Search for tag: "atrial"

Interviewer: We are here with Dr. Jared Bunch, Professor of Medicine and Section Chief for Electrophysiology at University of Utah Health. Now, Dr. Bunch, when it comes to atrial fibrillation or AFib, what exactly is happening with the patient, and what are they experiencing?

Dr. Bunch: That's a great question. Atrial fibrillation is the most common abnormal heart rhythm that's sustained or maintained that we see in practice. I suspect most people who are listening to this know somebody that has atrial fibrillation. One in three of us to one in four of us will develop it. In fact, we live long enough, we live over 80, 40% of us will develop atrial fibrillation. And what it is is it's an abnormal electrical rhythm in the upper heart chambers, and these upper heart chambers normally beat in a really ordinary synchronized manner at 60 to 70 beats per minute. Atrial fibrillation replaces that maybe to 300, 350 beats a minute, the upper heart chambers. And that can cause stroke, it can cause heart failure, and it can cause a lot of symptoms such as chest pains, shortness of breath, dizziness, exercise intolerance, anxiety, fatigue. You may know somebody that has atrial fibrillation that called 911 the first time they developed it. In some people, the symptoms are more mild. So it's a symptomatic abnormal rhythm that's quite common amongst us.

Interviewer: And the potential for stroke, that sounds pretty serious.

Dr. Bunch: That's our biggest worry is stroke, because these upper heart chambers aren't squeezing and pushing the blood forward. So the clots that form can be larger than other sources of stroke and cause more disability and higher risk of death. So we really focus on trying to prevent stroke as an upfront treatment strategy.

Interviewer: Now, you said that some people live with AFib their whole life, and maybe it shows up at a physical or another kind of doctor visit. And other people, they feel it, and then they call 911, and they come in. Once a patient knows that they have some sort of AFib, what is the next step, and what are some of the treatments that can help kind of alleviate those symptoms or treat the disorder?

Dr. Bunch: So we look at this in three primary pillars, three primary treatment approaches. First, we want to prevent stroke, and our best way of doing that is early use and appropriate use of anticoagulants. They're often sometimes called blood thinners, but really they don't thin the blood. They make it slower to form a clot. So they're less likely to form a clot in the heart. And they can reduce the risk of stroke less than 1% a year, or it can be as high as 5% to 10% a year.

Our second concern is the heart is just a muscle. If the heart's going too fast or too long, it can begin to dilate, weaken, just like any of our muscles. And so we use medications to slow the heart down if needed. We want the average heart rate less than 100 beats per minute on average at rest. Sometimes we need to control it with exercise as well.

And then, finally, we focus on symptoms. Some people aren't aware that the symptoms they're experiencing is related to atrial fibrillation. They don't put that correlation together till we make the diagnosis. Other people know right away. So then we begin treatments to restore the heart rhythm really to help you feel better and do better and enjoy your quality of life at a higher degree.

Interviewer: Are there any kind of treatments that could potentially fix the kind of problems that they might be seeing that goes beyond, say, medications or some of these other things you've talked about?

Dr. Bunch: There's three primary ways that we treat this. First, we work on risk factor modification. What causes atrial fibrillation? The most common causes in the community, the most common we can't do anything about, we get older. It's a disorder of aging. But the other things we can do a lot about and that is high blood pressure, getting our blood pressure well-controlled, screening for sleep apnea when we hold our breath at night and treating that, decreasing alcohol intake, treating diabetes better, losing weight, and being more active. We want people to be active 30 to 60 minutes a day, that's the dedicated time towards activity, whether that's walking, jogging, running, swimming, yoga, whichever you like. It's important to have that time where we exercise our bodies.

So that is one part that we do to help lower the risk of atrial fibrillation. In fact, if we do those things really well, it will lower atrial fibrillation by 30%. We have medications that help force the heart to beat normal, what we call antiarrhythmic drugs. And there's a number that are currently available, and we can use them depending on the health of your heart. So sometimes we can use a lot if your heart's healthy. If your heart's weak or you've had heart attacks or surgeries, then there's only a few we can use.

Then, finally, there's approaches to do this without medication. So the most common is called catheter ablation, and that's a procedure where . . . it's a minimally invasive procedure where we advance little specialized tools that are flexible and move in your heart called catheters through the veins in your leg up into your heart and cauterize around the sources of fibrillation and block them. These electrical sources are like throwing a rock into a pond. The waves carry from outside from where the rock enters throughout the whole leg. We want to block these signals at their origin. And then sometimes also, if needed, the same procedure can be done by our surgical colleagues through open-heart surgery in patients with really advanced heart disease or disease that we can't get to from within the vessels.

Interviewer: So what kind of patient is best served by the cardiac ablation procedure? Is it the sickest of the sick or anyone with atrial fibrillation?

Dr. Bunch: Well, we've learned a lot just over this past year. A large trial came out that said, "When should we do it? Should we do it early?" And they took patients that developed atrial fibrillation within one year of diagnosis. We found that if we're going to get the most bang for your buck, the most efficacy for the procedure, we really should start looking at either using a medicine that helps the heart beat normal or an ablation within that first year. But that doesn't mean if you had atrial fibrillation longer that you wouldn't benefit from something like an ablation. Ablation is twice as effective as our medications.

And our patients that are the most sick really need their heart to be very efficient and those upper chambers to contract and squeeze just like the lower chambers. Sometimes they benefit from ablation as well and more so than medicines. And the best example of that is our patients with atrial fibrillation and heart failure. Ablation clearly is a better approach and actually can impact how long you live. If we can restore the rhythm effectively and get you off these medicines, it helps you live longer.

Interviewer: Now, one of the things I think we really need to talk about is that cardiac ablation is not necessarily a cure-all for AFib. Is that correct?

Dr. Bunch: Yeah, very much so. And it goes right back to that first thing I said regarding risk factors. If you still have risk factors that aren't treated at all, then our treatment approaches decrease in their efficacy and their success rates by as much as 50%. If you have sleep apnea that's untreated, then our success rates go down by 50%. So that's why when you see specialists, like myself, they will ask you about sleeping even though you came in with a heart problem. So you have to be diligent about the risk factors that you can control.

And then, also, atrial fibrillation, just like other chronic diseases, it can progress beyond the initial focal sources that we treat. And as it progresses, new areas can develop, and you could need a repeat ablation, or you could need a medication with the ablation to control it long term. But the good news with that is, if I am a patient that has atrial fibrillation, there's a lot I can do personally to help myself have a better outcome and to help the physician who is ultimately performing the procedure have a better outcome as well with the procedure.

Interviewer: For a patient that has been dealing with AFib for a while or maybe they just barely got their diagnosis, what advice would you give them for the treatment options available to treat their condition?

Dr. Bunch: Again, we need to work and minimize risk of stroke first. We're going to focus on that, and we're going to minimize risk of any potential injury or weakening to the heart. And then my approach has changed in the past year. I say, if we're going to do something about this rhythm, we should do it earlier, within the first year if possible, to keep the heart normal. The heart rhythm is a lot like kids. I have teenagers, and one teenager learns from the other. And the heart rhythm learns from the beat before it. So the more it's in fibrillation, the more it wants to be in atrial fibrillation. So we want to set the heart on a trajectory to want to beat normal. And so that's what we aggressively do in patients that have symptoms and want to pursue that route. People that don't have any symptoms at all, they said, "I came in for a test, and you found atrial fibrillation. I don't know why I'm here." In those people, we spend more of our time just making sure we lower stroke rates and making sure that that heart rate is well controlled, and so the muscle isn't in jeopardy of weakening.

Interviewer: Perhaps you're a patient that has been suffering in one way or another from atrial fibrillation, otherwise known as a-fib, and you've been working with a specialist and perhaps the medications aren't quite working, or your symptoms don't seem to be getting better. A potential option for treatment is called cardiac ablation, a non-invasive surgical procedure.

We're here with Dr. Jared Bunch, Professor of Medicine and Section Chief for Electrophysiology at University of Utah Health. Now, Dr. Bunch, what does a patient need to know about the cardiac ablation procedure itself? What's going to be happening, and what can they expect?

Dr. Bunch: There's a number of different aspects to consider if you're at the point that you want to pursue a catheter ablation for atrial fibrillation. First, it's that you go to a center that has experience. Centers should at least do 100 atrial fibrillations a year and should do more. Second, the operator that has done it. Have they done over 100 ablations? Have they seen different complications and managed them well? So picking the center and having someone with expertise is critical. It changes the outcomes.

And feel comfortable asking whoever is recommending ablation, how many of these have you done, how many does your center do, have you seen any complications and how did you manage those and did the people do okay? So that's an important foundation in choosing where to go.

The second is understanding what the procedure is. Most centers do ablation under general anesthesia. Some do it under what we call conscious sedation, where you're asleep but you don't need a tube to help you breathe. And the reason mainly this is done is not necessarily because the procedure is overly painful. It's that you'll have to lie flat on a table, what we call a catheterization table, from anywhere from two and a half to four hours, and that's a long time to lay still, and if you shift even a few millimeters, our maps that guide us in the heart have to be redone.

So the way we get to the heart is we put catheters or what we call IVs or intravenous accesses into the big veins, and we thread these long, flexible tools called catheters into the heart. And we go from the vein side to the artery side. The artery side is the oxygenated blood side, the bright red blood side, by making a small hole in the middle of the heart method. That heals up in about two to four weeks. And then fibrillation actually begins in sources outside of the heart, what we call the pulmonary veins, and these are the veins that drain, or bring oxygenated blood from the lungs to the heart. And they can trigger at 300 beats a minute and cause the heart to become unstable and create this rhythm called fibrillation.

So we identify the veins, and then we cauterize around where the veins enter the heart. We can't work in a heart, in the veins directly because they're fragile and they collapse and stenose. So we have to work around them.

Many people ask me, well, how do you choose which vein to treat? And I was part of those studies years ago. We would find the vein that was active and just treat that. And then, we would find that the patients all came back and one vein had replaced the other. So now we find all the veins that you have and treat around all of them. And then, we pull the catheters out and these IV accesses out of the legs, there's not stitches, usually before you wake up, some centers right as you wake up, and then you lie flat from anywhere from two to four hours after. It's a same-day procedure, and if you come off anesthesia well and you're relatively healthy, some centers will send you home that day. Other centers will watch you overnight just to see how you're feeling and how you're doing with the treatment.

Interviewer: Now, when we're talking about a procedure like this, what are some of the potential complications that a patient should keep in mind for a procedure like this?

Dr. Bunch: That's a great question, and it's really important to understand the complications and understand how those are influenced by operator experience and center experience and skill and centers that have dedicated time to be an atrial fibrillation center of excellence. So the most common complication is we access these veins in your leg, and there can be bleeding around them, bruising. Bleeding is what we call a hematoma. We may see that in 1% to 2% of people.

Our tools are designed to work in the heart, move with the heart that's beating, and they're flexible, so they can do that, but occasionally, there can be a small hole in the heart or a tear in the heart that can cause bleeding around the heart. That happens in about 1 in 500 to 1 in 1,000. Typically, we can treat this conservatively, meaning you don't need a surgeon to repair the entry, but about 1 in 10 of the people with these bleeds will need surgical help. There's a risk of stroke or clot formation on our tools. Our tools irrigate themselves. They have fluid bathing around them, so clot is less likely to occur, and that occurs about 1 in 1,000 to 1 in 3,000.

And then, the part that concerns me the most is the, not necessarily the heart at all, it's the structure behind the heart, the esophagus. So we have to identify where the esophagus is and make sure we avoid it, because if you heat two tissues or you freeze two tissues, they can grow together and form a communication. And we perform ablation either with heat injury or with extreme cooling or freezing, and both of those can cause injury to the esophagus. We have to know where that is to avoid.

But those are the most common things that we worry about. There's some other minor things. Major risk RE less than a percent, anywhere from less than a percent to 1 in 1,000. Success rates of the procedures for what we call paroxysmal atrial fibrillation that comes and goes, in most centers is 70% to 80%, and for atrial fibrillation that's persistent, meaning that it lasts longer than a week or we need to shock the heart to restore it, procedures' success rates will fall by about 10% to 20%.

Interviewer: So it sounds like the procedure has a decent success rate, but there are still things that we've got to look out for and what better reason to really be sure that you're going to a good center and have a good surgeon. So, after the procedure, on the same day they're put under general anesthesia, you're saying that some people have to stay overnight?

Dr. Bunch: And it varies a lot from person to person. So, again, once you wake up at our center, all the IVs are out, there's just bandages on the legs. We put little closure devices in the veins so they heal more quickly. So most people are up walking in two to four hours. I would say right now, approximately 50% to 2/3 of our patients go home the same day after being observed in recovery for 3 to 4 hours. We want people up and walking that day, in that evening. We don't want people lifting over anywhere from 10 to 20 pounds for about a week after, not necessarily because of the heart but the veins that we go in through, they have to heal as well. And typically, veins heal a little bit quicker than our skin. So, if there's no evidence that we were in the vein from the skin, you can rest assured that the vein is also healed at that time as well.

But what we have learned after to encourage exercise and activity. A lot of people with fast heart rates worry that they're going to exercise and their heart's going to go fast and it's going to cause fibrillation. But studies have shown that those that engage in exercise, yoga for like 30 to 60 minutes a day, they can influence the risk of recurrence by about 30%. And so we want our patients active right after.

But what I tell most people is follow their body. These procedures, they make people nervous. If it's your first one, you're nervous, you're anxious, you're under anesthesia, and some people just feel tired after it. And so, if you have a few days where you're fatigued, that's your body saying that you need time to recover. But most people can expect to be up and active and walking the day of their procedure with minimal to no pain.

Interviewer: What is recovery like for a procedure like this? It seems like a pretty major procedure to me as a lay person. But how long until a person heals, when can they get back to work, you know? What does the aftercare look like?

Dr. Bunch: That's a great question as well. So we want them up and active, but one of the things our heart doesn't like is to be touched. So our heart's surrounded by sacs. It's surrounded by ribs and muscles, so you can't touch it. And so, when we work in the heart, sometimes it actually gets more irritable for the first few weeks to months. So, if you have abnormal rhythms in the first three months, those really don't mean that this, the procedure has failed. That's part of the heart healing. So about one-third of people will notice some abnormal heart rhythms in that first three months. We want to know about those. We treat them. We'll use medications while the heart's healing. About two-thirds, their heart will be really quiet. And then, anything that happens after three to six months, then there's more significant long term, but it's just important to remember the heart has to heal.

It's easy when we have open heart surgery and there's stitches and our ribs hurt and our sternum hurts to know that the heart was worked on. When there's just some small dots near your veins in your legs, you kind of forget after a week or so that the heart still has to heal. So it is important to realize that our heart is beating 100,000 to 120,000 beats per day. So it's really healing on the run. So it takes time to heal. Even if we don't feel pain or anything, it's still undergoing this reparative or this healing process.

Interviewer: Now, say we're a couple of months after the ablation procedure, and a patient's heart is starting to heal, what are some of the quality of life improvements that we can expect? Keeping in mind that as we've talked about on an earlier interview, this procedure, the cardiac ablation is not a cure for a-fib. After all, there are still medications and other risk factors and other treatments.

Dr. Bunch: Some are intuitive that most people, when we study people and ask them specifically, people have more energy, they don't feel their heart symptoms as much, they want to do more, they're more engaged, they're more active, and those are all what we call physical measures of quality of life improvement. People also tend to have quality of life improvement in mental scores, how often do they feel depressed or a depressed mood. Those tend to improve as well. We can see that as early as three months, and those quality of life scores continue to be higher in patients that have an ablation compared to those that don't upwards to three to five years.

A lot of my research is on the cognitive component of atrial fibrillation and brain health, and we also see that the cognitive scores go up after an ablation as well, particularly in the regions of memory and memory storage. So people do also report a little bit better memory and cognitive function after ablation as well, which I think is exciting, because years ago we found that atrial fibrillation was associated with multiple forms of dementia, and these scores teach us that if we apply aggressive treatment, we improve the rhythm, we lower risk factors, that we can really help the general brain health, and a disease that really is terrifying to all of us or to lose our memory and our brain function and develop severe cognitive impairment or dementia.

Interviewer: A procedure called catheter ablation lowers the risk for complications and death in patients with atrial fibrillation.

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Interviewer: Today I'm talking with Dr. Nassir Marrouche from University of Utah Health about catheter ablation for treating atrial fibrillation in patients with heart failure.

Dr. Marrouche: You know, more than 20 million people in America suffer from heart failure, and a significant amount of these people have an ejection fraction or weak heart muscle, less than 35 percent. That's defined as weak heart muscle. And these guys are high risk of sudden cardiac death. We know this for years now, and that's why they need to protect it.

Now, more than 30 percent of the heart failure patients are suffering or will suffer from atrial fibrillation. It's a big number. Very enormous. So this is becoming a big dilemma, how to treat these patients, and we know that in this patient population, the atrial fibrillation itself increases the risk of dying, increases the risk of stroke and so on. And over the years, there's multiple studies have been done using different kind of drugs to improve outcome in these patients.

In fact, our papers published in the New England Journal show there's no difference if you use any kind of drugs or use nothing. The mortality will stay the same. Stroke risk will stay the same. Hospitalization rate will stay the same.

Interviewer: Catheter ablation is a completely different approach. Can you explain what that is?

Dr. Marrouche: Me, personally, and our team has started working on this before we came to the University of Utah, around 1999, 2000, which is, simplified, is the catheter-based procedure, as the name says, to target specific cells within our heart, specifically in the atrial, the upper chamber of the heart, to cauterize or kill, trigger the tissue causing irregular heartbeat. There's different ways to do this, and over the last 20 years we learned a lot how to do that and what's the best way to do it, but still there is still at least 5 to 6 strategies of ablating atrial fibrillation.

Interviewer: And all of this is done within a few hours and the patient walks away, or ...

Dr. Marrouche: If I would have given you this interview in 2000, when we were in the Cleveland Clinic, I would have told you 11 hours procedure to 10, nine. We went up to six, we were excited. It's a two-hour procedure today. I mean, the ablation itself, the delivering energy and heating tissue, is probably 45 to 90 minutes maximum.

Interviewer: So even though this procedure has actually been done, like you said, for about 20 years I think you said?

Dr. Marrouche: Mm-hmm.

Interviewer: It sounds like really what wasn't known is how effective it was, especially compared to drug treatments.

Dr. Marrouche: The unknown, until we just presented the recent study was, does a-fib ablation, per se, improve primary endpoints of mortality or worsening heart failure hospitalization in a group of patients suffering from heart failure? Now, that's that we focus on, because we wanted to look at sick patients who suffer from this disease to look at.

Interviewer: I see.

Dr. Marrouche: Not quick, but to look at . . . they have higher events. These patients die, about 30 percent, 40 percent of them die because of the heart failure and diseased hearts. So we wanted to look at this population, see can we save life in this high-risk population? And that wasn't done until recently.

Interviewer: In a nutshell, what were those results?

Dr. Marrouche: Catheter ablation showed a significant reduction in all cause mortality when compared to conventional guidelines based standard treatment, standard of care treatment. Catheter ablation, when you looked at the mortality and heart failure combined as a composite endpoint, showed a significant reduction of the composite point of the two together. When you looked at the hospitalization only, catheter ablation was superior to drugs or standard of care treatment in lowering hospitalization for heart failure.

Catheter ablation was also, which is very important for the listeners as well to know, in lowering the risk of cardiovascular mortality. Not all cause mortality only but also cardiovascular mortality.

Interviewer: Okay, specifically, yeah.

Dr. Marrouche: Sudden cardiac death and failing pump and so on. So that improved the outcome. And actually the relative risk reduction in cardiovascular mortality was 51 percent. That means that every other patient will recover. And what's important for causal AF, if you look at the data and hopefully the paper will be out soon and you read it, we need only to treat eight patients to save . . .

Interviewer: Eight?

Dr. Marrouche: Eight patients to save one life. That's a big deal for a study like this.

Interviewer: One thing you alluded to earlier is that, I mean, these patients are already pretty sick, right? And so it seems pretty impactful that you can make a change even at this stage.

Dr. Marrouche: You have the data from causal. The earlier we treat this patient in this progress, in the stage of heart failure, the better the outcome. So if you treat them when they start getting to heart failure and the pump is 30 percent and 35 percent, 29 percent in function and ejection fraction, they do way better when they are at the end stage of the disease, when they're almost dying. So that's important as well, go and seek treatment as early as possible, and ablation should be the best option for this population.

Interviewer: And so what's next in this line of research?

Dr. Marrouche: As much as I'm excited about catheter ablation and promoting it worldwide now because of the solution of our patient, but I'm telling my colleagues and partners, be careful and don't explode and start giving it to everybody randomly. We need to be thinking about selecting this patient and the MRI imaging, the finding fibrotic tissue and the extension of the disease in our atrial and our ventricles will better help redefine this patient. That's the next big study we're putting together now is randomize this patient based on the amount of scarring in their heart, to ablation procedures or not, and see what the primary or how the primary endpoint looks like, mortality, hospitalization, and strokes.

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Dr. Miller: Atrial fibrillation and stroke, are they related and can it be treated? Today on Scope radio, this is Dr. Tom Miller.

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Dr. Miller: I am here today with Dr. Dana DeWitt. She is a professor in neurology and a stroke specialist in the University of Utah, the department of Neurology. Dana, tell us a little bit but atrial fibrillation, what is it and does it lead to stroke? Can it cause stroke?

Dr. DeWitt: Atrial fibrillation is an irregular heartbeat. It causes a portion of the heart, called atrium to contract in a very irregular manner and when that happens, clot can form in that portion of the heart and break off and go up to the brain and cause a stroke. It is clearly a major risk factor for stroke.

Dr. Miller: Atrial fibrillation, in my experience, is more common in older patients and older people, and sometimes goes unnoticed. Many times its picked up on a routine physical and sometimes in E.K.G. or patients who complain of palpitations which when you look into it, turns out to be atrial fibrillation. The issue that I have is, in telling the patient, well it's not just this irregular heart rhythm but you might have a stroke down the road if we don't take care of this. In your experience, how many of these strokes that you see, when they come in through the emergency room due to atrial fibrillation.

Dr. DeWitt: It's a fairly large proportion, probably a quarter at least. The hard part is that in many cases, patients will come in and having had a stroke, not have atrial fibrillation at the time so the atrial fibrillation can be intermittent and can sometimes be difficult to detect.

Dr. Miller: How do we detect for atrial fibrillation nowadays? What's the best way?

Dr. DeWitt: When the patient comes in and he has had a stroke, they are usually in a hospital with a cardiac monitor that watches their heart rhythm during that hospitalization. The problem is that the atrial fibrillation may not be detected during that time and so we may recommend, what we call the 30 day event monitor, which is an E.K.G. monitor that they wear for 30 days. There are also things that are called loop recorders which are these very small implantable devices that are M.R.I. compatible and they are put in by the cardiologist just over the heart with a very minor office procedure, and it monitors your heart over time.

Dr. Miller: So potentially, it can pick up intermit atrial fibrillation.

Dr. DeWitt: Exactly, which carries a high risk of stroke.

Dr. Miller: Now, many of our patients and public know that to prevent a stroke, you take an aspirin a day. Does that work to prevent stroke in atrial fibrillation?

Dr. DeWitt: It has not proven to be effective enough in patients with atrial fibrillation. The best treatment are blood thinners, and now blood thinners come in two different forms. There is a drug called Warfarin which is being used for many, many years.

Dr. Miller: That's rat poison. Isn't it?

Dr. DeWitt: It is rat poison and it is the primary treatment for atrial fibrillation to prevent stroke. The problem with warfarin is, that it requires regular blood test monitoring. There are some dietary interactions like green leafy vegetables that have to be regulated.

Dr. Miller: Antibiotics, if you take antibiotics, seizure drugs.

Dr. DeWitt: Antibiotics, drugs for seizure. There are many interactions and you have to blood test regularly to make sure your dosing is correct. If your dosing is too low then it doesn't protect you, if your dosing is too high, it could cause hemorrhage and this actually leads to a lot of fear sometimes, in not treating patients who are either elderly or might be falling.

Dr. Miller: Or who can't get their testing.

Dr. DeWitt: Who can't get their test done?

Dr. Miller: I know a number of physicians who are uncomfortable treating atrial fibrillation with warfarin. Just because of it narrow window of therapy [inaudible 00:04:00]. That's a big deal, that's a problem. If you have a team of experts, and many times those are pharmacists who take on that monitoring, that's a pretty good way to assure that the patient remains within the therapeutic window. We, at the University of Utah, taken that out of the hands of the physicians if they want us to and monitor that through our [inaudible 00:04:21], and that's have been a very effective way to manage warfarin. Warfarin is not expensive but the monitoring is key. Would you say that's true?

Dr. DeWitt: Absolutely. I tell patients who are on warfarin, the important things is really getting their blood test regularly. There are three new oral agents that have been shown to be effective for treating atrial fibrillation.

Dr. Miller: They are pricey, aren't they?

Dr. DeWitt: They are very pricey because they have a standard dosing and you don't need to do blood test. They have been a bit attractive. The problem is that, a lot of times, the patients are not able to be monitored as well if they do have a stroke, so they may not be a candidate for a thrombolytic agent. In many cases, we just don't feel totally comfortable with them as we are with warfarin in many cases.

Dr. Miller: The problem that I have in practice is, either the cost of neural medication is too much for the older person to afford or the fact that they have to be able to come in for testing and monitoring on a regular basis, whether it's by myself or a team. So there are pluses and minuses with each type of treatment.

Dr. DeWitt: I think the important thing though is that we know that atrial fibrillation is a big factor in stroke. In many cases, it's not just the monitoring but the impression, because the patients are getting older or because they are a little unsteady on their feet, that they shouldn't be treated with anti-coagulation and unfortunately, we are the ones who see those patients come into the hospitals with their big strokes.

Dr. Miller: And aspirin is not enough.

Dr. DeWitt: Aspirin is not enough.

Dr. Miller: Dana, final thoughts?

Dr. DeWitt: Well, I think the important thing is that, with strokes of certain types we suspect clot form the heart and even if we don't pick up atrial fibrillation, I think it's important to monitor the heart and keep looking for it and treat it appropriately.

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