Lee L. Eckhardt, MD, FHRS is an Associate Professor of Medicine and Cardiac Electrophysiology, Cellular and Molecular Arrhythmia Research Program at the University of Wisconsin-Madison. She is co-writing group chair of the scientific statement, “Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association,” published recently in Circulation. In April 2020, she was interviewed by Jennifer Cook, MD, Global Medical Director at Itamar® Medical, and also serves as Professor of Medicine, Advanced Heart Failure Cardiologist at the University of Cincinnati.
Dr. Cook: Congratulations on the publication of this paper. It has been part of my work to increase awareness of sleep apnea and atrial fibrillation and emphasize the importance of sleep-disordered breathing in atrial fibrillation, especially among patients undergoing ablation. This manuscript is an important tool for getting the word out.
Dr. Eckhardt: I was excited to work on this project. I was also a little bit bittersweet as I designed a clinical trial around five years ago that we never got funded. Although the work did not get off the ground, the topic was lifestyle risk factor modification and the impact on atrial fibrillation. As outlined in the manuscript, there are still large gaps in our knowledge, however, the motivation of this project was to emphasize that what is already known is quite important.
Dr. Cook: How did this group come together to write this manuscript?
Dr. Eckhardt: The spirit behind this paper was to bring awareness to what we know from clinical trials and where there are gaps in our knowledge and to identify what needs emphasis over the next few years. The group was chosen in large part because it is people who are doing research in this exact area.
The manuscript is meant to be something one can digest in an easy after-dinner read, something more digestible than the formal guidelines. This is a statement identifying where we are, and what needs to be done going forward. I have had a scientific interest in this for years and still think that there’s room for a lot of impactful science here.
Dr. Cook: Your manuscript was a very interesting read for me because it includes sleep apnea as an important factor impacting clinical outcomes in atrial fibrillation. Where do you believe the field is right now, are electrophysiologists interested in sleep apnea? Is this something that is on the radar or a second thought?
Dr. Eckhardt: Yes, that is a good question. I’m not sure that I have a deep knowledge of how most practices incorporate screening for sleep disorder breathing in their clinics. I know what our practice is and that of the others in the writing group. There is understanding that sleep apnea is associated with atrial fibrillation and the better controlled the sleep-disordered breathing is, the better controlled the arrhythmia will be. In our clinic, we send everyone (for sleep evaluation) independent of their STOP-BANG score. If they have atrial fibrillation with or without structural heart disease (they receive) some type of sleep study evaluation. I would say 35 to 40% of the time we find sleep apnea.
Some people would have a positive STOP-BANG score, however, it has been documented in the literature that the screening symptoms, looking for excessive daytime sleepiness, does not always identify people with obstructive sleep apnea. Last year at the American Heart Meeting, we hosted a “How To” session that discussed screening and management for sleep disordered breathing. I think there’s interest among electrophysiologists, but part of the difficulty is that, as an electrophysiologist, we do not have deep knowledge about
Dr. Cook: When it comes to lifestyle modifications, we seem to struggle to support change in our patients. You mentioned that at the University of Wisconsin there is a long history of cardiac rehab. Do you have any special services in your clinics to support lifestyle modification? Is there hope for such support disease-specific focus?
Dr. Eckhardt: I think that is the way of the future, atrial fibrillation centers where a holistic approach to management is available. Instead of singly treating atrial fibrillation, we are addressing the whole patient. The value of this approach is recognizing it is not just the atrial fibrillation that brought the patient to the electrophysiologist. Programs are becoming more attuned to the idea of treating the patient with a multidisciplinary group, dietician, exercise physiologist, and sleep physician, where the electrophysiologist becomes the cheerleader for the team. Primary care also plays a big role in management of underlying hypertension. The biggest barrier to institutional support is lack of reimbursement for these services.
Dr. Cook: We recognize there is an opportunity for improved outcomes following atrial fibrillation ablation with treatment of sleep disordered breathing. If we had a magic wand, what would we need to make screening and treatment compulsory by 2025?
Dr. Eckhardt: I think probably more sleep doctors. First, it is improving patient access to treatment, incorporating sleep apnea as part of my whole treatment plan. Today there is fragmented care. If you use the comparison to cancer treatment, let’s say, for example, you have cancer and you go into a cancer center. They have a surgeon, medical oncologist, imaging people, chemotherapy, wigs, accessories, and support that is needed. It is all there is the cancer center. We need to do the same for atrial fibrillation.
So it would be a center to support exercise, diabetes, and nutrition, helping patient understand why they cannot lose weight or achieve better blood pressure control. Proximity of sleep disordered breathing expertise would improve the ease of implementation. Often I hear from my patients, “My mask did not fit right, then it was so long before I got another appointment and then I just gave up on it.”
Dr. Cook: I really appreciate all of your insights. So much of what is true for atrial fibrillation is also true for heart failure. Let’s imagine a world where we are able to build these strong networks to treat obesity, diabetes, sleep, and cardiovascular disease. We definitely need to keep it up, continue working together. Thank you so much for joining me today.
Mina K. Chung, Lee L. Eckhardt et al. Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association, Circulation. 2020;141:e750–e772