that we are a bit more aggressive in that with women. Many of you will hear about the CHA2DS2-VASc score. You collect points if you have got different things like heart failure or hypertension or as you get older. You actually get a point for being a woman, which I always joke with my patients is a little bit unfair, that we get a point already just for our gender, but that is because women are at higher risk for stroke. So it's built into those algorithms that we should be considered for blood thinners earlier than men of the same age. So that's really important that we don't lose sight of that. And I know for many of my patients, stroke is their biggest fear and we really need to be proactive.

And now we have Warfarin, which has been our longstanding preventative blood thinner for atrial fibrillation. But now we have these newer agents too that don't require the stringent blood tests and are a really nice alternative for people who can still travel and do other things, obviously balanced against the risk of bleeding. So I think that's really something important. If you do have AFib, make sure you're asking your primary care doc or your cardiologist, whether or not I should be on a blood thinner. Particularly for women as they're getting older, over 65 typically, we would start to consider blood thinners for women with atrial fibrillation.

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