Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk, Episode 84 I'm your co host, Dr. Kane. I'm Dr. Schuman, and I'm Dr. Patel, and the title of today's episode is rate. Rate, don't tell me rate versus rhythm control and atrial fibrillation. So we'll be providing an overview a little bit about afib, but mostly talking about what are the advantages and disadvantages and kind of the nuts and bolts of rate control or rhythm control in patients with atrial fibrillation. Dr. Khyati Patel 00:55 And if you were waiting to hear something from Peter Sagal, you might as well just change your radio channel right now. So we'll kick Dr. Sean Kane 01:01 it off with a patient case. And this is a fictitious patient. We're going to call her Elsa may she's a 79 year old female who comes to the clinic for just a routine checkup with no specific complaint. She has diabetes, hypertension, hyperlipidemia and heart failure with reduced ejection fraction, also known as systolic heart failure. In terms of her heart failure, she's a New York heart association class two patient, so she has some limitation of her physical activity, and during her vital sign check, it's discovered that she has an irregular and fast heart rate. And her heart rate is somewhere between 100 and 120 it's highly variable. So Dr. Patel's clinic does a 12 lead ECG, and they confirm that she has afib, atrial fibrillation, and this is a new diagnosis for her kind of in talking to the patient, she says, Yeah, I've had some palpitations for a couple months, very non specific. For the most part, she's asymptomatic. When she exerts herself, she might get a little bit of these palpitations, but for the most part, she doesn't even know that there's a problem going on. So in terms of her vitals, as we said, her heart rate's around 100 to 120 and her blood pressure is 125 over 85 and of course, when we have a patient with a new a new arrhythmia, we always worry about ischemia. So we do do an ischemic workup for her, and that, for the purposes of this discussion, is negative. So she has no new ischemia, just a new onset arrhythmia called atrial fibrillation. Speaker 1 02:22 So really, the clinical conundrum here is, is a question of, should we try to convert her back into sinus rhythm using a rhythm control strategy, or should we try to control the rate using a rate control strategy? And so I think the first question for you guys is, what exactly is going on in the in the body in atrial fibrillation? Dr. Khyati Patel 02:38 So basically, it's kind of like an electrical mismatch or a short circuit, right? The definition of atrial fibrillation is when the atria is quivering at a very high rate. So we're talking anywhere between 300 to 600 beats per minute, without any coordination of that movement with the ventricles. So usually they kind of beat in synchrony, but this one atria kind of beats on its own very fast rate, has no synchronization with the ventricles. Dr. Sean Kane 03:08 Unfortunately, all humans have an AV node so that those atrial impulses of 300 to 600 don't convert through to the ventricle, because if your ventricle beat at 300 beats per minute, you would die because you wouldn't have enough time to fill that ventricle. So the role of the AV node is to basically only send some of the impulses from the atria to the ventricle, and in afib, it still does that job, but instead of a normal heart rate of we'll call it 60 to 100 oftentimes, these patients will send too many impulses through that AV node, and they'll have a higher ventricular rate, and that's where they get some of these palpitations. Speaker 1 03:44 So the venture the ventricle does depolarize at irregular intervals here due to a variable number of impulses being conducted via the AV nude. And so again, that one's at the fast rate. And then keep in mind, though, the SA node is usually sending an impulse of 60 to 100 times a minute. But in a fib, the atria are sending the impulse, as you mentioned, hundreds and hundreds and hundreds Dr. Khyati Patel 04:03 of times per minute. So I guess the big question is, can we just not leave Elsa the way it is, because she's not symptomatic for the most part, right? What's, what's the big deal of leaving her in a fib? Dr. Sean Kane 04:15 Well, so one thing to think about, and this is common in many patients with afib, is heart failure. So one of the roles of the atria as it relates to cardiac contraction is that you get this atrial kick, which is this coordination of the atria pushing blood into the ventricle right before the ventricle is ready to contract. So you do lose some degree of cardiac output that's probably related to how fast that ventricle is going. So with Elsa may, for example, her heart failure could get worse. It doesn't appear that it has been, but in the future, especially, she became more stressed or tachycardic, she could go into heart failure or worsening heart failure because of that arrhythmia. Speaker 1 04:50 And so then the heart has to work harder, increasing those two demands, and then you have an increased ventricular rate, possibly symptomatic palpitations. I don't want to talk to my patients. I always like to use. Cars and plumbing as analogy. So I think about the idea at your car not converting into the right gear, and you keep those RPMs going on and on and on in your engine, and again, that can be destructive and keep it from the system itself is less efficient. So I think that kind of applies here as well. Dr. Khyati Patel 05:14 The biggest comorbidity of atrial fibrillation is clot, right that ends up in the brain and then results into a stroke. So the idea over here is that the atria is quivering so fast that it's not pushing out all the blood, and the remaining blood in the atria can clot, producing a clot that can mobilize and dislodge in any of your arteries in the brain. Dr. Sean Kane 05:36 And of course, the other thing that we worry about is kind of the long term complications of being in an arrhythmia that your heart isn't designed to be in. So again, for someone like Elsa Mae, we worry that if her ventricle is going at this pace for too long, we might start seeing structural changes to the heart, especially the left side of the heart, that could actually worsen her heart failure over a long period of time, not just in the acute phase, where it could put her into acute heart failure, but more the chronic phase, where maybe her ejection fraction worsens, maybe the atria becomes more ballooned out. So these kind of chronic structural changes is something that we definitely worry about in leaving someone with afib. Speaker 1 06:13 So Dr. Patel, what are some of the risk factors that would make Elsa Mae at higher risk, or make other individuals potentially at risk for afib? Dr. Khyati Patel 06:21 So our patient here is 79 years of age, so I would say older age definitely puts patient at a higher risk. We are looking at overall population of less than 1% of prevalence. But if you look at those older age patients, we're talking about greater than 80 years of age, that prevalence increases to 8% which is pretty wide difference. Dr. Sean Kane 06:39 And if you actually look at any clinical trial in afib, the mean age is always quite elevated compared to many other trials. So if you look at the doacs, for example, a typical doac trial for venous thromboembolism, like DVTs, those patients are typically like 50s, maybe 60s. If you look at the same drug class, doacs for afib, the mean age is closer to 7075, or even higher than that. Speaker 1 07:04 And the other thing we look at is the NYHA classification. So we mentioned that Elsa May is class two, and so it can range anywhere from class one a 4% prevalence of a fib, all the way to 50% with class four. So this, again, is, as you see, a worsening of progression, again, that the rates of AFib vastly higher there Dr. Khyati Patel 07:24 and other structural heart diseases, such as, you know, cardiomyopathies, left ventricular hypertrophy, long standing untreated or even treated hypertension, but that's, you know, out of control that can lead to atrial fibrillation. Dr. Sean Kane 07:39 And then finally, in my neck of the woods, which is probably a very different pathophysiology, we see AFib in acutely stressed patients. So this could be after open heart surgery, where the heart has just been cut on and now we start seeing these electrical short circuits, or my favorite patient population, the septic shock patient population, we see a ton of new onset AFib in that population, just because of the acute stressors and the cytokine storm that happens. Again, it's an irritation of the heart that causes these arrhythmias, but probably a different patient population. Speaker 1 08:09 And so then, now, you know, again, we look forward, before we get to kind of talking about medications, really want to define the goal that we're trying to target and then determine what treatment to get there. So really, with our goals, first thing to do is to look at slowing that AV node conduction, again, Dr. Kane, as you mentioned, so that fewer of those impulses get through the ventricle, and so that system is not going so fast. And maybe a net effect of slowing that ventricular rate or the heart rate, and then, because of that, subjectively, the individual may feel fewer of those palpitations within the chest. Dr. Khyati Patel 08:37 And so obviously we were talking about rate control, and so we had to talk about, what is that heart rate goal for most patients, if we are using medications to control the rate. So the classic goal is to keep the heart rate less than 80 beats per minute unresting and less than 100 beats per minute, if it's with exertion. But then we look at some trial results, and the race to trial showed that keeping a little bit more lenient goal, so that's the resting goal of less than 110 beats per minute is okay as long as patient is not symptomatic and having palpitation complaints. Dr. Sean Kane 09:11 And the problem here is, again, heart failure is a common comorbidity in this patient population, and the vast majority of the AFib trials they under represent this really important patient group of heart failure patients. So using race two as an example, we didn't see a lot of class two, and definitely very few class three and almost no class four heart failure patients. So because they're underrepresented, and it's a population group that may have a detrimental effect from tachycardia, the AHA/ACC/HRS guidelines, which are linked in our show notes for episode 84 they actually recommend this more lenient goal for everyone, unless you have a reduced ejection fraction. And then they still recommend this more conservative, less than 80 beats per minute resting heart rate goal if you do have systolic heart failure. Dr. Khyati Patel 09:56 So I mean the common therapy that comes to mind when. Comes to rate control, are things that slow down AV node conduction. We are looking at beta blockers. We're looking at the non dihydropyridine calcium channel blockers and perhaps even digoxin Speaker 1 10:12 for Elsa may you're thinking, Should probably already be on a beta blocker. So something like Metoprolol, probably the succinate formulation, or carvedilol. What about non dihydropyridine, something like diltiazem or Verapamil. Dr. Sean Kane 10:23 So normally this would be a great option for someone with afib. The problem is that she also has systolic heart failure. This drug class, diltiazem, verapamil, these are contraindicated in systolic heart failure. So we've really knocked out that drug class for her with respect to rate control. Speaker 1 10:37 And for me, the burning question always is, what is the role currently of digoxin. So where are we at? Dr. Khyati Patel 10:42 Guys? Probably not for monotherapy. My understanding is that it should be used as an add on, because, again, it doesn't work very effectively to control the atrial rate, and we have to be careful with this drug having narrow therapeutic windows. So we have to dose accordingly and check the levels and make sure that, you know the levels are appropriate for AFib versus the heart failure. Again, our patient has heart failure, so will be a lot of people who have afib. Speaker 1 11:10 So I think to expand out beyond just, okay, the medications, but looking at the this overall idea about rate control, advantages of it, again, these are medications I think that we're all pretty familiar with. Again, I'm sort of by no means a cards expert, but, you know, I'm fairly comfortable with the use, for example, of beta blockers to address heart rates. Drug titration is easy. Monitoring fairly straightforward. Again, we've got a heart rate we want to control it. What's the rate at now? So what are some disadvantages, though, that the kind of a clinician may want to look for? Dr. Sean Kane 11:38 So one problem is that, if you think about it, we're actually treating the symptom, not the underlying problem. So the patient is an afib. We've done nothing for the afib. We've just controlled the ventricular rate. And it feels weird, right? That we haven't actually done the underlying problem. It's like giving Tylenol for an infection. Sure, that's something that's helpful, but intuitively, you want to fix the underlying problem that caused the palpitations in the first place, and it just seems wrong to not bring a patient back to their natural rhythm of sinus rhythm. Dr. Khyati Patel 12:08 And what would be some of the risk if we were to leave patient in afib, right? So we're, as we talked about earlier, will be increased cardiovascular events, even worsening of their existing heart failure, if that was the case. So talking about fixing the underlying problem, I guess you're pointing out that we should fix the rhythm itself, right? So the other strategy is, do we do the rhythm control or not? What's the deal there? Speaker 1 12:33 So again, at this point, we're looking at, actually, as you mentioned, treating the underlying concern. So cardio, averting the individual back into NSR, normal sinus rhythm using direct current cardioversion electricity, or potentially we have medications that are designed as an antiarrhythmic Dr. Sean Kane 12:48 then, of course, once you temporarily convert the patient back to sinus rhythm, very commonly, you'll give them additional drug therapy to maintain them in sinus rhythm again with antiarrhythmic drugs. So it's kind of this two step approach. One is the actual cardioversion, and then the second one is this drug strategy to maintain their sinus rhythm and prevent them from going Speaker 1 13:07 back into afib, right? So as far as again, medications again, I said my clinic, we're usually more focused on rate control, the meds I'm more comfortable with. So what is out there? What are kind of the current strategies as far as rhythm control? Dr. Khyati Patel 13:19 So for the rhythm control, we have to look at what are the other concomitant comorbidities that the patient has. So if our patient has heart failure, so if the patient can has a past medical history of heart failure, the appropriate therapy will be amiodarone or dofetilide. Brand name is Tikosyn, good. Speaker 1 13:36 So that really hasn't changed since I was in pharmacy school. All right, I can work with that. Dr. Sean Kane 13:39 So the other thing to think about is, if you don't have heart failure, but you have either structural heart disease, so on echo, they see problems with the actual structure of the heart, or if you have a history of coronary artery disease, that means CABG stent and MI anything like that, your drug therapy is different. So our first line therapy for those patients is again, dofetilide or Tikosyn, dronedarone or Multaq or sotalol. Brand name is Betapace-AF, with the caveat that the sotalol component here is not appropriate if you have left ventricular hypertrophy, if that heart muscle is very enlarged. Speaker 1 14:11 So I guess the question then is always think about amiodarone as the go to. So why not use amiodarone in that situation? Dr. Sean Kane 14:17 So the problem is that amiodarone is really effective, but has a ton of what they call extra cardiac toxicities. So this is everything from your skin turning blue gray to your thyroid not working, to pulmonary fibrosis, to lft increases, to rash. It has a ton of toxicities associated with it, almost all of which don't deal with the heart at all. So because of that, if there are other drug therapies that we can use, especially if you're a little bit younger, we really prefer to avoid the use of amiodarone, unless we really have to use it. Dr. Khyati Patel 14:46 And what if a patient doesn't have any of the comorbidities that we just talked about? What do we do then? Speaker 1 14:51 So I guess in that point we've really got all of the options available. First line is probably still going to be dofetilide, Tikosyn. We've got dronedarone or Multaq. Again, we've got flecainide, which haven't mentioned yet, Tambocor, brand name, propafenone, Rhythmol brand name, sotalol, again, Betapace as that option. And again, I think in this case, amiodarone relegated to second line instead is because of some of those same extra cardiac toxicities. Dr. Khyati Patel 15:15 And again, another reason for amiodarone to be second line, in addition to all these toxicities and monitoring that you said, Dr. Kane, is drug interactions, right? Some of these patients are going to be on anticoagulant drug. If they can't afford or the insurance doesn't cover the doacs, then they're going to be on drugs like warfarin, which carries a huge drug interaction with amiodarone. Dr. Sean Kane 15:35 And I think if you the listener, are a little overwhelmed by the barrage of drug names that we just listed, we could easily do an entire episode just on anti arrhythmic selection. And that actually proves a point too, which is, this is a really complicated topic, when you get into this rhythm control strategy, that we'll talk about some of the disadvantages in a second. But hopefully that proves the point that it's not a simple, straightforward pick a beta blocker and titrate up. Now we're really thinking about who is appropriate for what agent, and how do we monitor it, and things like that. Speaker 1 16:04 So then there's a couple advantages of this strategy we already kind of covered. The first one is that we're putting you into that natural sinus rhythm, rather than just simply a symptomatic treatment. However, not all the time. A number, a good number of individuals will not stay out of afib, so they'll kind of spontaneously go back in, in and out of rhythm. The rates of rhythm will vary depending upon how often you're monitoring the patients too. Yeah. Dr. Sean Kane 16:27 So as an example, if you do a spot check where every six months you go in and see if you're in afib, the risk of going back into AFib is about 20% depends on a lot of different factors. But if you look at a study where they do more continuous monitoring, so they send a patient home with a Holter monitor for an extended period of time, the risk of failure approaches 50% or even higher at one year, meaning that 50% or more of patients will end up in AFib for a couple seconds or a couple minutes, maybe while they're sleeping, and no one knows it, and you wouldn't detect that in clinic, but there is some amount of breakthrough that happens in a patient population with afib. Speaker 1 17:03 The other thing I note I do know is a number of the patients who are monitoring for anticoagulation because of history of afib, if they end up in normal sinus or them for a period of time, there ends up being kind of a dialog going with cardiology about whether or not you can stop the anticoagulant. So what are the thoughts there, though? Because I know anytime that I see it in our clinic, there's usually a pretty good argument about what to do. Argument about what to do. Dr. Khyati Patel 17:23 Yeah, most of my patients are, you know, ready to go off of warfarin, especially because of the very frequent INR monitoring. But regardless, you just said, Dr. Kane, that, you know, you might put these patients on Holter monitor or do the spot check and find that there are still have episodes of AFib or in the paroxysmal atrial fibrillation. And so it is a little controversial whether we can pull the plug of anticoagulate completely for this patient, but it might be helpful to decide in patients who are perhaps high risk of bleeding, poor candidates for anticoagulation, that we can use this strategy to pull the anticoagulant drug. Dr. Sean Kane 18:02 Yeah, so I would still list this as a potential benefit or advantage for the rhythm control strategy. Is that in some patients, you may be able to get rid of the anticoagulant, but as a blanket statement, it's not correct that you don't have to be on an anticoagulant. Speaker 1 18:16 So then, what are some disadvantages as far as the strategy that we have to look at. Dr. Khyati Patel 18:21 Well, antiarrhythmics are, to begin with, very complex. Again, we talked about how the drug selection depends on lot of different factors, mainly the comorbidities that the patients have, but also looking at whether they are ready to do frequent monitoring for drugs such as amiodarone. You know, some of these clinicians are not very familiar with the drug. Some of these drugs needs to be actually started in the hospital with proper monitoring, right? So we were looking at all these drug specific issues that we need to know and patient needs to know before we can say, this is your chronic therapy. And then Speaker 1 18:55 just another thing to mention, just like we talked about antidepressants and renal function the past, renal function here matters for a lot of these medications too. So again, individual with a lot of complex comorbidities, this is one other wrench in the works we have to be very careful of, Dr. Sean Kane 19:09 and for me, especially, being in the ICU, with respect to acute kidney injury and renal dysfunction, as soon as I see a patient on any of these anti arrhythmics, a red flag always goes up, because it is a huge safety issue in terms of now that they're in the hospital, things have changed, right? And antiarrhythmics are pro arrhythmic in almost all circumstances, especially if you're giving the wrong dose or monitoring inappropriately. So someone has hypokalemia, you start a new drug that causes Qt prolongation, their renal function gets worse. For whatever reason, things can change when they get to the hospital. So from a safety perspective, that should always raise a red flag. But even in the clinic setting, proper monitoring is important to make sure that they don't get things like Qt prolongation and put them at risk for arrhythmias. That's a huge deal. Dr. Khyati Patel 19:55 And I think you're pointing out to the bad ones, like the torsades de pointes that. Is a possibility if patient is an acute alterations of health status. Speaker 1 20:05 So, yeah. So I think in the end, some of it is that the process of, kind of choosing that medication which you want is is based on clinical trials, number of them showing harm when giving an antiarrhythmic to a certain patient population. And again, we always have to look at is always about what is the actual population, in those studies relative to your patient population you have you want to keep in mind things like using propafenone or flecainide patients with history of CAD they died more often there. So probably something you want to be careful of in choosing that medication for your patient population. Dr. Sean Kane 20:34 Yeah, so I think suffice it to say, the biggest disadvantage with the rhythm control strategy is going to be extra monitoring, extra side effects, and potentially a side effect, including death because of side effects of the drug, absolutely. Dr. Khyati Patel 20:48 So I guess the golden question here is, what is the best strategy? Do we go with the rate control? Do we go with the rhythm control? Unknown Speaker 20:55 Dr. Kane, what do you Dr. Sean Kane 20:55 think so if you look at the guidelines as with any good question, the best answer here is, it depends so the guidelines, whether you look at the American guidelines or the European guidelines, they don't specifically say we endorse x approach, whether it's rate or rhythm control. But one thing that I really liked about the European guidelines, for example, is that they brought in things like patient preference, where you educate the patient on the two strategies, and you give them pros and cons of each one, and you have shared decision making, which I think is incredibly important, especially in someone like this, where these are typically older patients that may not want to be in the hospital for a couple days to have their anti arrhythmic monitored, or maybe they don't want to pay for this new, expensive anti rhythmic medication. Yeah. Speaker 1 21:40 So I think, in general terms, we're also looking at, again, the likelihood of things like, can, you know, staying in or out of rhythm. So one of the things rhythm control may be better in those younger individuals, patients who haven't been in a fib as long, there's less structural heart disease, more symptomatic palpitations. Again, we want to try to put them back in rhythm so you can keep them in there for a period of time. On the flip side, you've got an older individual with long standing afib, and there's really concern about whether or not we're gonna be able to get them back into rhythm or mild or palpitation. That may be best then just to slow down and do a rate control strategy. Dr. Sean Kane 22:11 And if you actually look at the literature, there's kind of rationale for why there is not a first line preferred therapy. A lot of it deals with the trial called the affirmed trial. Dr. Khyati Patel 22:21 Yep. And to our listeners, the reference for the affirm trial is in our show notes. But basically, what this trial did is compared about 4000 patients and give them either rate control or rhythm control strategy. And what we found is there was no difference in mortality, right? That's like the biggest outcome that really matters, whether you know they're in the sinus rhythm or afib, but the ultimate result is that, so there was no difference between the two strategy when it came to mortality. However, patients who were in the rhythm control group had more hospitalization. So we are looking at morbidity data over here. There was 80% in the rhythm control group versus 73% in the rate control group. Speaker 1 22:59 Now there's got to be other trials out there? Maybe some. Dr. Kane, are there others? Maybe some with some fun, catchy, sounding names. You got anything for me? Dr. Sean Kane 23:05 There are. We have the PIAF trial, the RACE trial, RACE one, the STAF trial, and then my personal favorite, the HOT CAFE trial, yum. And these were all way smaller than AFFIRM, which is why AFFIRM is such a big deal. And as soon as you talk about rate versus rhythm AFFIRM is the thing that comes to your mind. But these are still important trials, right? So if you kind of group them all together and kind of take them out, what the results were, we basically saw similar clinical outcomes, whether it was kind of mortality or some cardiovascular endpoint. For the most part, we see a similar quality of life, and we see similarities with respect to symptoms related to afib, like palpitations, so we don't really see any difference with respect to those end points. Some of the trials did indicate maybe slightly better exercise tolerance if we had a rhythm control strategy, but we did see, again, more hospitalizations and also more adverse drug reactions with a rhythm control strategy versus rate control, just like what we saw in AFFIRM and just to put a number to it, in HOT CAFE, for example, one of my favorite acronyms, 74% risk of being hospitalized with rhythm control versus 12% risk of being hospitalized with rate control. So that's pretty significant. It's super significant, and part of that may deal with the fact that some of these agents for rhythm control, you have to be in the hospital to have titration done, especially with monitoring and things like that. But even with that said, that is incredibly inconvenient for a patient to have to sit in a hospital bed just to have their drug therapy titrated. Speaker 1 24:32 Yeah, I think it goes back to again, something you mentioned is the quality of life piece about what we're trying to do here, Dr. Khyati Patel 24:38 and then thinking back to our patient also may she has heart failure, right? So it's keeping in mind that most of these trials don't include or under represent the patient who has that concomitant comorbidity of, you know, having a heart failure. So again, remember that AFib and CHF co exist very commonly, but these patients are underrepresented. In these trials. So question is, can we apply the results of these trials to our patient? Speaker 1 25:05 So maybe there's a really good trial, again, with a really catchy name. Dr. Sean Kane 25:09 There is Dr. Schuman. So in this case, the trial would be called the AF-CHF trial. It's not catchy. So the AF-CHF trial was 1300 patients with afib who also had a reduced ejection fraction and had CHF, symptoms of CHF. And Try as they might, they did not show any difference with any clinical outcome that you would care about, whether it's cardiovascular death, all cause mortality, worsening heart failure. But again, they also did show that if you were in the rhythm control strategy arm, your risk of hospitalization in the first year was higher, 46% versus 39% and then the trial failed to show a statistically significant increase for the entire duration, so not just a one year hospitalization rate, but the entire trial duration. But they were really close with a P value point 06 So given all of the data that we have, I think it's fair to say that whether you have heart failure or not, whether you're in the smaller HOT CAFE type trials or the AFFIRM trial, we see a similar scenario, that clinical outcomes are probably the same, but hospitalization risk is worse with the rhythm control strategy. Speaker 1 26:09 I think it kind of goes back to what you're mentioning, Dr. Kane about you know, especially early on, that it's about getting it right, trying to figure out the right dose the hospitalization, to start the medication, and that as time goes on, maybe the difference seems to level out as now the individual, once they've gotten through all the the ups and downs of adjusting their rhythm with troll regimen that they seem to in the long run, hospitalization similar. So that may be important to note Dr. Khyati Patel 26:32 down the road and also to think about. You know, these studies looked at whether the patients were hospitalized or not for various different reasons. Dr. Shuman, you just mentioned, but antiarrhythmics do come with monitoring requirements too, right? So again, what you said, Dr. Kane earlier, about involving patient and making a shared decision whether they are willing to come to the clinic very often to do this extra monitoring or even that spot checking, as you were saying earlier, it's really important to discuss that with patients. Dr. Sean Kane 27:01 So let's go back to our patient, Elsa May. You know, we've kind of covered the pros and cons of both the rate and the rhythm control strategy. What are some factors? Obviously, we've talked to Elsa May, but what are some factors that might push us in one direction or the other? So I think the Speaker 1 27:14 first thing to look at is some of those patient specific factors. You know, maybe we're initially leaning towards rate control, but reasons for it? Again, we're talking somebody who's maybe an older individual, very mild symptoms, so maybe in that case, we can just up titrate on her beta blocker regimen. Again, especially, you know, an outpatient setting, fairly easy to do, fairly easy to monitor. And if you think about it, beta blocker is used pretty commonly for CHF as a whole, and so she may benefit from the medication, as it were, just to increase it anyway. Dr. Khyati Patel 27:43 So here we're talking about not adding another medication, but just optimizing what she's on, so maybe less drug related cost, less pill burden. You know, these are all favorable things if you look at patient adherence perspective, Speaker 1 27:55 and then I think also to look at, you know, the patient preference. So does she want to be cardioverted? Is that going to be again for an older and is that? What kind of hassle? Is that? What else we bring into the table when we hospitalize somebody maybe doesn't want that and all the path of initiation, titration, Mantra, again, anything else going on in the hospital, the stress of it all. Dr. Sean Kane 28:14 And, you know, I think that it would be absolutely wrong of us to just conclude without talking about her stroke prevention management because of her afib. Dr. Khyati Patel 28:23 So as we as we said earlier, patients with afib are at higher risk of embolic stroke. And so the strategy we employ in deciding whether a patient goes on anticoag or not is calculate the CHADS2 score, right? So if we calculate her CHA2DS2-VASc score, she gets one point for heart failure, one point for hypertension. Her age gives her two points. Because we're looking at CHA2DS2-VASc score. She has diabetes, so she gets one more point for that. And her gender, being female, gives her one point. So we got six points. And what it means to have six points is that she's a very high risk of having a stroke. So whatever strategy that we go with, either rate control or rhythm control, we have to make sure that she's on proper anticoagulation treatment right. Speaker 1 29:07 And then we have to look again about some of those drug interactions that may influence the rate control versus rhythm strategy. Dr. Sean Kane 29:14 And of course, this could be its own podcast episode in terms of anticoagulation management in afib. But the most important thing to take away is that AFib management is kind of this bi directional approach where you're worried about the stroke management and the stroke prevention, but you're also worried about the rhythm component of it, whether it's rate or rhythm control and the palpitation management. So you really have two very distinct goals of therapy that you always have to think about when you have a patient with afib. They're both very important. So to kind of wrap things up in terms of some key points for me, number one is older age and heart failure are two of the most common risk factors for afib. With that said, though heart failure is a very commonly underrepresented patient population in the AFib trials, and sometimes we have some question marks in terms of, what are our goals of therapy? What is the most. Appropriate management strategy for those patients. Speaker 1 30:02 And so the second point is, maybe one of the first things that come to mind is the idea about a rate control strategy using a beta blocker, non dihydropyridine calcium channel blocker, maybe digoxin, to reduce the ventricular rate, give that symptomatic relief, to decrease the palpitations. Dr. Khyati Patel 30:16 On the flip side, if you're looking at rhythm control, that involves, you know, a cardioversion in the hospital, and then the use of antiarrhythmic medications on the outpatient side to maintain that sinus rhythm and prevent the recurrence of them coming back to afib. Dr. Sean Kane 30:32 And essentially, there is no long term clinical outcome difference between rate and rhythm control. Rate control, you have fewer hospitalizations, which is a big deal. You also can utilize drug therapy that has fewer ADRs, that people are more familiar with, in contrast. So rhythm control may give you slightly better exercise tolerance, but the problem with rhythm control is that it isn't always effective, and actually, for a number of patients, it's ineffective in maintaining sinus rhythm, and it requires very close monitoring. So I think that wraps up episode 84 quite well. If you'd like to take a look at our show notes, we have both the AFFIRM trial, the AF-CHF trial, and also the AHA/ACC/HRS guidelines for management of afib. We love the five star reviews on iTunes, so keep those coming with that. I'm Dr. Kane, Dr. Khyati Patel 31:17 I'm Dr. Schuman, and I'm Dr. Patel, and as always, study hard. Narrator - Dr. Abel 31:22 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 31:33 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.