Atrial Fibrillation with Dr. Aseem Desai: Rational Wellness Podcast 181

Dr. Aseem Desai speaks about Atrial Fibrillation with Dr. Ben Weitz.



Podcast Highlights

9:58   Arrhythmia is an abnormality of the heart’s electrical system that can result in bradycardia, where the heart rate goes too low and often presents with fainting or extreme fatigue. It can result in tachycardia, which is when the heart rate becomes fast and in some cases can go above 200 beats per minute.  And then there are irregular heartbeats, which are broken down into two categories: 1. Benign, which include premature beats that can occur from the top chamber of the heart, the atria, or the bottom chambers of the heart, the ventricles. 2. Conditions like Atrial Fibrillation (AFIB), which are quite dangerous and can cause stroke, congestive heart failure, as well as reduced quality of life.

11:09  How dangerous AFib is depends upon your stroke risk factor, which is determined by the CHA2DS2-VASc scoring system. C is for congestive heart failure. H is for hypertension. A is for age. D is for diabetes. 2 is for prior strokes or blood clots. A higher score is correlated with a higher risk of stroke.  Even though age increases the risk of AFib, there are significant numbers of young people with AFib, esp. athletes. For example, NFL players have 6 times higher risk of AFib. This may be because athletes tend to have a lower heart rate and people who have a very low resting heart rate have an increased risk of having premature beats and these can be a trigger for atrial fibrillation.

14:07  Dr. Desai does not think it makes sense for those with a low heart rate, like athletes, to attempt to raise their heart rate with increased sodium consumption or by taking licorice.  Arrhythmia does not occur simply because you have a low heart rate. A resting heart rate of 40 or 50 is only one factor along with drinking a lot  of alcohol, sleep apnea, or goes on to gain weight after retirement goes on to develop high blood pressure or diabetes.  It is the over activation of the parasympathetic nervous system that can trigger arrhythmias like AFib. This is not to say that being stressed out, in flight or fight mode too much of the time and having overstimulation of your sympathetic nervous system is not also a problem and a risk factor for AFib.

18:01  Some of the most common risk factors for AFib include: 1. age over 65, diabetes, 2. high blood pressure, 3. thyroid disease, 4. heavy alcohol use, 5. sleep apnea, and 6. obesity. Even one glass of alcohol is associated with an 8% increased risk of an AFib episode.  Chronic high blood pressure increases the stretch in the left atrium, the the top left chamber of the heart, which is the trigger for AFib. There is an inflammatory component with AFib, which is why diet and supplements can be beneficial.  Environmental toxins can be triggers for AFib. And there is a close connection between the gut and the heart and gut issues can trigger heart problems.  Acid reflux can be a trigger for AFib, since the esophagus sits right behind the heart.  Even just eating really large, fatty meal can activate the vagus nerve and trigger an AFib episode.

27:37   Diet can play a role in preventing and controlling AFib, though this should be individualized to each person.  The Mediterranean diet is probably best for most patients, though some do better on vegetarian or a lower carb diet like Paleo.  Some patients are able to take care of their AFib purely with diet and lifestyle modification, though some need medication and some need a catheter ablation procedure. AFib is a progressive disease and AFib begets AFib.  It is an electrical cancer.  Early detection is important and in order to detect AFib, there are some great biometric tools out there, including the Apple watch and KardiaMobile, which you can buy on Amazon for $90.




Dr. Aseem Desai is a cardiac electrophysiologist (EP), a physician specializing in heart rhythm disorders.  He has been caring for people with atrial fibrillation (AFib) for over seventeen years and currently practices in Orange County, California.  He has published a number of scientific papers and he just published his first book, Restart Your Heart: The playbook for thriving with AFIB. His website is DrAseemDesai.com

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



Podcast Transcript

Dr. Weitz:            Hey this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website drweitz.com. Thanks for joining me, and let’s jump into the podcast.

                                Hello Rational Wellness Podcasters. Thank you for joining me again today. Our topic is atrial fibrillation with Dr. Aseem Desai. This is actually the most common form of arrhythmia diagnosed in clinical practice. It’s estimated that between 2.7 and 6.1 million Americans are living with AFib. I got that from Dr. Desai’s book. Interestingly there’s such a broad range I guess it’s not clear necessarily whether people know they have this or not, but that’ll definitely be something we want to understand.  But as our population ages AFib incidence is increasing. So I just mentioned arrhythmia, so what is arrhythmia? Well this is basically a problem with the rhythm of the heart which occurs when your heart beats too fast, too slow, or irregularly. Some forms of arrhythmia are harmless while others can cause serious damage and even death. Your heart has four chambers. There are two upper chambers known as the atria and two lower chambers known as ventricles. Your heart also has a built in electrical system that controls the coordinated contraction of the muscles of these chambers resulting in your heart beating between 60 and 100 beats per minute while at rest.  If the heart beats too fast this is a type of arrhythmia known as tachycardia. Well with slow heart rate is known as bradycardia. Atrial fibrillation is a type of tachycardia that originates in the atria and it can be a serious condition that can lead to stroke if it’s not controlled or managed properly.

Now we’ve had a number of discussions about the cardiovascular system on this podcast, but we essentially have focused on conditions like how to prevent and reverse atherosclerosis and hypertension.  So essentially we focused on, to use a analogy from construction, we’ve focused on the plumbing, and then the engine that helps drive the blood through the body which is the heart. But now we’re going to talk about the electrical system of the heart. Our interview today is with Dr. Aseem Desai who’s a cardiac electrophysiologist which means that he’s a physician specializing in heart rhythm disorders. And he’s been caring for people with atrial fibrillation for over 17 years and currently practices in Orange County, California. He’s published a number of scientific papers and he just published his first book Restart Your Heart: The Playbook for Thriving With AFib. Dr. Desai thank your for joining me today.

Dr. Desai:             Thank you very much Dr. Weitz. Thank you for having me.

Dr. Weitz:            So before we get into the specific questions about the cardiovascular system, I noticed that you and I have something in common which is that we both have an undergraduate degree in philosophy. How did you come to study philosophy with an interest in cardiology?

Dr. Desai:             I love it. I love that I’m meeting a fellow philosopher. We could talk about Aristotle the whole episode here. Yeah no so I was part of the seven year medical program at Northwestern so as a high school senior you gain admission to college and med school at the same time, and the idea was to foster an interest in liberal arts. And so we did have a double course load. Pre med as well as liberal arts major, but it really kind of opened my mind. I think I tend to look for challenges and I don’t know about you Ben but this was probably one of the biggest challenges was reading philosophy and writing the papers. And what’s interesting is to this day I still use a lot of the logical reasoning, the deductive reasoning even when I’m doing, when I’m taking care of heart patients and making diagnoses.

Dr. Weitz:            Right. I know for myself one of the things that I got out of philosophy is when you study philosophy you learn that there’s not a lot of concrete answers, but you want to get closer to those answers. And the way you do that is by being critical and asking good questions.  And so I think that’s also important in medicine to be critical when people make statements and challenge them and try to get closer to the best answer we’ll have at that point in time.  So I think that’s helpful–how philosophy has helped me.

Dr. Desai:             Absolutely Ben and to your point I also think it keeps you with an open mind, a beginners mind. 

Dr. Weitz:            Yes.

Dr. Desai:             I think that as physicians we do have a tendency to not have that and especially…

Dr. Weitz:            We think we know everything yeah.

Dr. Desai:             Yeah. Right. Exactly. And so I think that, I mean I look forward to learning as much from you as you will from me perhaps during the podcast and as well as your viewers. I always welcome feedback, your listeners. So I do think that these two philosophers on this podcast today will have a lot to say to each other.

Dr. Weitz:             So how did you come to specialize in heart rhythm disorders?

Dr. Desai:             Well it’s very personal. So when I was about three, my dad had a heart attack. He was 37 at the time and although I don’t have much memory of that, I think many things for kids, they get ingrained in your brain even if you may not be able to process what’s going on. And he was an oncologist so I actually saw him not only as a physician but I saw him becoming a patient and I saw how this heart disease really robbed him of enjoying his life and he was fearful that he was going to have another heart attack.  And so as I went through college, high school and then college, I had an interest in science and unfortunately in the middle of medical school, me second year of medical school he actually suffered a cardiac arrest.  And he was in India at the time and in most cases the cardiac arrest is actually due to abnormal rhythms from the ventricle, from the bottom chamber.  It’s called ventricular tachycardia and ventricular fibrillation.  And in many cases as you mentioned with regards to the plumbing of the heart, a heart attack or a blocked artery, the clot that forms in a plaque can actually induce the ventricular tachycardia and ventricular fibrillation and cause sudden death.  So I think that really got me focused on the electrical system of the heart. And as I went through training and residency and then in fellowship I just found the electrical system quite a challenge. To be honest I was terrified of cardiac arrhythmias when I was a medical resident.  I mean they were really hard to understand and interpret electrocardiograms which are the recordings that we do for the heart’s electrical system and I don’t know about you Ben but mentors kind of come across your paths in different ways.  When I was a medical intern at Stanford and I was sitting reading EKG’s as part of the cardiology rotation. And it happened to be right near the electrophysiology office and electrophysiology is the branch of cardiology where we do study and treat these rhythms.  And one of the attending physicians saw me reading EKG’S and came up to me and said, “Hey you want to write a paper with me on IV Amiodarone?”, which is a drug that we use for cardiac arrhythmias.  And the next thing I knew I was writing a paper. Had no idea what I was doing, but I did publish it and I think the story goes on from there.

Dr. Weitz:            Yeah I had sort of a recent experience with arrhythmia.  I had a EKG done and after the EKG was done my doctor left the room, came back, and repeated it. And then decided to leave the room and repeat it again, and he brought another doctor in. So in between I got up and looked at the sheet of paper that read out, and the paper read that this patient is having an acute MI and I was feeling completely fine. And he came back in the room and I said, “Hey doc. Whatever’s going on, I could have something wrong with my heart, but I am not having an acute MI.”  And so it turns out I have a early repolarization variant.

Dr. Desai:             Mm-hmm (affirmative).

Dr. Weitz:            And which is something that happens in people who are athletic and so then I also had to have hernia surgery recently and I had to make sure everybody was on board with this. That they suddenly weren’t going to freak out when I was under anesthesia and somewhere or anywhere along the line that somebody saw my EKG.

Dr. Desai:             Well I think you make a great point Ben that you actually should carry a photocopy of an EKG.  If you have an abnormal EKG and it’s truly normal just a variant of normal which is what early repolarization is it’s always a good idea to actually carry a copy of it.

Dr. Weitz:            I do I have it in my phone.

Dr. Desai:             Yeah. Yeah. Yeah because like a radiologist with chest x-rays, as cardiologists we often will look at an old EKG to really get a sense of is there a new change and it really illustrates the room that we have to move on our artificial intelligence algorithms and these EKG machines.

Dr. Weitz:            Certainly the readout from that machine was not correct. Maybe you could explain a little more about exactly what is arrhythmia?

Dr. Desai:             So arrhythmia is a generic term used to describe any abnormality of the heart’s electrical system and that can result in something called bradycardia where the heart rate goes too low and often presents with fainting or extreme fatigue. It can result in tachycardia which is where the heart rate goes too fast. A common symptom there would be a sense of a racing heartbeat, and sometimes if the heart rate goes fast enough, and in many cases it can go over 180, 200 beats a minute, people can faint with that as well.  And then you have irregular heartbeats and so irregular heartbeats are really broken down into two categories benign which include what we call premature beats that can occur from either the top chambers of the atria or the bottom chambers of the heart, the ventricles. Or conditions such as atrial fibrillation which are quite dangerous and can cause stroke, congestive heart failure, as well as reduced quality of life. So it really is a generic term, arrhythmia. And it encompasses bradycardia, tachycardia, and irregular heartbeats, AFib being the most common. But it’s important to mention that not every irregular heartbeat is AFib.

Dr. Weitz:            How dangerous is AFib?

Dr. Desai:             It’s actually very dangerous. It depends on your stroke risk factor score first off. So we use a scoring system called CHADSVASC. It’s an acronym and you calculate the number of points that include some such as congestive heart failure, high blood pressure, age, diabetes. And as you add up these points there’s a lot of large databases that have shown that once you hit a score of 2 or higher your stroke risk is actually quite high with AFib and it continues to go up as the points get added up and so we, just like many areas of medicine and I’m sure in your case as well, you look at a person’s health and you do a risk stratification, priority stratification and it’s no different with AFib. So you can have young patients actually that get AFib, especially athletes.  We’re seeing a larger population. Those patients tend not to be as high risk for stroke but certainly impacts their quality of life though.  NFL players have a six times higher risk of AFib compared to their counterparts. Most people don’t realize this.

Dr. Weitz:            Really? Why do you think that is?

Dr. Desai:             That’s a good question. So we’ve now learned that the nervous system is a big component of heart rhythm problems. So the nervous system, just like inflammation is a big part of many different illnesses including coronary disease and GI issues. The nervous system, the autonomic nervous system which includes the Fight or Flight which is the sympathetic and the Rest and Relax–the parasympathetic, actually is heavily involved in the genesis of cardiac arrhythmias. So for example, athletes have often a low resting heart rate and that has to do with the vagus nerve. The vagus nerve, being that part of the nervous system that helps to preserve your energy really. There’s no point in your heart rate being 90 beats a minute when you’re sleeping. So a good conditioned athlete often has a low resting heart rate.  But just like anything in life, extremes may not be a good thing and people who have a very low resting heart rate have an easier ability to have what are called these premature beats that I referenced earlier.  Why I said that premature beats are benign, that’s not exactly true.  If you have enough premature beats, especially from the atria and under the right perfect storm so to speak it can be a trigger for atrial fibrillation so one thought with the football players and other athletes including triathletes for example is that this low resting heart rate predisposes to these premature beats.  Because there’s a longer time interval between beats with a low resting heart rate so it’s easier for these extra beats to be a trigger and if you think of AFib as a fire, you have the matches and you have the wood.  And the matches would include something such as these premature beats, would include things such as alcohol, variety of other factors.  And then the wood are the risk factors for AFib which would include things such as age over 65, diabetes, sleep apnea, a whole host of things that we can get into.

Dr. Weitz:            So would it make sense for an athlete who has a lower resting heart rate, for example myself, actually when I was on when I was in the pre op, they, my heart rate was right around 50 and down to 48 and up to 55 and they kept going, “Oh. You’re an athlete. You’re an athlete.” And they were freaking out a little bit. Does it make sense for somebody with a low resting heart rate to try to raise their resting heart rate?

Dr. Desai:             Well it’s a good question and the problem with this is you can’t really do that from the standpoint of, I mean other than taking in stimulants such as amphetamines.

Dr. Weitz:            Well could you for example take in more sodium? Could you eat licorice? We just heard about somebody who ate so much licorice that they died actually.

Dr. Desai:             Right. Yeah the problem with licorice consumption is that it more predisposes to dangerous heart rhythms rather than purely increasing your heart rate.  And it’s not that low heart rate in and of itself.  It’s, with arrhythmias like AFib it’s the perfect storm.  So we’re now learning there’s quite a bit of complex genetics with AFib. So not every athlete with a heart rate of 40 or 50 is going to get AFib by all means, but if that athlete consumes a lot of alcohol, if that athlete has unrecognized sleep apnea, if that athlete puts on weight after they retire and goes on to develop high blood pressure or diabetes, that’s really, it’s that adding up of risk factors.  It’s just that when you have a low resting heart rate that kind of puts you at a little bit of a higher risk.  But we’re still working it out. We’re still trying to determine what’s going on. But you ask a good question which is, is it the heart rate itself? And I would say no it’s more, it’s that over activation of the parasympathetic nervous system.  And it’s not just the heart rate.  The actual vagus nerve, when you stimulate it either in laboratory models or even when we’re doing a procedure called catheter ablation, and you stimulate the vagus nerve which you can do, it’ll actually trigger AFib and it has nothing to do with low heart rate. It’s literally stimulating that nerve and the release of the acetylcholine and other components that can be a trigger for arrhythmias.

Dr. Weitz:            Now is it the overstimulation of the parasympathetic or the sympathetic?

Dr. Desai:             That’s a great question. So now we believe in most cases it’s actually the parasympathetic that’s the problem.

Dr. Weitz:            Well that’s interesting because and when we have patients who have anxiety or they have adrenal problems or they have fatigue, we’re always working with them to increase parasympathetic stimulation because the thought is everybody’s stressed, everybody’s in sympathetic mode all day long and that’s why they’re drinking caffeine because they want to be in this sympathetic mode because they’re not sleeping enough and they’re trying to get more work done, etc.

Dr. Desai:             Well you’re absolutely right. For emotional and mental stress and even physical stress, I mean the parasympathetic nervous system’s a very important part.  You I’m sure are aware of heart rate variability and using heart rate variability in certain breathing techniques activates your parasympathetic nervous system. 

Dr. Weitz:            Exactly.

Dr. Desai:             So it’s not so much as you mentioned about calming down your fight or flight.  It’s about enhancing your rest and relax.  It’s about enhancing your parasympathetic nervous system.  The only reason why I’m commenting on this from the standpoint of arrhythmias is that the parasympathetic has been implicated honestly both parts of the nervous system have been.  So we clearly see sympathetic triggers if someone’s under a lot of stress and their heart rate goes up, they can end up having more premature beats.  So it’s not, I would just say anything out of balance in the body, right, is not a good thing. And so when you come to AFib we love using this term the perfect storm.  You have a few risk factors, you have a few of these matches, you have a little bit of that wood, and then it creates the fire and that’s why on a given day there’s something or a combination of things that could lead to a patients first AFib episode.

Dr. Weitz:            Well it’s interesting when we’re talking about these risk factors because it seems like this comes up all the time. At this point we’re still going through this COVID-19 pandemic, and what comes up all the time is that people are likely to have a worse prognosis if they have any of these chronic diseases like being overweight, having hypertension, having diabetes, having sleep apnea, having lung disease. These are the same chronic conditions that are so prevalent in our society that they make it more likely that you’re going to have AFib.

Dr. Desai:             That’s absolutely right and if you look at obesity for example that it one of the number one risk factors for AFib and there’s a lot of different mechanisms that are thought of with regards to that. But obesity itself leads to many of the other conditions you mentioned. The diabetes, the high blood pressure. Chronic high blood pressure increases the stretch in the left atrium which is the top left chamber of the heart. That’s the trigger for AFib. There are so many different types of mechanisms, but as you mentioned with COVID this inflammatory component is critical right?  I mean that’s why people get this multi organ system failure. That’s why people get this myocarditis that you’re seeing in cardiac cases.  And so many cases, or many people believe I should say, that AFib is along the same lines. It’s an inflammatory disease. It’s, so you do see elevated biomarkers in the setting of AFib.  We just don’t know what to do with those biomarkers, but we do know that there is an inflammatory component like many things. I think that’s also why probably treating your body with food as medicine, that certain foods definitely and supplements definitely do help cardiac arrhythmias, but the other, I think what distinguishes it a little bit, AFib from some of these other things we’re talking about is this interplay with the nervous system so I think the gut, as you know the enteric nervous system and the gut there’s that secondary nervous system. The heart has it’s own nervous system, and so it’s interesting to see this sort of two way street between the brain and the heart and the brain and the gut, and I think when those things are out of balance and it’s usually nature and nurture, there are some genetics probably and then there’s environmental triggers.  So many things we’re not aware of right? We don’t even, there may be multiple toxins in the environment that are big components of causing AFib that’s to why one person gets it and one person doesn’t. So there are well defined risk factors: age over 65, diabetes, high blood pressure, thyroid disease, heavy alcohol use, sleep apnea, obesity is the big one. And then there’s one that we really haven’t determined yet. But I would say that you see this I call it the electrical epidemic, AFib. It’s an epidemic because as we get older we’re living longer, and so it’s arthritis of the electrical system. So when you get AFib when you get older, you could be a totally healthy person. Lived a totally healthy life, and still get AFib. And it has to do with scar tissue that builds up in your electrical system just like it would in your knee. So that is, that’s the age related factor of AFib. And then you have that obesity component that our society as you mentioned Ben, I mean we’re getting unhealthier and unhealthier and the obesity epidemic is probably a big reason why we’re seeing AFib.  We’re seeing a lot of AFib in our practice right now so our patients who have AFib are getting more AFib right now during COVID. Two reasons we think.  One is increased alcohol consumption.  One glass of alcohol is associated with an 8% risk of an AFib episode. It’s not a small thing. And then the lack of physical activity and weight gain.

Dr. Weitz:            Yeah and the stress as well.

Dr. Desai:             The stress is huge absolutely. We see, it’s interesting you mentioned the stress. Just in observation there’s a lot of people who, they’ll be in AFib, they’ll go into this AFib episode at home. Their heart’s racing, it’s going irregular, they’re feeling terrible because the heart’s an engine so when you go into AFib you lose about 30% of the pump efficiency of your heart. It’s almost like losing a few pistons in your engine. That’s what the atria do for you and when you go into AFib the part of the heart muscle beats very poorly, very chaotically. So people are feeling terrible and they go into the hospital and they’ve been sitting in AFib even sometimes for a few days and they go into the hospital and the doctor is getting ready to shock the heart back into rhythm called the cardioversion which is often something that’s done for AFib. And literally you’re getting ready to press the button and the person converts to a normal rhythm. And the hypothesis here is that people feel safe when they get into a hospital in this context. Not always. But in this context they feel safe.  And so we see it over and over again where people, that’s why I’m a big believer in mindfulness. I do a daily mindfulness practice. I have a lot of interest in that, and we definitely see through activation of the parasympathetic and calming down that fight or flight response. I mean I mentioned all of these things about parasympathetic and arrhythmias, but don’t get me wrong. It’s not that the parasympathetic is bad and it causes arrhythmias.  It’s just that we’re learning specifically in athletes, but what’s also interesting is GI triggers for AFib. So people who have acid reflux, the esophagus sits right behind the heart, or people who eat a really large, fatty meal activates the vagus nerve. So again it’s these, it’s over activation.

Dr. Weitz:            Yeah I mean, be honest with you in my practice we see a lot of patients with GI disorders, especially irritable bowel syndrome and reflux. These functional disorders, and they’re extremely common.  When you combine those with obesity, and 70% of the patients in this country are overweight, you add in the rates of diabetes and hypertension and some of these other conditions, it’s surprising that we don’t have more people with AFib.

Dr. Desai:             Oh absolutely and I’ve been on different kinds of shows and I’ve talked about these things and one of the things I started realizing and gotten humbled about is patients are saying to me, they’re like, “This is great. You’re telling me all these bad things. How do I change my life?” And I don’t know if you’ve heard of Thrive Global. It’s a organization funded by Arianna Huffington and it’s an amazing…

Dr. Weitz:            Oh I know who she is, but I haven’t heard of the organization.

Dr. Desai:             So yeah. So Arianna and I had a chance to connect as I wrote this book, partly because of my interest in mindfulness and I reached out to her to get her thoughts on the book, and she invited me to be a contributor for this website.  So for your listeners out there I would definitely encourage you to check out this website thriveglobal.com because they’re addressing so many issues of COVID right now.  Parents who are working from home, schooling people at home. I mean everything really under the sun. But what I like, their theme is microsteps.  So to make a behavior change, it’s a micro step.  It’s not what we used to think which is, 21 day challenge.  Give up this.  It’s really making those small changes every day and then, and building on that and having that accountability.  So I just wanted to mention that because you and I are having this great discussion about all these risk factors, but I don’t want people to be demoralized into thinking that there, it’s, there are ways to change, and I know that you do that you do that on a regular basis with your patients.

Dr. Weitz:            Absolutely and the greatest thing that could come out of this COVID crisis is if there’s more awareness about doing something about these chronic diseases that result from poor diet and lifestyle like we’ve just been talking about like obesity and hypertension and diabetes and etc. etc. We, America needs to wake up and get healthy and exercise and eat healthy and get control of their stress and all of these chronic, all of these conditions like AFib are, we’re going to see less of.

Dr. Desai:             Yeah I totally agree. I mean it’s interesting, a virus that is decimating part of humanity is also connecting part of humanity and waking up part of humanity that all of these thing’s we’re talking about, these are huge risk factors for massive COVID infection and poor outcomes.

Dr. Weitz:            Yeah.

Dr. Desai:             So I think you’re right. People are sort of saying well this is this end goal that we all have of not wanting to get infected and certainly not wanting to have a bad infection.



Dr. Weitz:                            I’ve really been enjoying this discussion, but now, I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements. Pure products are meticulously formulated using pure scientifically-tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners and preservatives.

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                                                Now, back to our discussion.



Dr. Weitz:            Are there certain diets that are associated with less risk of AFib or that can be beneficial for patients that have AFib?

Dr. Desai:             Yeah I think that the… 

Dr. Weitz:            And keep in mind the background is that there’s a lot of confusion today as far as what the best diet is and it’s almost like partisan politics.  We’ve got the vegans on one side and the people who only eat meat, the carnivores on the other side.

Dr. Desai:             Right.

Dr. Weitz:            And then we’ve got the Paleo and the Mediterranean [crosstalk 00:28:12] and everybody’s claiming that their diet is the best.

Dr. Desai:             Yeah and I think it raises the point. This is for AFib, this is for diet. You have to individualize to your case. You may have a certain blood type if you believe that, where a certain diet is better or you may have a lot of chronic inflammatory disorders whether it’s fibromyalgia or lupus or even cancer and a vegan diet with all the data we know about reducing inflammation on that. So as cardiologists we typically recommend the Mediterranean diet. There’s a fair amount of data with regards to that. Lean proteins, good fats, but I think that it really comes down to balance. But you also have to look at your individual situation because whatever food plan you adopt, you want to adopt something that you can stay with the long term.  Yeah you can have your cheat day once a week or what have you, but you want something that’s really going to sustain you long term which is why I’m not a big fan of things like Atkins and really high fat diets. I agree sugar is not good, but I think you really have to individualize and AFib is the exact same way. No two patients with AFib are treated the same or are the same. So some people, they may be able to take care of their AFib purely with diet and lifestyle modification. Losing weight, not drinking alcohol, etc. etc. Treating sleep apnea which is very unrecognized as trigger for AFib.

Some people, they need a medication in some cases. Some people need a catheter ablation procedure and there’s other kinds of things that we can do, but AFib is a progressive disease.  AFib begets AFib. This is an electrical cancer. People need to know about this disease. They need to know how to screen themselves for it. They need to know how to help their loved ones with it because you don’t want to wait until someone has stroke to figure out that they have AFib.  And nowadays with all these great biometric tools, Apple has their EKG function on several of their watches. KardiaMobile has a device you can buy $90 on Amazon. These are devices that actually allow you to record an EKG and tell you with a reasonable amount of accuracy, not perfect that you may be having AFib.  So we are big proponents now of early detection, early intervention.  So if someone gets diagnosed with AFib for example you don’t want to just say, “Lifestyle and diet and let’s regroup in four weeks.” Every episode of AFib even if it’s five minutes and this is really important changes the cellular and electrical architecture of the heart to want to have more AFib. It’s a muscle memory thing.   So we’ve had cases of patients where they think they’re only having one or two episodes a year, where in fact they were having a lot more silent episodes, but that’s common actually while people are sleeping. Silent episodes of AFib they don’t feel anything and their AFib is progressed by the time they go to treatment. So early detection, learn how to take your pulse after you brush your teeth. It should be like a metronome. It shouldn’t be fast and irregular.  Many patients have very subtle symptoms. This is really common. 

Dr. Weitz:            Yeah what are the symptoms of AFib?

Dr. Desai:             Yeah I’m glad you asked. So the, it depends on your age, so younger people and we’ve seen people as young as 18 by the way, tend to get that rapid, irregular heart rate. The palpitations that we described. But it’s more than just skipping beats. It’s a tremendous amount of fatigue or shortness of breath because again the engine analogy, you lose pistons when you go into AFib. That’s different. If you’re having these skipping beats, these premature beats, you don’t lose pistons in your engine. You, they may be bothersome but you don’t feel terrible and with AFib that’s the big thing is this general sense of lack of energy, fatigue, shortness of breath. But what’s interesting is that as people get older, and especially people who aren’t that healthy who aren’t that active, they may not be aware at all they’re in AFib.

                                They’ll show up for gallbladder surgery as pre op and they’re in AFib. We that so commonly. And then you ask them, “Well over the last six months or year, have you noticed a change in your endurance or activity level?” “Yeah I have I just thought it was I was getting older.” We hear that so commonly. Well it’s not until you restore someone’s rhythm back to normal which is what we often do in those cases at least once. At least as a trial. When someone says they don’t have symptoms with their AFib, we believe as electrophysiologists that unless there’s a strong reason not to, everyone, or most people I should say not everyone, most people should have some kind of attempt at restoring the rhythm. Because you don’t know how much you’re actually having symptoms of something until you restore the rhythm. It’s like having a bad knee and doing less.   You don’t really, and decide to have a knee replacement and realize that you could do more. So that, it’s the same thing with AFib. It’s the great masquerader. It’s electrical cancer. There’s so many different presentations and that’s why the early detection and these devices that I mentioned are so important.

Dr. Weitz:            So the most common symptoms, list four or five of the most common symptoms.

Dr. Desai:             Yeah so most common symptoms, fast irregular heartbeat called palpitations, shortness of breath, sometimes chest discomfort, tremendous fatigue, and that would probably be, and then unfortunately stroke is an often common presentation of AFib where there’s no symptoms. But I would probably say the fatigue part and what’s, the key thing with any of these arrhythmias in the beginning, they’re episodic so what’s different with the heart, the coronary arteries, the three coronaries, they’re, it’s plumbing as you mentioned. So if you have a blockage, it’s going to show up on a stress test. It’s going to show up on a variety of testing. AFib, it can come and go. It’s like the electrical system in your car or your house. It’ll act up sometimes, and then it won’t be there. So you show up to a doctor’s office for an EKG and then you come back in six months and you’re in normal rhythm, you could be having AFib that night and you don’t know it and it’s not until you go from this in and out AFib which is called paroxysmal to continuous AFib which is called persistent that people really then get diagnosed.

                                And the problem is by the time you get to persistent, the treatments are much less effective. We have lots of ways of treating people with persistent AFib, that’s an important point. One of the reasons I wrote this book is people are, there’s so much misinformation out there. People are told they have to live in AFib. It’s too far gone, there’s nothing that can be done, and in the introduction of the book I talk about a man who was told that for five years continuous AFib and we got him to rhythm because of current technology. It’s also lifestyle changes. So those will probably be the most common symptoms. I wanted to circle back to your question which I really didn’t answer about diet. Magnesium is really important with regards to, and I think the important thing about magnesium is you can’t go based on a blood level. 90 something percent of magnesium is stored in your tissues, not in your blood [inaudible 00:34:59][crosstalk 00:34:59]

Dr. Weitz:            Right.

Dr. Desai:             And that’s the same with potassium as you know. So we have a low threshold to recommend a magnesium supplement to someone with heart rhythm issues unless they have advanced kidney failure that’s really the only time where you want to be careful about the magnesium. As far as a specific diet I wouldn’t say, I’d be curious to see if you’ve come across anything in your research. I haven’t come across anything that says this diet is really good for AFib, but I would definitely argue that anything that results in reduced inflammation in your body is likely going to be a good thing for AFib. If nothing else it’s going to help your risk factor’s right? It’s going to reduce your obesity and all these other things which then help your AFib so it’s really about trying to prevent the AFib. Now its [crosstalk 00:35:39]

Dr. Weitz:            There are now a number of forms of magnesium [crosstalk 00:35:44] we use frequently in our office and so there’s magnesium citrate, magnesium glycinate is known to be better absorbed and have less issues with bowel laxity. We’ll [crosstalk 00:35:59] use magnesium citrate if someone is constipated. We use magnesium threonate which has been known to affect the brain and central nervous system a little better. Is there a form of magnesium that you think is more effective for AFib?

Dr. Desai:             I’m so glad you asked that because a lot of people just go to Costco or what have you and pick up whatever magnesium is on the shelf and this is nothing against Costco by the way, it’s more [crosstalk 00:36:26]

Dr. Weitz:            I’m with you.

Dr. Desai:             Yeah magnesium oxide is one of the [crosstalk 00:36:29]

Dr. Weitz:            I got this big giant bottle of fish oil for five dollars.

Dr. Desai:             Exactly. Well there’s a reason why it’s five dollars. So, but magnesium oxide is probably one of the worst absorbed forms of magnesium. And it’s one of the most common sold ones in stores. So yeah the ones you mentioned are great. Magnesium citrate, it actually comes, I love Natural Calm. Natural Calm is a product that you find online, you find in stores. [crosstalk 00:36:54]

Dr. Weitz:            It’s a powdered form of magnesium. [crosstalk 00:36:57]

Dr. Desai:             Yeah it actually comes as a gummy. Now the gummy has some sugar in it, so you’ve got [crosstalk 00:37:01] to be careful about that one.

Dr. Weitz:            Forget the gummies.

Dr. Desai:             Forget the gummies. So but magnesium citrate is a good one, magnesium glycinate as you mentioned, Doctors Best is a really good brand for magnesium glycinate for example. Magnesium malate. Malate is a really good one. And taurate, magnesium taurate. So taurate has kind of more of a specific cardiovascular effect. Sort of derivative or related to taurine amino acid and there is data with regards to taurine and heart health and even rhythm. So there’s a company Cardiovascular Research Lab makes magnesium taurate that we will often prescribe to people. So it’s really about just getting people to take it. And I always tell people go based on the serving size of the bottle. People always ask what dose you should take. It’s really, it’s very manufacturer specific, company specific, but I would say those would be the main ones to consider.

Dr. Weitz:            Yeah I would like to say when it comes to magnesium, manufacturers are often very careful and often will recommend one tablet or something line that. But they have no idea your particular circumstances.

Dr. Desai:             Right.

Dr. Weitz:            And for the most part the only side effect of taking more magnesium is that you’ll get diarrhea and you’ll [crosstalk 00:38:12] know that pretty quickly. So- [crosstalk 00:38:15]

Dr. Desai:             Right.

Dr. Weitz:            You very well may need 400, 600, even 1000 milligrams would not be at all excessive for our magnesium need so a lot of time just what says on the bottle may not be [crosstalk 00:38:29] what you need.

Dr. Desai:             I’m glad you raised that point, Ben. A few things. One is we’ve seen cases where if we give someone magnesium glycinate. Hey go based on the serving size on the bottle, continue to have rhythm issues whatever the rhythm issue is and then we add in another magnesium. So the combination of magnesiums. Know that I’ve had one patient who said, “Well the glycinate didn’t work but when I added in the taurate and lowered the glycinate.” You know so you really have to titrate based on if you’re taking it for palpitations for example, or AFib you want to titrate it based on your episodes. Is your heart calming down? That’s the point of the magnesium is there’s what’s called phase two of the action potential in the heart and the electrical system is part of your heartbeat, and magnesium and calcium have this exchange pump in the heart cell and that’s the theory behind why magnesium helps so much as a stabilizer of the electrical system. And the point you made about the GI distress, so we do have a fair number of patients that just can’t tolerate any form of magnesium orally.

                                So you have magnesium foil. You have bath flakes. There are other ways of taking magnesium that you can absorb some. [crosstalk 00:39:34]

Dr. Weitz:            And the glycinate has less effect on the bowel. But [crosstalk 00:39:39] taurine is another supplement just used [crosstalk 00:39:41] individually. Have you had experience with using that?

Dr. Desai:             Yeah I have one gentleman actually who, and of course I’m telling you stories about different people. We don’t have [crosstalk 00:39:50] these large randomized crowds, but I have this one gentleman who, he struggled with premature atrial beat. So these are benign things but it just debilitated him because if you’ve ever had one it feels like your hearts going through this rollercoaster. And so he tried initially the Natural Calm. That didn’t really work for him, he switched to the glcinate that didn’t really work for him. So then we had him on magnesium malate, and then we added a little bit of taurine in. And that, not the full dose of taurine that’s often recommended. And that really calmed him down so I do think that there’s a role certainly for taurine. My go to if someone’s having rhythm issues or heart issues is to say start with magnesium. Start with glycinate as you mentioned is well absorbed. If it doesn’t work maybe consider magnesium taurate or Natural Calm. And then if you continue to have issues that’s where you start to think about these other things.

                                And it’s also important to mention just for your listeners, there are a lot of drugs that deplete your body of magnesium and you have to be aware of that. Proton pump inhibitors for example that block acid secretion for ulcer disease notice deplete the body of magnesium. The diuretics [inaudible 00:40:59] deplete your body of magnesium and potassium so to your point Ben, those are people who probably need to have a super dose of magnesium because they’re losing so much of it. And the last point about magnesium I’ll make is intravenous magnesium has a powerful anti arrhythmic effect and what that means is we have people who have come into the hospital with AFib or with what’s called ventricular tachycardia dangerous heart rhythm and you just give the magnesium even with a normal level and it has this amazing immediate calming effect and I mentioned with the magnesium that the serum level is not very helpful. You can ask your doctor to order what’s called a RBC magnesium level within the blood [inaudible 00:41:36] and that tends to be a little bit more accurate.

Dr. Weitz:            Yeah we use that regularly. A few other supplements. Have you had any experience with coenzyme Q10 which is frequently recommended for heart health?

Dr. Desai:             Yeah I obviously recommend it to my patients generally for heart disease [crosstalk 00:41:55] treatment or prevention. [crosstalk 00:41:55]

Dr. Weitz:            By the way CoQ10 since we’re talking about nutrients that are often depleted, cholesterol lowering drugs like statins deplete [crosstalk 00:42:01] the body of CoQ10.

Dr. Desai:             Yeah it’s so interesting how we have people and so many treatments that fight each other. I mean it’s just they’re in the ring together and they’re fighting each other and it’s sort of like you’re not really sure what that outcome you’re having.

Dr. Weitz:            Oh yeah. We, statins increase your risk of diabetes and some of the most common diabetes drugs increase your risk of heart disease so.

Dr. Desai:             Right. Exactly. So I’ll be honest with you. I don’t really have a lot experience or knowledge of specifically Coenzyme Q10 and it’s impact on the heart’s electrical system or AFib. Have you come across anything in that regard? [crosstalk 00:42:34] With Coenzyme Q10 [inaudible 00:42:34]?

Dr. Weitz:            I’ve, yeah I’d seen some studies on it and CoQ10 seems to have a lot of benefits for congestive heart failure for a series of issues with the heart, so it’s probably one worth experimenting with and another one is hawthorn berry which is often [crosstalk 00:42:52] included in supplements for hypertension and heart health.

Dr. Desai:             Yeah my feeling on supplements is as you know there’s a lot of criticism from western medicine on these I think having functional medicine is such an amazing step forward. That you have physicians and practitioners from all different disciplines really focused on maintaining function not so much on giving a pill or doing a procedure. But I think that people just need to be careful that the supplement alone isn’t going to necessarily fix the problem. And you really, there is definitely a role and we do a lot of catheter ablation so I’m a very integrative electrophysiologist, but I’ll be honest catheter ablation if you look at all the different treatment options for AFib, I’m talking about people now who have the disease that is not being managed by just diet and lifestyle. It is a highly effective form of treatment and there’s a lot of misinformation including from healthcare providers about the efficacy of catheter ablation that nowadays with early AFib, the early onset of AFib peroxisomal we have some trust rates of almost 85 to 90% with a [crosstalk 00:44:03] risk of around 1%.

Dr. Weitz:            What do you hear healthcare providers saying that’s incorrect about ablation? What’s [crosstalk 00:44:12] the common misconceptions?

Dr. Desai:             It’s too risky and it doesn’t work. And then number two is it’s not going to work for you, patient, because your AFib is too far gone. And so, and then the third is well it doesn’t make sense to treat your AFib or try to get you into rhythm because you’re not having any symptoms. So those are the three. And this book that I wrote is not just for patients or family members. This book is for healthcare providers. Not just for education, but It’s hard to, nowadays in a 20 minute patient visit how are you going to talk about such a complex disease and we just have these kind of five page pamphlets that really don’t tell you much. So the idea is really to provide people with a little bit more detailed information. But catheter ablation for the listeners who haven’t heard the term, it’s simply a way of destroying abnormal tissue and preserving normal tissue. So destroying cells that aren’t supposed to be there. So if you think of the sources of AFib which are called the pulmonary veins as capsules of AFib sending out sparks, then we, well with kind of the fire analogy that we used.

                                We’re essentially creating some insulation around the fire. We’re creating insulation around a broken wire. Drug therapy, there’s a role for it, but anti arrhythmic drugs, which is what we use, they have such a high side effect in toxicity rate and at best the most effective one which is amiodarone has only about a 40 to 50% long term success rate. So again our first step always with heart disease or any kind of disease including AFib is diet and lifestyle. Lose weight. That can make a huge, I’ve had patients that have had ablations and they were overweight and then, and their AFib kept coming back. And then when they lost the weight, their AFib didn’t come back. And that’s something that shame on us as electrophysiologist in our field that we’re now learning you have to optimize those risk factors before and after any intervention to have the best outcome. And there is this mentality unfortunately in our society about sort of quick fix. Do an ablation, there’s a lot of sort of altered expectations. People come in and think that the ablation is going to reduce their risk of stroke or fix their AFib.

                                And it’s a big [inaudible 00:46:26] this is what you do. It’s a big picture functional medicine holistic standpoint. You’ve got to manage everything. Everything’s got to get in balance.

Dr. Weitz:            Yeah. I guess when I think about AFib the idea of doing a procedure that could potentially cure it instead of having to take some of these drugs for the rest of your life that have all these side effects. To me that sounds much more appealing. On the other hand, when I watched one of your videos describing how you do the ablation, boy it is a really complicated procedure that involves threading this little wire into the vein, going through one side of the heart into the other side of the heart and it makes me realize you really want an expert who’s going to do that because it is, at first watch you think oh well just go into this part of the heart and just burn this little thing and everything’s fine. It’s like I just fix this electrical socket and it’s a really complicated procedure.

Dr. Desai:             I’m so glad you mentioned that. That’s important feedback for me. Because actually that’s how, electrophysiologists consider AFib ablation to be one of the easiest procedures we do. Because the femoral vein is a vessel in your groin, we put an IV in there, we thread the catheter through the IV so there is no cutting, and there’s a, it’s a straight shot into the heart. That’s our mindset because we deal with it everyday right? But we don’t think about the other side of it, and I should really think about redoing that video because if that video sent a message to you that this is a really complicated procedure, it’s actually changed a lot over the decades and so it’s actually become quite a simple procedure. There’s, for example we use something called the cryoballoon.  It’s a balloon. We go to these four different structures in the heart. We freeze each for basically 210 seconds and we’re done. The actual ablationt takes only 20 minutes. A lot of it’s set up, a lot of it’s technology and things like that, so.

Dr. Weitz:            Okay.

Dr. Desai:             I’m glad you mentioned that because I have to really rethink what I’m putting out there now because it can look a lot more complicated that it is, you know?

Dr. Weitz:            Yeah. Yeah. You were talking about some and the risk is you go through one [crosstalk 00:48:37] side of the heart to the other and you know.

Dr. Desai:             And I’m not discounting that. I mean [crosstalk 00:48:43] to your point, you don’t just want to go to, you know whenever you’re having a procedure done or any treatment you want to go to someone who has high volume, done a lot with a low complication rate. And that’s the case with anything that you do on your body.

Dr. Weitz:            Absolutely. Absolutely. Including getting chiropractic adjustments or- [crosstalk 00:48:59]

Dr. Desai:             Including getting chiropractic adjustment absolutely. Yeah I mean for sure.

Dr. Weitz:            So what are some of the most common medications that are used?

Dr. Desai:             So oftentimes beta blockers include drugs such as metoprolol, atenolol, these are drugs to what we were talking about earlier about the fight or flight sympathetic nervous system. Those are drugs that block the effect of that on the electrical system of the heart so naturally they lower the heart rate, they lower the blood pressure. And so they can be effective if someone especially has a rapid heart rate. There’s a drug called propranolol which often has an anti anxiety effect as well which can be helpful for premature beats. But the problem is that those drugs aren’t easily titratable and so especially for young people often don’t like being on them because it really blunts your heart rate response to exercise, so people feel tremendous fatigue. It can exacerbate depression. It can exacerbate insomnia. For men it can exacerbate ED. So there’s definitely trade outs.

                                But what’s nice about beta blockers is they typically don’t harm you compared to other drugs that we use. Calcium channel blockers such as one called diltiazem and one called verapamil, these lower adrenaline in a different way and what’s nice about them compared to the beta blocker is not as much fatigue but they do, they can cause constipation and some ankle swelling. Those two classes of drugs have about a 40% efficacy rate for AFib long term. So not the highest. And then you have the next tier of drugs called anti arrhythmic drugs and there’s about five or six that we choose from. And these drugs, if you think about the heart’s electrical system as a bunch of doors opening and closing those are what we call ion channels and this is what these different electrolytes like we’re talking about, magnesium and sodium and potassium and calcium, these move in and out of the heart cells and the electrical system and it generates current. Just like you think of any electrical thing it generates a current. And so the drugs actually block these different doors, these doorways called ion channels and so as a result the drug can manipulate the current.

                                Well sometimes that works well in treating AFib and other issues, but sometimes it manipulates the current too well and it slows the heart rate down too much or it creates a dangerous rhythm called ventricular tachycardia and so the problem with drug development with AFib is that there’s been no improvement in decades. And one of the reasons why is that we still don’t have a good handle on the genetics, and we still don’t have a good handle on how do you create a drug that’s just specific for the top chambers of the heart, but do not affect the bottom chambers of the heart? Cancer for example, oncology, wonderful drugs now targeting the immune system. Same thing for many other conditions like rheumatoid arthritis, psoriasis. We don’t have that quite yet for the electrical system, so those are the two, and so the anti arrhythmic drugs would include drugs such as amiodarone, sotalol, propafenone, flecainide, multaq, tikoson, in case your listeners if they’ve ever heard of those drugs they have an efficacy of about 50% long term with very high side effect profile.

                                And again I, my job here is not to push ablation. Obviously I am biased. I do a lot of ablation. Of course I am biased and I believe in it, but I have been humbled in many cases where we ablate, AFib keeps coming back, and one day a spouse comes to the office and mentions the husband snores and we have this aha moment, “Oh I should’ve done a sleep study.” And then I do a sleep study and the AFib disappears and it’s that much of a connection between sleep apnea and AFib.

Dr. Weitz:            Yeah. There’s a huge connection between sleep apnea and a whole series of [crosstalk 00:52:34] chronic conditions and it’s definitely underdiagnosed and I think part of it just because people don’t want to be put on a CPAP machine and they don’t [crosstalk 00:52:44] want to get diagnosed.

Dr. Desai:             Yeah I’m glad you mentioned that. Not that I’m a sleep specialist, but what I, I refer a lot of patients for either home apnea link studies which is where you can screen it at home, or a sleep study and the top number one reason why people don’t show up to the appointment or don’t want to have it done is they don’t want to get a CPAP machine. And my experience has been in many cases it’s because they didn’t have the right mask, they didn’t have the right pressure setting, they didn’t have the right education. They were just given a machine, it was ordered, they dropped it off one day and they suffered with it and then there was no follow up. So I think it’s important for people to know and then there’s a lot of other treatments. There’s dental appliances as you know. There’s stimulators now. Medtronic makes one for example for treatment of sleep apnea for different, for like the tongue for example the glossopharyngeal nerve. So, but it important to treat. And the number one way to treat is to lose weight and [crosstalk 00:53:37] that’s such a big trigger.

Dr. Weitz:            Yeah there’s also a correlation between low vitamin D levels and sleep [crosstalk 00:53:43] apnea.

Dr. Desai:             Yeah. I didn’t know that actually is that true? I didn’t know [crosstalk 00:53:47] that.

Dr. Weitz:            Yeah there’s a few studies on it. I interviewed a dentist who was described how he saw a number of his patients turn around with getting the right amount of vitamin D.

Dr. Desai:             I’m going to have to keep that in mind because so many of our patients have sleep apnea. [crosstalk 00:54:02]

Dr. Weitz:            Now in his case he felt it was important to get the vitamin D to the optimal level not the [crosstalk 00:54:07] normal level. So not [crosstalk 00:54:10] just over 30 but say in that 50 to 70 range.

Dr. Desai:             Okay. All right.

Dr. Weitz:            Nanograms per milliliter.

Dr. Desai:             Okay.

Dr. Weitz:            And then I guess blood thinners are recommended sometimes too to prevent stroke which is one of the side effects.

Dr. Desai:             Yeah I think it’s important you touch on that. So stroke is the most catastrophic and so the mechanism of a stroke is a blood clot forms in the heart through a substance called thrombin and the anti platelet drug such as asprin for example don’t work that well on thrombin. They work well on clots that form in the coronary arteries or in the brain but in the heart with AFib the atrium doesn’t beat properly, you have this sort of lifeless bag of contractions so the blood clot can form stagnant blood. And so we traditionally have had blood thinners such as Coumadine or Warfarin which has a lot of challenges. Efficacious but a lot of challenges. And then there are a whole host of neuro drugs that aren’t so new anymore. Eliquis, Xarelto for example, Pradaxa. And It’s nice these drugs actually have been studied in very large trials now showing relatively low bleeding risks. We use, it’s all about the risk assessment. So you have the CHADSVASC acronym I mentioned earlier, you add up the points to determine who’s at high risk for stroke and AFib.

                                And then you have what’s called HASBLED, H-A-S-B-L-E-D, and that is another acronym and that actually tells us who’s at risk for bleeding on a blood thinner. And we can compare the two to then say, well this 80 year old person who has a high risk for stroke also has a high risk for falls because they fell three times in the last year. So that is someone we may refer for there’s a set of procedures called left atrial appendage occlusion procedures. A device called Watchman for example that you see a lot on commercials now. [crosstalk 00:55:58] [inaudible 00:55:58] scientific. But these are devices that help isolate the part of the heart that is the source to the clot from traveling elsewhere. So the Watchman is like a little basket that get implanted in the heart, and it’s typically done, I mean these are invasive procedures, but they’re not cutting open the chest, you’re doing it still through the femoral vein for example. So there’s definitely options for people, but one thing I would definitely say to people is if you can’t take a blood thinner because you’ve had a side effect or for whatever reason, get evaluated by a cardiologist or I think especially and electrophysiologist because you may be a candidate for one of these other procedures and you don’t want to have a stroke. [crosstalk 00:56:36]

Dr. Weitz:            Right.

Dr. Desai:             That’s the most catastrophic thing.

Dr. Weitz:            Yeah. One more question. This is just kind of a personal case from one of my patients. I have a longstanding patient and he kept getting AFib from, he felt like it was coming from drinking something cold. Does that make any [crosstalk 00:56:54] sense?

Dr. Desai:             Yeah it’s that vagus nerve again. [crosstalk 00:56:57] [inaudible 00:56:57]

Dr. Weitz:            Oh okay.

Dr. Desai:             [inaudible 00:56:58] nervous system. Yeah [inaudible 00:56:59] a triathlete. Every time he drank Gatorade at the end of the race he went into AFib. How much of a reward is that? You just finished a race and you go into AFib because of the Gatorade. So yeah you get esophagal stimulation. Really hot, really cold beverages can stimulate the vagus nerve. And then the esophagus is right next to the vagus nerve so there’s actually a direct sort of mechanical type stimulation. So yeah there is actually reason for that [crosstalk 00:57:24]

Dr. Weitz:            Well interesting you know we talk about the vagus nerve all the time when [crosstalk 00:57:27] we talk about gastrointestinal conditions so.

Dr. Desai:             Yeah. Yeah. I  kind of feel like the vagus nerve is getting a bad rap now. It really is important. It [crosstalk 00:57:35]

Dr. Weitz:            Well absolutely it’s a pathway for communication through the body [crosstalk 00:57:41] between the brain and the gut, and the gut and the brain, and the gut and the heart, and the heart and [crosstalk 00:57:45] the gut.

Dr. Desai:             And it’s so important. When we mentioned earlier, and maybe this is a good parting note is stress is pervasive and there are so many great ways for creating toolboxes to deal with stress. The classic stuff like exercise and being in nature and things like that. But mindfulness and breathing techniques and even simple things a few minutes a day, it activates that parasympathetic nervous system that helps to counterbalance that fight or flight response. We were built to run away from dinosaurs the problem with this is that we think that a conflict at work is a dinosaur. And sometimes it actually may be [crosstalk 00:58:18] a person may look like a dinosaur. But sometimes not and so but our brain, our limbic system and our fight or flight response and everything interprets the threats that way so its important for us to always be mindful of how we are interacting with people. We can just, that way we can kind of show up as the best version of ourselves and not be so reactive that we have choices on how to act.

Dr. Weitz:            Yeah. Big scary arm chair dinosaurs. Doc.

Dr. Desai:             Yeah. That was a great way of saying it without saying it. I love that. I love that.

Dr. Weitz:            What’s the best way for listeners and viewers to get ahold of you and contact you and?

Dr. Desai:             Yeah. Yeah. So the book is called Restart Your Heart: The Playbook for Thriving with AFib. It’s on anywhere books are sold including Amazon, Barnes & Noble. If you go to my website which is draseemdesai.com D-R-A-S-E-E-M-D-E-S-A-I .com I have a ton of information about the book and where to purchase, but also I have a blog, lots of complimentary advice there. We have a variety of different videos and things like that. And then I am very active on social media so especially on Instagram and Facebook we even have AFib groups and things like that, so it’s @draseemdesai. That goes for Twitter, LinkedIn, Facebook, Instagram, and then I have a YouTube channel as well @D-R-A-S-E-E-M-D-E-S-A-I and you can direct message me or reach out to me or follow me.

                                I definitely, I thrive on feedback. So that’s the only way that any of us, I mean your feedback about my video, I’m going to go look at that video now because your feedback about my video is important because I may be scaring a lot of other people and I need to change the way that video looks, so yeah. That’s important feedback.

Dr. Weitz:            Okay good, doc. I enjoyed the conversation and then when I put it up in about five, six weeks I’ll send you links and hopefully you can share it with your followers.

Dr. Desai:             Yeah I’d love to and love to give you a roo. Thanks to Dr. Weitz for this conversation today. I appreciate you having me.

Dr. Weitz:            Great. Thank you. Thank you.


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