21: The Cardiology Connection, Part 2

In Vital Visions' second cardiology episode, the Vedalas speak to Norman Regional’s Archana Gautam, MD. As an interventional cardiologist, Dr. Gautam’s years of experience and accomplishments are evident in this episode. Dr. Gautam is a wealth of knowledge and talks to the brothers about Atrial Fibrillation (AFib) in The Caridology Connection, Part 2. Dr. 

Guest Bio:
Archana Gautam, MD, is board certified in Cardiovascular Disease, Internal Medicine, Echocardiography, and Nuclear Cardiology. She is an interventional cardiologist who completed her residency at the University of Texas Southwestern Medical School and her fellowship at the University of Oklahoma Health Sciences Center. Dr. Gautam was also an assistant cardiology professor in academic medicine at OUHSC. She has conducted numerous research studies and been published multiple times.
Dr. Gautam's special interests include coronary artery stent, peripheral artery angioplasty and stent, carotid angioplasty and stent, atrial septal defect repair, patent foramen ovale closure and varicose vein treatment.

Links:
Archana Gautam, MD
Heart Care at Norman Regional
Heart Plaza location page
Norman Heart & Vascular Associates, Heart Plaza
Norman Heart & Vascular Associates, Heart Plaza (Cardiovascular Surgery)
Blog - Patient Living With Less Worry, Medication After WATCHMAN Procedure

This podcast is for educational purposes only. The information in this show is not to be used as medical advice. If you are needing medical care, please consult with your physician.

Norman Regional is hiring! See all our open opportunities here: https://careers.normanregional.com/careers-home/

Transcript

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Welcome, friends.

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Doctor Veer Vedala here.

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And I'm Doctor Krishna Vedala.

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And we are the Vedala bros.

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Guess what, folks? We're back.

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And now with season three of our podcast.
That's right.

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Your favorite podcast, Vital Visions
with the Vedala Brothers is back,

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where we bring you insights
into health, wellness and our community.

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This season, we're diving deeper
into the stories, science, medicine,

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and strategies that shape our vision
for a healthier future.

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From breakthrough research to powerful
patient stories here at Norman,

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Regional and expert perspectives
from some of our amazing providers

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and new technologies and services
that Norman Regional has to offer.

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We're here to connect the dots and empower
you on your journey.

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So join us each episode
as we explore new dimensions in health.

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One vital conversation at a time.

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Let's get started on season three.

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Welcome back to Vital Visions,
where health meets community.

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Welcome back, my friends.

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Doctor Veer Vedala again here, joined
by my co-host, Doctor Krishna Vedala.

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And we are the Vedala brothers.

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Thank you again for joining us for yet

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another episode of Vital Visions
where we discuss all things vital.

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We are back again today with yet
another topic close to our heart.

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Hahaha. Thanks, Krishna.

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So we already talked about

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how heart disease has such a huge impact
on our nation's morbidity and mortality.

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But to go in a bit more depth today,
we want to talk about specifically,

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a disease that affects many people
in the United States.

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Atrial Fibrillation. There are more
than 454,000 hospitalizations for AFib.

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And even up to 158,000 deaths each year
related to AFib as well.

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And to talk to us about AFib
today is our favorite cardiologist, Doctor

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Archana Gautam, thank you again,
Doctor Gautam, for joining us today.

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Krishna, you want to remind our listeners

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about Doctor Gautam and give her an intro?

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Yes, yes, of course, of course.

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So once again, everybody,
we have Doctor Archana Gautam here

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our, one of our wonderful cardiologists
here at Norman Regional.

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And without any further
ado, Doctor Gautam,

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thank you so much for once again
being here.

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And let's get started.

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So the first question is,
what is atrial fibrillation

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and how does it, affect our heart's
rhythm and overall health?

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Atrial fibrillation

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is actually known as irregular heartbeat.

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So an irregular heartbeat,
the upper chamber of the heart

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beats faster and beats irregular.

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Usually heart beats very regular.

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And you do not feel
that your heart is beating.

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So when extra beat starts to come in,
they are called irregular heartbeat.

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So there is a difference
between irregular heartbeat and Atrial

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Fibrillation. Atrial
Fibrillation is a irregular heartbeat,

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with the upper chamber
beating more than 300 times a minute.

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And that makes the lower chamber
to beat fast.

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And that's when we feel it.

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That our heart is beating fast,
versus irregular heartbeat.

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When the upper chamber is throwing
few extra heartbeats.

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And, your smartwatch can tell you
that your heart is beating irregular.

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So there is a difference
between irregular heartbeat and

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Atrial Fibrillation is more organized.

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And then since that is beating very fast
and irregular, but it's lasting longer.

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So that's when we call it.

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It's an Atrial Fibrillation
Usually when people hear that

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they have arrhythmia of the heart, 
they get very worried about it. So

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Atrial fibrillation's actually not a life
threatening condition.

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So for the most part it's, it's a treatable
disease or treatable condition.

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And, it can affect the heart, condition

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of your heart
if it's continue to beat fast and beating

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for many days or months,
it can make the heart muscle weaker.

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And, so that's why when you are diagnosed
with Atrial fibrillation,

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do not worry,
it is treatable and we can treat it.

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In fact,
sometimes you can get cured for that.

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That's amazing.

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I feel like, medicine again
has come so far that we can cure AFib now

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and also for our, like, patient listeners
or people in our community, I guess,

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What kind of symptoms would patients have
that would bring them

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to their primary care physician or their
cardiologist to get diagnosed with AFib?

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So usually the Atrial Fibrillation
that you'll see in patients

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who have chronic heart conditions
or they have chronic diseases

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such as, high blood pressure,
diabetes, lung diseases,

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those are the people who are at higher
risk for developing,

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Atrial Fibrillation
or irregular heartbeat.

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They usually feel
that their heart is beating

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irregular or what they describes
as a pounding sensation.

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Or some people feel
fluttering of the heart.

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Some people may feel like a skipping,
or they have associated

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lightheadedness,
dizziness, fatigue, tiredness,

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getting out of breath very easily
so that can bring them

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to the doctor's office or nowadays
smartwatch when they notice.

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And that's right. Yes.

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That's right.

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So it's actually in one sense it's good
that people are paying attention

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to their health.

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And when the watch is telling them

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that their heart is beating
irregular is good to get it evaluated.

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It could be just as simple
as just a few extra beats,

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or it could be a Atrial Fibrillation.

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So that's the time that you should,
make an appointment

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with your primary physicians and at least
they can start looking into it.

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So just to add on,
because I get a lot of questions

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about this with the Apple Watch
and some other, digital clocks,

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how accurate are those when it comes to
detecting these, irregular heart rhythms?

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Great question Krishna.

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Yeah, it is a very good question.

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So we are seeing a lot more patients now
than we ever have seen before because of,

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and they are good in giving you a warning

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that your heart is not beating regularly.

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It could be just a plain, simple extra
beat from the lower chamber of the heart,

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what we call PBC, or just few extra beat
that the heart can go

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a little bit of an irregular rhythm
just for second to second,

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and your smartwatch can detect it.

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So it does not mean that you have got
irregular or atrial fibrillation per se.

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So this is the first line
that is giving you

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an indication
that you might want to check out.

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They are good and nowadays
they have a EKG strips.

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So they can capture that
from the smartwatch to the cell phone.

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And you're like you can show it
to your doctors.

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If we sometime we can diagnose it
Atrial Fibrillation

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based on that strip
that you can store in your phone.

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And sometimes it's hard
because if watch is just saying

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irregular heartbeat is not necessarily
a Atrial Fibrillation.

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So they are pretty good.

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But not good

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to make a confirmed diagnosis you do need
a further evaluation and investigation.

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So the rhythm strip app, if you can check
save it in your phone,

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that can help it be it was long enough
as well then yes, we can diagnose AFib.

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So overall they are good.

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But it's a one lead EKG.

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It's a one lead EKG you right right.
So it doesn't replace, or.

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It does not replace.

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So that's why you will have to do
the confirmatory diagnosis.

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So we do not usually say
we saw on your watch that this is a fever.

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But I'm going to start you
on the treatment.

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We need to have a further investigation.

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Right okay.
So that's a great that's a great point.

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So let's can we move on to like
how do I guess

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the best way to diagnose, AFib would
then would be with an EKG.

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That's right.

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So the best way to diagnose is the EKG,
which confirms it.

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But sometimes, AFib can come and go,
as we all know.

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So, and also doesn't mean that you,
you're not feeling any symptoms,

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that you are not in Atrial
Fibrillation.

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So this is a misconception
a lot of people think, well,

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I don't feel anything
that means nothing is at all.

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It's, it's not uncommon to see that
patients have irregular

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heart rhythm or atrial fibrillation
and they have no symptoms.

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And when we do the EKG,

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we see Atrial Fibrillation
So that's the best way to diagnose.

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And then people, AFib come and go.

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The other way to diagnose
is to put them on monitor.

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So we do 30 day monitoring.

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And it nowadays is a very simple
device is just a small sticky

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pad that you put on
on your left side of the chest.

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And it monitors your rhythm for 30 days.

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So if there is
any Atrial Fibrillation, it will capture it.

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So that's the one way to diagnose.

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There are people that they don't get
palpitation or fluttering of the heart.

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They may get for a few hours
in two months, three months,

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or they may have had a stroke
and we don't know why they had a stroke.

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So in that scenario,
the best way to do diagnose is implanting

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a monitor is a very small monitor,
what we call it loop recorder

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that we put underneath
the skin just below your collarbone.

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It literally takes five minutes
to put it in.

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And it it stays there for three years.

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So it will monitor for three years or
at three years the battery life is gone.

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So that's the another way
to diagnose Atrial Fibrillation.

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If someone is keep having the population
and we are not able to capture it

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on the 30 day monitor.

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So that's the
so those are the really three ways

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to confirm
for making a confirmed diagnosis of AFib.

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we mentioned some of the different types
of monitors, we're wondering

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if you could go over

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some of them in a little more detail
with the different types of monitors

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are there.

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So the heart monitors
so you can do the external and internal

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what we talked about it.

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External monitor is that a small device.

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It comes in.
You put on your left side of the chest.

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They can be 48 hours,
seven days, 14 days and 30 days.

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So that's how they go.

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So depending on the symptoms,
if someone is having every week

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we can opt for seven days
monitor or 14 days.

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But the device is pretty much the same
that the seven day versus 30 day monitor.

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So that's how we make our decision

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whether we should 48 hour monitor
or seven day or 30 day.

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We opt for a 30 day monitor
when someone is not

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having frequent symptoms
or someone had a stroke,

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and we are trying to figure it out
if they have an arythmia.

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Yeah. So these are the external monitor.

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And then the internal monitor
is the loop recorder

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that is implanted underneath the skin.

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It is literally a five minute test,
uh procedure that we make a small incision

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and put it there.

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If someone does not want sedation,
they don't have to take a sedation.

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We just give the local anesthesia and the
skin and just implant, and, that's it.

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It doesn't even require a suture
or anything.

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Just a little of, strips on it
and cover the dressing for seven days.

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Incision gets healed.

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It stays there and every month

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we get report a on that monitor.

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So any time someone had a feeling
that they have palpitation,

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they have a capability
that they can press on the button

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and that will restore the rhythm, but
it automatically stored the rhythm too.

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So let's say that you forgot
you couldn't do it or something.

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No worries.

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Device is already set for it.

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It has parameters.

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If the heart rate goes faster or lower

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or rhythm becomes irregular,
it will automatically mark that.

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And then at 30 day
we download the information

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and it will have information of a level.

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So we do it every month.

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So these are the

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internal another internal monitor
like a pacemaker.

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So if someone has a pacemaker
we can get the information

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if they are going in there
to have Atrial Fibrillation now.

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But it is not 100% diagnostic.

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But it is a good.

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So for the pacemaker patients
you don't have to put them on it

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as a first thing we can start
with the integration of the pacemaker.

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So basically
those are the three kind of monitoring.

222
00:11:39,536 --> 00:11:40,835
You can do it. Okay.

223
00:11:40,835 --> 00:11:44,935
So just to confirm the I guess the 7, 14,
and 30 days are patches. That's right.

224
00:11:45,568 --> 00:11:48,234
And then the loop, loop
recorder is up to three years.

225
00:11:48,234 --> 00:11:48,968
Up to three. Years.

226
00:11:48,968 --> 00:11:51,901
That's really good to know. Wow.

227
00:11:51,901 --> 00:11:55,033
And and the loop recorder, Dr. Gautam
I heard it maybe stores

228
00:11:55,033 --> 00:11:57,066
like size of, like a small Triple-A
battery or something.

229
00:11:57,066 --> 00:11:59,833
That's right. Even smaller than that. Oh,
my gosh that's amazing.

230
00:11:59,833 --> 00:12:01,399
Yeah. It's a thinner than that.

231
00:12:01,399 --> 00:12:06,665
And, it just goes in and a
it is a very good device for 3 to 3 years.

232
00:12:06,665 --> 00:12:09,331
It's long enough time
that if there is no arrhythmia,

233
00:12:09,331 --> 00:12:13,264
then you can confidently said that there's
risk of any significant arrhythmia's

234
00:12:13,864 --> 00:12:15,364
Not much.

235
00:12:15,364 --> 00:12:17,930
Wow. That's amazing. So moving on.

236
00:12:17,930 --> 00:12:21,296
So we've diagnosed AFib and,

237
00:12:21,763 --> 00:12:24,229
could we talk through
I know there's like various types

238
00:12:24,229 --> 00:12:25,896
of a paper diagnosis parameters.

239
00:12:25,896 --> 00:12:28,895
Could we talk through that
for our patients or listeners I guess.

240
00:12:29,062 --> 00:12:31,428
So we have three types of rhythm.

241
00:12:31,428 --> 00:12:33,261
Paroxysmal Atrial Fibrillation.

242
00:12:33,261 --> 00:12:36,928
When the edge of Atrial Fibrillation
or irregular heartbeat comes and goes,

243
00:12:36,928 --> 00:12:39,927
it could be from minutes to hours.

244
00:12:40,327 --> 00:12:42,327
And you do not require any treatments.

245
00:12:42,327 --> 00:12:44,860
So that's called paroxysmal
Atrial Fibrillation.

246
00:12:44,860 --> 00:12:47,726
Persistent Atrial Fibrillation is when

247
00:12:47,726 --> 00:12:50,892
irregular heartbeat
is lasting more than seven days.

248
00:12:51,292 --> 00:12:55,025
And you require a treatment
to go back to normal rhythm.

249
00:12:55,025 --> 00:12:56,592
So it doesn't go on its own.

250
00:12:56,592 --> 00:12:59,258
So you may have to take a medication
for it,

251
00:12:59,258 --> 00:13:02,657
or give a shock to the heart
and bring it back to the normal rhythm.

252
00:13:02,657 --> 00:13:04,357
So that's a persistent.

253
00:13:04,357 --> 00:13:07,357
Then we call it
permanent Atrial Fibrillation.

254
00:13:07,523 --> 00:13:10,690
When your irregular heartbeat or Atrial

255
00:13:10,690 --> 00:13:13,689
Fibrillation has been there
for more than 12 months

256
00:13:13,689 --> 00:13:16,955
and we cannot convert
back to the normal rhythm.

257
00:13:16,955 --> 00:13:19,988
So those are called permanent
in that scenario.

258
00:13:20,055 --> 00:13:22,688
The goal is to control the heart rate.

259
00:13:23,754 --> 00:13:25,987
And as far as the Paroxysmal Atrial
Fibrillation

260
00:13:25,987 --> 00:13:29,887
goes there, you may need a medication
to keep the heart in normal rhythm.

261
00:13:30,220 --> 00:13:34,020
And same thing with, persistent
Atrial Fibrillation that you may need

262
00:13:34,020 --> 00:13:37,752
the medication so you don't go back in
or Atrial Fibrillation, but in permanent

263
00:13:38,086 --> 00:13:41,785
just going to control the heart rate
and control the risk factor.

264
00:13:42,752 --> 00:13:46,785
So you have Paroxysmal,
Persistent and Permanent.

265
00:13:46,885 --> 00:13:48,518
And and then in terms of

266
00:13:48,518 --> 00:13:51,517
you already kind of touched it
a little bit on this with cardioversion.

267
00:13:51,651 --> 00:13:55,150
In terms of treating AFib
other than cardioversion, are there

268
00:13:55,150 --> 00:13:58,150
other options including medical options
that we could utilize.

269
00:13:58,783 --> 00:14:01,782
So nowadays
we do have more than one options.

270
00:14:03,349 --> 00:14:06,149
If you want to divide up
Atrial Fibrillation treatment,

271
00:14:06,149 --> 00:14:07,915
Actually there are two parts of it.

272
00:14:07,915 --> 00:14:10,915
One is to control the heart rate.

273
00:14:11,048 --> 00:14:14,014
And second is to control the rhythm.

274
00:14:14,014 --> 00:14:16,480
That means
you want to keep them in normal rhythm.

275
00:14:16,480 --> 00:14:21,880
And actually the third part is prevent the
complications from Atrial Fibrillation.

276
00:14:22,413 --> 00:14:25,679
So if we talk about
what are the medications we can use,

277
00:14:25,679 --> 00:14:28,579
one is definitely changing the lifestyle.

278
00:14:28,579 --> 00:14:34,045
So do the lifestyle modification
that includes if someone is overweight

279
00:14:34,378 --> 00:14:39,177
controlling the BMI to the normal range
control the blood pressure,

280
00:14:40,277 --> 00:14:43,043
exercise every day, healthy food,

281
00:14:43,043 --> 00:14:46,343
more natural food
rather than processed food.

282
00:14:46,910 --> 00:14:50,576
Cut down on any stimulant
like excessive coffee,

283
00:14:50,576 --> 00:14:54,942
caffeine, sodas, alcohol or other.

284
00:14:54,942 --> 00:15:00,008
Nowadays, methamphetamines, stimulant
marijuana all they can contribute.

285
00:15:00,008 --> 00:15:04,940
Alcohol is also one of the biggest factor
can contribute to Atrial Fibrillation.

286
00:15:04,940 --> 00:15:09,240
So that's the first thing we want to do it
that change the lifestyle.

287
00:15:10,473 --> 00:15:14,039
Then for the medications
there are various medications we use.

288
00:15:14,039 --> 00:15:17,039
We usually start
with the most benign medications.

289
00:15:17,339 --> 00:15:22,071
So when we say benign medications
those are beta blockers, calcium

290
00:15:22,071 --> 00:15:26,271
channel blockers such as metoprolol
and ...

291
00:15:26,304 --> 00:15:30,170
And so that's how first we start with that
can we control someone's Paroxysmal 

292
00:15:30,170 --> 00:15:33,970
Atrial Fibrillation just by
putting on those benign medications.

293
00:15:34,336 --> 00:15:37,802
If we can control by benign medicine
and the lifestyle.

294
00:15:37,802 --> 00:15:38,469
Great.

295
00:15:38,469 --> 00:15:40,802
So that's will be the line of treatment.

296
00:15:40,802 --> 00:15:44,502
If some, we cannot control with the beta
blocker or calcium channel blocker,

297
00:15:44,502 --> 00:15:48,568
then we talk about antiarrhythmic
medications, antiarrhythmic medications

298
00:15:48,568 --> 00:15:51,201
They have their own side effects.
And all those things.

299
00:15:51,201 --> 00:15:54,300
So that's the time that you need
to be seen by the cardiologist

300
00:15:54,300 --> 00:15:58,366
so they can decide what kind of
antiarrhythmic medication will be better.

301
00:15:58,366 --> 00:16:01,932
One in some patients we want to again
antiarrhythmic medications

302
00:16:01,932 --> 00:16:05,232
are more benign versus
you know like have more side effect.

303
00:16:05,432 --> 00:16:07,198
So we start with the benign medications.

304
00:16:07,198 --> 00:16:12,398
If they meet the criteria like class one
agent for the antiarrhythmic medications,

305
00:16:12,398 --> 00:16:13,731
you want to start with the patients

306
00:16:13,731 --> 00:16:16,964
who do not have heart disease
or coronary artery disease.

307
00:16:17,430 --> 00:16:19,430
So you can choose the class one agent.

308
00:16:19,430 --> 00:16:20,397
They are more benign.

309
00:16:20,397 --> 00:16:23,396
They don't have much interference
with other medications.

310
00:16:23,429 --> 00:16:26,629
Then if they cannot be on class
one medications

311
00:16:26,629 --> 00:16:29,295
because they have a heart failure,
they have coronary artery disease.

312
00:16:29,295 --> 00:16:32,961
Then you go more advanced medications
such as

313
00:16:33,228 --> 00:16:36,928
so sotalol dofetilide or amiodarone.

314
00:16:37,761 --> 00:16:40,760
So that's how we decide
the medical treatment part of it.

315
00:16:40,927 --> 00:16:44,493
And then the third comes in, ablation
so if you have done

316
00:16:44,493 --> 00:16:45,960
you have done the medications.

317
00:16:45,960 --> 00:16:50,326
And still we are not able
to control the symptoms.

318
00:16:50,759 --> 00:16:55,858
That's when we say that probably ablation
is a better option. Nowadays,

319
00:16:56,158 --> 00:16:58,958
it's changing
as the treatment is getting more advanced

320
00:16:58,958 --> 00:16:59,824
for the ablation

321
00:16:59,824 --> 00:17:03,324
So if someone doesn't
want to take lifelong medications

322
00:17:03,324 --> 00:17:06,623
and they want to choose Atrial
Fibrillation as a first line therapy,

323
00:17:07,623 --> 00:17:09,156
it can be done.

324
00:17:09,156 --> 00:17:12,856
But initially goal is to try benign
medications.

325
00:17:12,856 --> 00:17:13,956
It's doing it.

326
00:17:13,956 --> 00:17:17,622
Then that way you are not going to have
to go for any procedure itself.

327
00:17:18,089 --> 00:17:21,288
But it is
a ablation is a procedure where we

328
00:17:21,821 --> 00:17:25,654
it is done under anesthesia,
go through the leg, through your brain

329
00:17:25,721 --> 00:17:29,620
to the heart and there are two ways
of doing ablation
By freezing

330
00:17:29,620 --> 00:17:34,253
it is called cryo ablation 
or by delivering the heat to the tissue.

331
00:17:34,386 --> 00:17:37,019
So basically
in the upper chamber of the heart

332
00:17:37,019 --> 00:17:41,152
there are very various fibers
going on or electricity's going going on.

333
00:17:41,252 --> 00:17:43,285
So you want to break their connection.

334
00:17:43,285 --> 00:17:46,651
So that way they are not communicating
to each other and going very fast.

335
00:17:46,651 --> 00:17:50,584
So you can do two ways by freezing it
or by delivering the heat.

336
00:17:51,017 --> 00:17:52,317
And it's done.

337
00:17:52,317 --> 00:17:54,417
You can go home
the same day after the procedure.

338
00:17:54,417 --> 00:17:56,683
Or sometimes they are kept overnight.

339
00:17:56,683 --> 00:17:59,783
And recovery
time is not much just for a day or two.

340
00:17:59,783 --> 00:18:00,616
No driving.

341
00:18:01,616 --> 00:18:04,349
So that's what the ablation is.

342
00:18:04,349 --> 00:18:06,982
So that's where the rate control

343
00:18:06,982 --> 00:18:10,048
versus rhythm control
the strategy that you want to.

344
00:18:10,315 --> 00:18:13,081
There are some people that they are
in active Atrial Fibrillation.

345
00:18:13,081 --> 00:18:14,314
They have no symptoms.

346
00:18:14,314 --> 00:18:16,647
They say I don't feel any difference.

347
00:18:16,647 --> 00:18:20,613
And I would like to just
do with the medications, which is fine.

348
00:18:21,013 --> 00:18:23,213
Then you want to control the heart rate.

349
00:18:23,213 --> 00:18:26,446
So at the end of the day,
the goal is to control the heart rate.

350
00:18:26,446 --> 00:18:29,445
If our heart rate is not controlled,
that's when the problem starts.

351
00:18:29,512 --> 00:18:31,578
That can lead to congestive heart failure.

352
00:18:31,578 --> 00:18:34,578
And we'll talk about more more
about the complications or the other

353
00:18:35,478 --> 00:18:38,477
risks can come with Atrial Fibrillation.

354
00:18:38,911 --> 00:18:41,910
And another part
when we're talking about anticoagulation.

355
00:18:41,910 --> 00:18:44,910
So the anticoagulation once
you are diagnosed with Atrial Fibrillation

356
00:18:45,310 --> 00:18:49,609
your doctor will decide whether you need
to be on a strong blood thinner medicine.

357
00:18:49,609 --> 00:18:53,942
So when the time comes in for blood
thinner medicine in Atrial Fibrillation,

358
00:18:53,942 --> 00:18:59,574
aspirin and Plavix pretty much
has no role or clopidogrel, I would say.

359
00:18:59,574 --> 00:19:03,274
So any of the other lot of patients wants
to know, well, I'm already taking aspirin

360
00:19:03,274 --> 00:19:06,540
or I'm already taking another blood
thinner medicine for whatever reason.

361
00:19:06,773 --> 00:19:07,707
Would that work?

362
00:19:07,707 --> 00:19:11,006
Know for atrial fibrillation,
you have to be on a anticoagulation.

363
00:19:11,006 --> 00:19:16,339
That means, warfarin or some other newer
anticoagulants that we have.

364
00:19:17,072 --> 00:19:20,172
And that is that decision is made

365
00:19:20,172 --> 00:19:23,271
based on the CHA2DS2‐VASc score
that what is your age?

366
00:19:23,271 --> 00:19:25,171
High blood pressure,
congestive heart failure.

367
00:19:25,171 --> 00:19:28,437
Do you have any atherosclerotic disease
anywhere in the body,

368
00:19:28,437 --> 00:19:30,537
including in your carotid, in your legs?

369
00:19:30,537 --> 00:19:32,070
That becomes a risk factor.

370
00:19:32,070 --> 00:19:36,003
So if your risk factor is two
for men or three for women,

371
00:19:36,369 --> 00:19:40,769
then you need to be on blood thinner
anticoagulants, because at that point,

372
00:19:40,769 --> 00:19:45,268
your risk of having a stroke versus
the risk of bleeding from anticoagulants

373
00:19:45,268 --> 00:19:48,034
are two different things. Yeah.

374
00:19:48,034 --> 00:19:49,601
That was like a wealth of knowledge.

375
00:19:49,601 --> 00:19:49,767
Yeah.

376
00:19:49,767 --> 00:19:52,500
Yeah,
I one of my questions is going to be ask

377
00:19:52,500 --> 00:19:54,167
asking you
to go over the CHA2DS2‐VASc score okay.

378
00:19:54,167 --> 00:19:57,666
So it's so important for our students
to learn because when in primary care

379
00:19:57,666 --> 00:20:01,932
we put that score and I think we look
smart, you know, that was great.

380
00:20:01,932 --> 00:20:03,865
So treatment wise, just in summary,

381
00:20:03,865 --> 00:20:06,898
lifestyle modification
definitely rate control, rhythm control

382
00:20:06,898 --> 00:20:10,931
ablation and then anticoagulation
to reduce the stroke risk.

383
00:20:11,131 --> 00:20:14,031
If, we're based on CHA2DS2‐VASc score, 

384
00:20:14,031 --> 00:20:16,997
and make sure there don't have
any bleeding issues or anything like that.

385
00:20:16,997 --> 00:20:19,397
I had a question to ask you.

386
00:20:19,397 --> 00:20:24,629
In the scope of primary care, sometimes we
we diagnose AFib because patients come

387
00:20:24,629 --> 00:20:27,795
in, we get an EKG, and we're like, whoa,
we need to refer you to a cardiologist.

388
00:20:28,829 --> 00:20:29,395
I guess,

389
00:20:29,395 --> 00:20:32,595
I, I'm very comfortable
starting rate control meds.

390
00:20:32,595 --> 00:20:35,261
I've never,
I don't think. Have you ever prescribed.

391
00:20:35,261 --> 00:20:37,694
No, we've never done any rhythm
control medications.

392
00:20:37,694 --> 00:20:38,127
Yeah.

393
00:20:38,127 --> 00:20:40,927
And so if you wouldn't mind like,
what are you go tos for rate

394
00:20:40,927 --> 00:20:42,693
control and rhythm control...

395
00:20:42,693 --> 00:20:46,793
And where do you think you know
the cutoff should be for primary care.

396
00:20:46,793 --> 00:20:48,426
If if it's going to take

397
00:20:48,426 --> 00:20:51,426
a little bit of time
to get to a cardiologist for a patients.

398
00:20:51,526 --> 00:20:52,425
That's a good question.

399
00:20:52,425 --> 00:20:55,125
So yes,
you are the one primary care physician.

400
00:20:55,125 --> 00:20:57,058
So the one see the Atrial Fibrillation
first

401
00:20:57,058 --> 00:20:59,124
most of the time
because patients are complaining.

402
00:20:59,124 --> 00:21:02,124
So the best way to start with of course
like getting a EKG

403
00:21:02,457 --> 00:21:03,824
getting an echocardiogram

404
00:21:03,824 --> 00:21:07,457
to make sure that you know
what is the ejection fraction is.

405
00:21:07,923 --> 00:21:11,823
And based on that the first line
we like to do as a cardiologist,

406
00:21:11,823 --> 00:21:13,389
we prefer beta blocker okay.

407
00:21:13,389 --> 00:21:17,555
So that way you do not have to worry about
knowing ejection fraction right away.

408
00:21:17,755 --> 00:21:19,888
So the beta blocker are safe to prescribe.

409
00:21:19,888 --> 00:21:21,488
Even someone who has a heart failure.

410
00:21:21,488 --> 00:21:23,021
So you want to go with the metoprolol.

411
00:21:23,021 --> 00:21:24,588
You can start with the short acting

412
00:21:24,588 --> 00:21:27,321
and then change to longer
acting like a metoprolol.

413
00:21:27,321 --> 00:21:31,287
So metoprolol is a very good rate
controlled medicine as well as carvedilol.

414
00:21:31,287 --> 00:21:33,820
Carvedilol
has a more blood pressure effect,

415
00:21:33,820 --> 00:21:35,719
so it will drop your blood pressure more.

416
00:21:35,719 --> 00:21:39,619
So metoprolol is not that much
antihypertensive medication.

417
00:21:39,619 --> 00:21:42,152
So metoprolol is the first way to go.

418
00:21:42,152 --> 00:21:46,051
Or bisoprolol 
also that a good rate control medication.

419
00:21:46,251 --> 00:21:48,051
So that's what I would choose first.

420
00:21:48,051 --> 00:21:52,450
If someone has severe asthma to have
an active wheezing and your concerned

421
00:21:52,450 --> 00:21:58,350
beta blocker in the, effect,
then you could choose diltiazem Okay.

422
00:21:58,350 --> 00:22:02,049
So diltiazem,
it has a stronger blood pressure effect.

423
00:22:02,049 --> 00:22:04,015
So that's why you are somewhat limited.

424
00:22:04,015 --> 00:22:07,748
You can aid digoxin in
if they don't have renal insufficiency.

425
00:22:07,748 --> 00:22:09,048
You're not concerned.

426
00:22:09,048 --> 00:22:11,948
digoxin works
better when you combined with

427
00:22:11,948 --> 00:22:15,281
any AB nodal agent,
like a beta blocker or cortisone.

428
00:22:15,281 --> 00:22:17,380
So if you combine with that,
that will be good.

429
00:22:17,380 --> 00:22:20,080
Always check that the digoxin level,
your the digoxin level

430
00:22:20,080 --> 00:22:21,613
should not go more than one.

431
00:22:21,613 --> 00:22:25,146
So you need to kind of instruct patients
also that they are dehydrated

432
00:22:25,146 --> 00:22:27,945
or they had nausea or vomiting, diarrhea
probably at that time.

433
00:22:27,945 --> 00:22:29,212
It's good to hold the digoxin.

434
00:22:29,212 --> 00:22:31,845
So they are not allowing
the digoxin toxicity.

435
00:22:31,845 --> 00:22:34,978
So that will be the best
one for the primary care physicians.

436
00:22:34,978 --> 00:22:37,377
To start I would recommend antiarrhythmic.

437
00:22:37,377 --> 00:22:40,077
Probably better
to be started by the specialist

438
00:22:40,077 --> 00:22:43,410
so we can assess, you know
like which antiarrhythmic will be better.

439
00:22:43,977 --> 00:22:49,509
Amiodarone is most commonly used
but it is a long acting drug.

440
00:22:49,509 --> 00:22:52,975
So it takes days
to build up in your system.

441
00:22:52,975 --> 00:22:56,275
So even you start with the dose,
it will take you 15 days to get there.

442
00:22:56,908 --> 00:22:57,475
And then

443
00:22:58,508 --> 00:23:01,407
as one
can develop the toxicity from Amiodarone

444
00:23:01,407 --> 00:23:06,073
and it could be the rapid onset
rather than the long term like lung effect

445
00:23:06,073 --> 00:23:11,406
can come acutely with amiodarone, liver
toxicity, thyroid and all those things.

446
00:23:11,406 --> 00:23:12,973
So those have to be monitored.

447
00:23:12,973 --> 00:23:17,139
So it's better to leave those drugs due
to prolonging effect with the amiodarone.

448
00:23:17,139 --> 00:23:19,238
And that what medications.

449
00:23:19,238 --> 00:23:22,371
So for primary care
best to start with the beta blocker.

450
00:23:22,505 --> 00:23:25,271
And if needed can add
a little digoxin in there.

451
00:23:25,271 --> 00:23:27,004
And of course check the thyroid hormone.

452
00:23:27,004 --> 00:23:28,470
Yeah that's the.

453
00:23:28,470 --> 00:23:30,570
Always get labs.

454
00:23:30,570 --> 00:23:31,970
Always get labs.

455
00:23:31,970 --> 00:23:37,236
So one of the things that we tend to see
in primary care is sometimes,

456
00:23:37,602 --> 00:23:40,235
people that have no history
of having a primary care provider

457
00:23:40,235 --> 00:23:44,135
or seeking health care in the past,
and then they come in with AFib.

458
00:23:44,668 --> 00:23:47,501
And so this is a new found,
new found diagnosis.

459
00:23:47,501 --> 00:23:48,301
But these are people

460
00:23:48,301 --> 00:23:51,667
that haven't really done a good job
of taking care of themselves in the past.

461
00:23:52,300 --> 00:23:56,366
What are some of the complications of,
untreated atrial fibrillation,

462
00:23:56,366 --> 00:24:01,599
particularly just leaving it by
and not really getting it treated?

463
00:24:01,599 --> 00:24:04,732
Untreated
Atrial Fibrillation can cause a lot of

464
00:24:06,298 --> 00:24:09,198
issues because
of forming a blood clot in the heart.

465
00:24:09,198 --> 00:24:10,331
So that's the number one.

466
00:24:10,331 --> 00:24:12,598
So if Atrial
Fibrillation is untreated

467
00:24:12,598 --> 00:24:17,197
and they have risk factors like we talked
I talked about CHA2DS2 VASc score.

468
00:24:17,430 --> 00:24:20,363
If their score is more than two or for women
more than three,

469
00:24:20,363 --> 00:24:23,396
it can cause a stroke
because heart can form a blood clot.

470
00:24:23,396 --> 00:24:24,829
And then when the heart is squeezing

471
00:24:24,829 --> 00:24:27,662
or pumping,
that blood clot can break off, can

472
00:24:27,662 --> 00:24:31,662
Goes can go to to the legs, brains

473
00:24:31,695 --> 00:24:35,294
and stroke is the biggest risk
that it comes with that your Fibrillation

474
00:24:35,994 --> 00:24:39,427
You can have that blood clot
dislodge anywhere in the body

475
00:24:39,594 --> 00:24:45,026
so it can go to your legs and can present
with, the acute limb ischemia.

476
00:24:45,026 --> 00:24:47,259
That means the blood supply to
the leg is low,

477
00:24:47,259 --> 00:24:50,259
and now you're having a red leg
and a painful leg.

478
00:24:50,359 --> 00:24:55,825
It can go to any internal organ,
including arteries to your kidney

479
00:24:56,092 --> 00:24:59,024
or the blood supply to the intestine.

480
00:24:59,024 --> 00:25:01,857
So they can have,
they give a presentation

481
00:25:01,857 --> 00:25:04,790
with the abdominal pain
or with a kidney failure.

482
00:25:04,790 --> 00:25:07,790
So that's the biggest threat
forming a blood clot.

483
00:25:07,890 --> 00:25:10,423
Another one,
they can develop cardiomyopathy.

484
00:25:10,423 --> 00:25:15,056
That means weakness of the heart muscle
because heart has been beating very fast.

485
00:25:15,056 --> 00:25:18,922
And it's like I usually tell my patients,
it's like doing a marathon for the heart

486
00:25:18,922 --> 00:25:23,854
for days and days, and heart muscles get
weaker and cause congestive heart failure.

487
00:25:24,321 --> 00:25:28,120
So those are the biggest risk
comes in blood clot and congestive

488
00:25:28,120 --> 00:25:29,120
heart failure. Then

489
00:25:30,120 --> 00:25:32,653
symptomatic lightheadedness, dizziness,

490
00:25:32,653 --> 00:25:36,453
shortness of breath, fatigue and tiredness
that can all be a part of it,

491
00:25:36,619 --> 00:25:39,286
Atrial Fibrillation.

492
00:25:39,286 --> 00:25:39,719
Yeah.

493
00:25:39,719 --> 00:25:42,352
So these are important things
for our patients to remember.

494
00:25:42,352 --> 00:25:44,518
Come see your primary care doctor or someone

495
00:25:44,518 --> 00:25:47,918
to get things, taken care of.

496
00:25:47,984 --> 00:25:52,050
Are there any newer emerging therapies,

497
00:25:52,050 --> 00:25:55,050
that are presenting for a-fib.

498
00:25:55,050 --> 00:25:58,649
For AFib, the new emerging therapy,
like we were talking about ablation.

499
00:25:58,683 --> 00:26:01,716
So there is,
definitely change in ablation.

500
00:26:01,716 --> 00:26:04,315
What used to be done 15, 20 years ago.

501
00:26:04,315 --> 00:26:05,682
Then what they are doing it.

502
00:26:05,682 --> 00:26:09,615
So basically now a lot of ablation
is done around the pulmonary veins.

503
00:26:10,415 --> 00:26:11,348
So pulmonary veins, are the one,

504
00:26:11,348 --> 00:26:15,780
they drain the blood from the lung
to the atrium, the left atrium.

505
00:26:16,080 --> 00:26:19,013
So the electrophysiologist
go through the leg, cross

506
00:26:19,013 --> 00:26:22,013
the right side of the heart,
goes to the left side of the heart.

507
00:26:22,080 --> 00:26:25,079
And then they isolate those
four pulmonary veins

508
00:26:25,146 --> 00:26:28,345
because a lot of electricity
is generated around that area.

509
00:26:28,512 --> 00:26:31,912
So that's what new concept nowadays
in Atrial

510
00:26:31,912 --> 00:26:34,978
Fibrillation and also more

511
00:26:36,478 --> 00:26:37,744
indication based on the

512
00:26:37,744 --> 00:26:43,777
studies that going for the ablation
as soon as possible could be a better

513
00:26:43,777 --> 00:26:48,343
or has a, can decrease long term complications.

514
00:26:48,709 --> 00:26:51,875
So those are the new emerging concept
in Atrial Fibrillation.

515
00:26:52,142 --> 00:26:55,875
Doing ablation sooner
rather than waiting longer.

516
00:26:57,208 --> 00:27:00,341
After ablation,
is there a risk of the AFib coming back?

517
00:27:01,574 --> 00:27:02,907
That is very good question.

518
00:27:02,907 --> 00:27:06,073
So as we talk about different types
of Atrial

519
00:27:06,073 --> 00:27:09,340
Fibrillation, paroxysmal,
persistent and permanent.

520
00:27:09,540 --> 00:27:13,006
So permanent atrial
fibrillation has a least success rate.

521
00:27:13,039 --> 00:27:16,072
If someone is in the Atrial Fibrillation
for more than a year or

522
00:27:16,072 --> 00:27:19,072
so, success
rate is quite low on those patients.

523
00:27:19,238 --> 00:27:23,004
So the highest success rate
is in paroxysmal Atrial Fibrillation

524
00:27:23,204 --> 00:27:27,304
It can be about somewhere
between 80, 70 to 90%.

525
00:27:27,304 --> 00:27:30,003
So there is a some chances of recurrence.

526
00:27:30,003 --> 00:27:34,303
There is a there may be they may require
a second ablation or third ablation.

527
00:27:34,603 --> 00:27:38,436
So recurrence is there again
depending on their co-morbidities.

528
00:27:38,436 --> 00:27:42,868
If they didn't have any other chronic
diseases then success rate is higher.

529
00:27:43,102 --> 00:27:47,134
And also depending on the size of the left
atrium and permanent

530
00:27:47,201 --> 00:27:50,601
Atrial Fibrillation
also has a higher success rate about 80%.

531
00:27:50,601 --> 00:27:51,867
So they're not 100%.

532
00:27:51,867 --> 00:27:56,166
But yes, so you can have a recurrence of
Atrial Fibrillation even after ablation.

533
00:27:56,366 --> 00:28:00,799
And that's when electrophysiologists or
cardiologists decide after the ablation,

534
00:28:00,799 --> 00:28:03,799
do you still need a medication
to control your heart rate?

535
00:28:03,832 --> 00:28:06,165
Or you can go off, and low risk patients,

536
00:28:06,165 --> 00:28:09,165
Actually, after ablation,
they may not require any medications

537
00:28:09,231 --> 00:28:13,897
as far I studied control,
but anticoagulation depends on

538
00:28:14,897 --> 00:28:16,530
the blood...

539
00:28:16,530 --> 00:28:17,097
I'm sorry.

540
00:28:17,097 --> 00:28:19,830
Anticoagulation
depends on the risk factor.

541
00:28:19,830 --> 00:28:22,363
If you have a risk factor
for the stroke CHA2DS2-VASc,

542
00:28:22,363 --> 00:28:24,729
then you will need anticoagulation
regardless.

543
00:28:24,729 --> 00:28:26,829
of it. Okay.

544
00:28:26,829 --> 00:28:29,262
So in terms of,

545
00:28:29,262 --> 00:28:32,128
being with, living with atrial
fibrillation,

546
00:28:32,128 --> 00:28:35,128
are patients, okay to exercise?

547
00:28:35,128 --> 00:28:38,127
Are they okay to lead normal lives
once they're on the appropriate treatment?

548
00:28:38,861 --> 00:28:40,360
That that is a very good question.

549
00:28:40,360 --> 00:28:43,527
And a lot of people get worried about when
they have Atrial Fibrillation.

550
00:28:43,927 --> 00:28:47,559
We do we want them
to continue the healthy lifestyle.

551
00:28:47,559 --> 00:28:48,759
So if they are exercising,

552
00:28:48,759 --> 00:28:51,992
they need to continue the exercise
as long as their heart rate is controlled.

553
00:28:51,992 --> 00:28:54,658
So if there are periods
when the heart rate is not controlled,

554
00:28:54,658 --> 00:28:58,824
then you do not want to do more exercise
and cause the elevation of the heart rate.

555
00:28:58,824 --> 00:29:01,124
So if they have a control
of the Atrial Fibrillation,

556
00:29:01,124 --> 00:29:03,024
they are doing well on the medications.

557
00:29:03,024 --> 00:29:05,590
It should not limit their lifestyle.

558
00:29:05,590 --> 00:29:08,690
They can do any and live a healthy life

559
00:29:09,623 --> 00:29:11,789
as far as anticoagulation is concerned.

560
00:29:11,789 --> 00:29:14,089
If they are on anticoagulation,
then yes it does.

561
00:29:14,089 --> 00:29:15,189
You have to be mindful

562
00:29:15,189 --> 00:29:17,855
what you do, because once you're
on the blood thinner medications

563
00:29:17,855 --> 00:29:20,855
and if you are doing a high risk activity
where you can have

564
00:29:20,921 --> 00:29:23,954
head trauma or so,
then it can put you at risk.

565
00:29:24,221 --> 00:29:29,420
So nowadays, for those people also,
we have, actually alternative options.

566
00:29:29,420 --> 00:29:32,420
So there are people
who cannot take anticoagulation

567
00:29:32,786 --> 00:29:36,119
such as if they have a GI bleed
multiple times

568
00:29:36,419 --> 00:29:40,519
or they have bleeding anywhere
in the body, including in the brain,

569
00:29:40,519 --> 00:29:44,818
or they are in the high risk job
where they can get into trauma

570
00:29:44,818 --> 00:29:49,617
or they do not want to take blood thinner
medicine for whatever reason.

571
00:29:50,684 --> 00:29:51,950
They can have

572
00:29:51,950 --> 00:29:55,683
watchman device or what we call left
radial appendage occlusion.

573
00:29:55,950 --> 00:29:59,483
As we know, 90% of the atrial fibrillation

574
00:29:59,483 --> 00:30:02,882
comes in from the clot
in the left atrial appendage.

575
00:30:03,449 --> 00:30:08,248
So left atrial appendage is a
just the extra chamber in the heart.

576
00:30:08,515 --> 00:30:11,981
What I describe as appendix of the heart,
because you have two upper chamber

577
00:30:11,981 --> 00:30:16,114
two lower chamber and left atrial appendage
just hanging from the left atrium.

578
00:30:16,880 --> 00:30:18,780
And that's where the clot forms.

579
00:30:18,780 --> 00:30:21,046
So a watchman is a good option.

580
00:30:21,046 --> 00:30:24,079
Or there are other left appendage
occluder devices.

581
00:30:24,613 --> 00:30:26,379
It is just a procedure.

582
00:30:26,379 --> 00:30:29,312
That is,
it takes about an hour or so to do it.

583
00:30:29,312 --> 00:30:31,212
Then they stay overnight in the hospital.

584
00:30:31,212 --> 00:30:32,511
You go home the next day.

585
00:30:32,511 --> 00:30:35,511
Not really much restriction of activity.

586
00:30:36,411 --> 00:30:38,577
It is done under anesthesia.

587
00:30:38,577 --> 00:30:41,410
So they are under anesthesia.
We go through the leg again.

588
00:30:41,410 --> 00:30:44,710
We cross from the right side of the heart
to the left side of the heart

589
00:30:44,710 --> 00:30:49,442
by making a small opening in the membrane
between the left atrium and right atrium.

590
00:30:49,709 --> 00:30:52,142
You go there and then we put the device.

591
00:30:52,142 --> 00:30:56,741
So it basically closes off
the mouth of left atrial appendage.

592
00:30:56,908 --> 00:31:01,607
So that's that way blood cannot go in
and out and it cannot form a blood clot.

593
00:31:01,907 --> 00:31:05,807
After that you take six months
of aspirin and clopidogrel.

594
00:31:06,007 --> 00:31:07,773
So those are two antiplatelet agents.

595
00:31:07,773 --> 00:31:10,773
After six months you just have to take
aspirin 81 milligram.

596
00:31:11,473 --> 00:31:16,672
So it has these are the new treatment
options in Atrial Fibrillation.

597
00:31:16,739 --> 00:31:17,472
Oh wow.

598
00:31:17,472 --> 00:31:21,405
That has saved
a lot of people from having a stroke.

599
00:31:21,405 --> 00:31:24,538
Because there were patients
that had a stroke.

600
00:31:24,538 --> 00:31:26,404
And now they're having
a lot of bleeding problem.

601
00:31:26,404 --> 00:31:28,337
And they could not be on the blood
thinner medicine.

602
00:31:28,337 --> 00:31:30,770
And they had recurrence of a stroke. Wow.

603
00:31:30,770 --> 00:31:33,936
So for watchman device
then they need to put you need to be on

604
00:31:34,203 --> 00:31:38,469
dual antiplatelet therapy with Plavix
and aspirin for six months.

605
00:31:38,469 --> 00:31:39,502
Six months. Okay.

606
00:31:39,502 --> 00:31:43,935
And is is that
because the device has like...

607
00:31:43,935 --> 00:31:44,535
So yes, the reason

608
00:31:44,535 --> 00:31:48,101
you need to be on antiplatelet agent
because these are metals right.

609
00:31:48,101 --> 00:31:52,134
So and nitinol, you, in about six month body

610
00:31:52,134 --> 00:31:55,133
tissue grows over it
and it becomes a part of your body.

611
00:31:55,400 --> 00:31:58,399
So endothelialization happens over the device

612
00:31:58,499 --> 00:32:01,732
so that after that
your risk of blood clot is less.

613
00:32:01,732 --> 00:32:06,032
So we are trying to prevent any blood clot
on newly placed device

614
00:32:06,032 --> 00:32:09,065
because this is a foreign object
sitting in the heart and blood

615
00:32:09,065 --> 00:32:10,464
clot can form on it.

616
00:32:10,464 --> 00:32:14,331
So just to give a time for device
to become realized.

617
00:32:14,531 --> 00:32:17,130
As just like a like a. Stent.
That's right. Exactly.

618
00:32:17,130 --> 00:32:18,930
Just like a stent. That's amazing.

619
00:32:18,930 --> 00:32:22,096
And then the bleeding risk, also like,

620
00:32:22,096 --> 00:32:25,429
we're taught that there's that has blood
score that we talk about too.

621
00:32:25,429 --> 00:32:26,529
And then if that risk is high,

622
00:32:26,529 --> 00:32:29,862
that's when you consider this device
when anticoagulation is not an option.

623
00:32:29,862 --> 00:32:31,828
Right. That's right. That's amazing.

624
00:32:32,795 --> 00:32:33,328
So the

625
00:32:33,328 --> 00:32:36,328
watchman
is consider if your CHA2DS2-VASc score is high.

626
00:32:36,494 --> 00:32:40,294
You know, like two for man and three
and his blood test score.

627
00:32:40,460 --> 00:32:43,893
So if they are,
if both of them are high, then, yes,

628
00:32:44,793 --> 00:32:47,493
they should consider watchman device.

629
00:32:47,493 --> 00:32:49,092
Well,
thank you, Doctor Gatuam, for being here

630
00:32:49,092 --> 00:32:51,725
and talking to us about all things AFib
related.

631
00:32:51,725 --> 00:32:53,358
We we can't appreciate you enough.

632
00:32:53,358 --> 00:32:54,858
This was such good info.

633
00:32:54,858 --> 00:32:57,925
Not just for our patients,
but students and learners,

634
00:32:57,925 --> 00:33:01,657
because we talked about treatment
and various options and CHA2DS2-VASc scores.

635
00:33:01,657 --> 00:33:03,924
And it has been great.

636
00:33:03,924 --> 00:33:05,723
Once again, Doctor Gautam,
thank you so much.

637
00:33:05,723 --> 00:33:07,590
And before we end the episode today,

638
00:33:07,590 --> 00:33:09,890
there's one quick thing
I want to say about Doctor Gautam.

639
00:33:09,890 --> 00:33:12,789
A lot of people have asked me
what I think

640
00:33:12,789 --> 00:33:15,789
makes a great physician or a great doctor.

641
00:33:15,889 --> 00:33:19,155
And one of the things that,
I want our audience to know

642
00:33:19,188 --> 00:33:22,754
is we usually record these episodes,
a few months before they're published.

643
00:33:23,188 --> 00:33:26,787
And, Doctor Gautam actually, was very, had a

644
00:33:26,787 --> 00:33:28,520
she always has a very hectic schedule.

645
00:33:28,520 --> 00:33:32,253
And at the one of our shooting
episodes, shooting days, she,

646
00:33:32,653 --> 00:33:36,153
was not able to make it,
but she actually took the time,

647
00:33:36,153 --> 00:33:39,152
to scrub out, of the procedure
that she was doing at the time.

648
00:33:39,319 --> 00:33:42,018
Gave me a call, apologized,

649
00:33:42,018 --> 00:33:45,818
and then once again, was very respectful
and very courteous.

650
00:33:45,818 --> 00:33:49,917
And then, went back in, scrubbed in
for the procedure, did the procedure,

651
00:33:49,917 --> 00:33:52,917
and then later that evening,
she still gave me a call back again.

652
00:33:53,417 --> 00:33:57,650
And, that's just an amazing aspect
to see in anyone,

653
00:33:57,650 --> 00:34:01,516
but specifically in terms of,
being a doctor and being a provider.

654
00:34:01,816 --> 00:34:04,649
So when people ask me what I think
makes a great provider,

655
00:34:04,649 --> 00:34:07,648
I think at the end of the day, it's
really just respecting those around you.

656
00:34:07,715 --> 00:34:11,248
And Doctor Gautam, we're not trying to
say that you're 100%, you know, perfect.

657
00:34:11,248 --> 00:34:14,247
Although you are, 
but thank you so much for doing that.

658
00:34:14,247 --> 00:34:15,714
And thank you so much for being here.

659
00:34:15,714 --> 00:34:19,080
And we really appreciate everything
that you do for us, here

660
00:34:19,080 --> 00:34:22,413
in the Norman community and also,
for answering all of our questions.

661
00:34:22,413 --> 00:34:23,179
Thank you so much.

662
00:34:23,179 --> 00:34:25,712
We know how busy you are, and we can't

663
00:34:25,712 --> 00:34:28,645
thank you enough for taking the time
to be with us here today.

664
00:34:28,645 --> 00:34:31,045
Well,
thank you so much. It's my pleasure.

665
00:34:31,045 --> 00:34:35,811
No, I, I agree that everybody's time is
valuable is just not one person.

666
00:34:35,811 --> 00:34:39,744
And, I respect it, but it's still some of
my patients have to wait for it.

667
00:34:39,744 --> 00:34:42,910
I can't, I apologize, but, I do feel that,

668
00:34:43,177 --> 00:34:46,176
and I feel guilty
when someone has to wait long for me.

669
00:34:46,609 --> 00:34:49,176
But that's the nature of the job, so.

670
00:34:49,176 --> 00:34:50,809
No, no, no, we totally understand.

671
00:34:50,809 --> 00:34:52,709
But you didn't have to,

672
00:34:52,709 --> 00:34:54,942
you know, call the second time
and even call the first time.

673
00:34:54,942 --> 00:34:57,708
You could have just said, hey, I'm not
going to be able to make it by text, but.

674
00:34:57,708 --> 00:34:59,274
A simple text would suffice.

675
00:34:59,274 --> 00:35:02,907
But the fact that you actually took
the time to call it made it very special.

676
00:35:02,907 --> 00:35:05,840
And we can't thank you enough for
for everything that you do.

677
00:35:05,840 --> 00:35:06,507
Thank you.

678
00:35:07,507 --> 00:35:08,740
Well, that's it folks.

679
00:35:08,740 --> 00:35:12,406
This has been another episode of Vital
Visions where we discuss all things vital.

680
00:35:12,406 --> 00:35:13,072
You just listened

681
00:35:13,072 --> 00:35:17,139
to a great presentation with Doctor
Archana Gautum regarding AFib.

682
00:35:17,538 --> 00:35:19,605
And, thank you for joining us today.

683
00:35:19,605 --> 00:35:22,104
And as always, stay classy, my friends.

684
00:35:22,104 --> 00:35:23,138
And stay out of trouble.