The Beat Goes On
What You Need to Know About Atrial Fibrillation
By Gregory A. Cogert, MD, FACC, FHRS

WHAT IS ATRIAL FIBRILLATION?
Atrial fibrillation (AF) is the most common heart rhythm problem in America, with over 4 million people who carry the diagnosis of AF and many more yet to be diagnosed. So, just what is AF?

Normally, every beat of the heart is initiated by the upper chamber (atrium) contracting. This atrial impulse facilitates the flow of blood to the ventricle, which in turn pumps blood to the body. In addition to keeping the blood flowing normally, the atrium sets the heart rate, going faster during periods of stress or exercise and slower during rest. With atrial fibrillation, there is continuous chaotic electrical activity in the atrium with no atrial contraction and no atrial control of the heart rate. The loss of normal atrial blood flow can result in clotting of blood in the heart. The loss of heart rate control results in an erratic heart rate that can often be dangerously fast or slow.

Atrial fibrillation can result in a dramatic reduction in quality of life, physical condition, mental health, social functioning as well as cause congestive heart failure, stroke, dementia, and death.

WHO IS AT RISK FOR ATRIAL FIBRILLATION?
There is an increasing incidence with age and it is estimated that 25% of adults over 40 will develop AF during their lifetime. The most common risk factors for AF are age, high blood pressure, obesity, and obstructive sleep apnea. Patients with any chronic medical problem are at an increased risk for AF, especially problems of the heart, lungs, kidney, thyroid and diabetes.

HOW IS ATRIAL FIBRILLATION TREATED?
Preventing Stroke
The first step in the treatment of AF is to evaluate the risk of stroke and initiate a treatment plan to minimize that risk. There are 5 classic risk factors for stroke in AF. They are the “CHADS risk factors”
C = Congestive Heart Failure
H= Hypertension
A= Age over 75 years old
D= Diabetes
S= prior Stroke or TIA

The risk for stroke in AF with none of these risk factors is under 2% whereas in the presence of all 5 the annual stroke rate approaches 20%. Stroke risk is also increased in women, patients over 65 years old, and the presence of vascular disease.

There are currently three approved anticoagulant medications (blood thinners) used to minimize stroke in AF.

Warfarin: Blocks the liver’s production of clotting factors. Warfarin was the only option prior to 2010. Warfarin is a once daily medication that is affordable. An individual’s dose is highly variable and frequent blood tests are required to confirm the correct dosing. Negatives include multiple food and drug interactions resulting in frequent dose changes and blood tests.

Dabigatran: Direct Thrombin Inhibitor. Approved by the FDA October 2010. In a large research trial was found to be superior to warfarin. If kidney function is stable, the dosing is reliable and no blood tests are required. There are significantly less food and drug interactions than warfarin. It is more expensive and there are less long term safety data than warfarin. Negatives include the cost, twice daily dosing, and 10% of patients do not tolerate due to stomach irritation.

Rivaroxaban: Clotting factor (Xa) inhibitor. Approved for treatment of AF November 2011. Similar to dabigatran with stable dosing and minimal food and drug interactions negating the need for frequent blood tests in patients with stable kidney function. Cost is similar to dabigatran. In the large research trial that led to approval, its effectiveness was found to be equivalent to warfarin (as opposed to superiority seen with dabigatran). Advantages include once daily dosing and an improved side effect profile.

Treating the Symptoms
There are two strategies to minimize symptoms of AF: the “rate control” and “rhythm control” strategies. The goal of the rate strategy is to keep the heart rate within a normal range while permitting the atria to remain in fibrillation. The goal of the rhythm strategy is to maintain normal atrial function.

The advantage of the rate control strategy is the ease with which it is employed. If the heart is too fast, slowing medications are given. If the heart is too slow, a pacemaker is inserted to speed it up. If the medications are not effective or not tolerated, a simple ablation of the heart’s electrical connection from the atrium to ventricle (AV node) is performed making the heart dependent on the pacemaker to beat.

The main disadvantage to the rate control strategy is the commitment to AF. Often symptoms continue despite rate control due to the absence of atrial contraction and the loss of a physiologic heart rate control. This strategy is generally pursued in elderly, sedentary patients with a long history of atrial fibrillation and minimal symptoms.

The advantage of the rhythm strategy is that, when successful, it restores normal heart function. Rhythm control is obtained by medications, catheter ablation, or heart surgery. In its early stages, AF tends to be intermittent (paroxysmal). If it progresses to become persistent, an electrical shock (cardioversion) is often required to regain normal rhythm. The longer a patient remains in AF, the greater likelihood they will become permanently in AF.

Catheter ablation involves electrically isolating the pulmonary veins in the left atrium that trigger AF. Prompted by research trials of over 7000 patients undergoing ablation showing superiority to medication, the Heart Rhythm Society, American College of Cardiology, and American Heart Association published the 2011 AF guidelines giving ablation a class I recommendation for the first line treatment of many patients with AF1. Through 2011, the Oklahoma Heart Institute physicians have performed over 350 AF ablations. Although research data is mounting that ablation can reduce the risk of stroke, congestive heart failure, and dementia, ablation is currently restricted to patients with symptomatic AF pending validation of this data.

The main disadvantage of the rhythm control strategy is the time and expense required to eliminate AF. The single procedure success rate without medication is 70%. Often additive medications or additional procedures are required to maintain normal rhythm.

SUMMARY
Atrial Fibrillation is the most common heart rhythm problem in America. It can decrease quality of life and cause congestive heart failure, stroke, dementia, and death. Risk factors for AF include older age, hypertension, and obesity.  The first step in management is to minimize stroke risk. The second step is to minimize symptoms. Ablation of AF is superior to medical therapy and recently received a class 1 recommended for the first line treatment of AF.

REFERENCES
1. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation, Heart Rhythm 2011;8(1): 157-76

Every Woman’s Greatest Health Risk
Heart Disease is Different for You
By Eugene J. Ichinose, MD, FACC

Do you realize that more women die of cardiovascular disease than from stroke, lung cancer, chronic lung disease and breast cancer combined?

Regardless of race or ethnicity, cardiovascular disease is the leading cause of death among women, both in Oklahoma and nationwide. It accounts for nearly 500,000 deaths in the U.S. each year. Despite these sobering statistics, 45percent of women fail to identify cardiovascular disease as their greatest health risk. (Reference 1)

HOW DO YOU DETERMINE YOUR RISK FOR CARDIOVASCULAR DISEASE?
Medical history, lifestyle behavior and family history are indicators of early disease. Other conditions influence a woman’s risk for heart disease and determine if a woman needs further screening tests to detect heart disease.

In the “high risk” group, there is a 19 percent chance that within 10 years a woman will experience a heart attack, stroke or die from heart disease.

In the “at risk” group, there is a 5.5 percent chance that within 10 years a woman will experience a heart attack, stroke or die from heart disease.

In the “optimal risk” group, there is a 2.2 percent chance that within 10 years a woman will experience a heart attack, stroke or die from heart disease.

In the ”unclassified” group, there is 2.6 percent chance that within 10 years a woman will experience a heart attack, stroke or die from heart disease. Women in the unclassified group are without risk factors for heart disease. Because they do not maintain a healthy lifestyle, they are excluded from the optimal risk group. (Reference 2)

Obesity is defined as a condition of having a body mass index of greater than 30.

Evidence of atherosclerosis (coronary heart disease) can be determined by obtaining a screening test called a carotid ultrasound or coronary calcium score, which is available through the Oklahoma Heart screening program (918-592-0999).

The 10-year predicted cardiovascular disease (CVD) risk can be calculated using the Framingham Risk Score which you can find at http://hp2010.nhlbihin.net/ATPiii/calculator.asp?usertype=profand.

Pregnancy is a natural cardiovascular and metabolic stress test that may estimate a woman’s lifetime risk for heart disease. Histories of preeclampsia will double the risk for subsequent ischemic heart disease, stroke and venous thromboembolic event over the five to 15 years after pregnancy. This may be an indication to carefully monitor and control risk factors during those years after pregnancy. (Reference 2)

All women should stop smoking and avoid second hand smoke. All women should also plan regular physical activity such as 30 minutes of brisk walking. For women who need to lose weight or sustain weight loss, a minimum of 60-90 minutes of moderately intense physical activity is recommended.

High blood pressure is a systolic blood pressure of greater than 140mmHg or diastolic blood pressure greater than 80mmHg. High blood pressure becomes more common in women over 65 years. The prevalence of hypertension in blacks in the United States is among the highest worldwide. It is especially high in black women at 44 percent. (Reference 2) Unfortunately, women tend to be under treated. Although, men continue to improve their rates of treatment and control, in the NHANE survey of 1999-2000, the treatment and control of hypertension in women has not changed.

Women should strive for a blood pressure of less than 120/80mmHg through lifestyle approaches such as weight control, increased physical activity, sodium restriction and increased consumption of fresh fruits, vegetables and low fat dairy products.

There is a frightening trend of increased body weight. Nearly two of every three U.S. women over 20 years old are now overweight or obese. This is a major contributor to the epidemic of type 2 diabetes mellitus now seen in more than 12 million women in the U.S. Type 2 diabetes mellitus greatly increases overall risk for heart attack and stroke.

Both lifestyle and medications should be used as indicated in women with diabetes to achieve a hemoglobin A one c (HbA1c) of less than seven percent if this can be accomplished without significant hypoglycemia.

During perimenopause, cholesterol and triglycerides become erratic, increasing by approximately 10 percent. HDL gradually declines after menopause. In the U.S., saturated fats come mainly from meat, seafood, poultry with skin, and whole-milk dairy products (cheese, milk, and ice cream). A few plant foods are also high in saturated fats, including coconut and coconut oil and palm oil. (Reference 4) The intake of saturated fat should be less than seven percent of total calories and cholesterol intake should be less than 200mg per day.

The use of hormone therapy and selective estrogen-receptor modulators should not be used for primary of secondary prevention of coronary heart disease. The use of vitamin supplements such as vitamin E, C, beta-carotene, folic acid with or without B6 and B12 have not been found helpful in preventing or treating coronary heart disease.

Women more frequently experience non-classic symptoms on presentation of a heart attack. Shortness of breath, nausea & vomiting, fatigue, sweating and arm or shoulder pain without chest pain occur more frequently in women than in men.

Based on a 2009 survey from the Center for Disease Control, Oklahoma remains in the top five states for the highest rate of heart attacks. 25 percent of the population of Oklahoma actively smokes, which is the third highest smoking rate. Oklahoma also placed third as the most sedentary state with 31 percent of the population not participating in any physical activity in the past 30 days. Tragically, Oklahoma had the greatest percent of people, 85 percent, consuming less than five servings of fruits and vegetables per day.

By following the above recommendations, you can begin to prevent heart disease from jeopardizing your health and longevity. Screening today could save your life tomorrow. Take time to take care of yourself.

REFERENCES
1. Mosca L. Mochari H, Christian A, et al:National study of women’s awareness, preventive action, and barriers to cardiovascular health. Circulation 113:525, 2006.

2. Mosca, L et al: Effectiveness-Based Guideline for the Prevention of Cardiovascular Disease in Women 2011 Update. JACC 2011:57;1404-1423

3. Braunwald’s Heart Disease: A textbook of cardiovascular medicine, Eighth Edition, 2008 Chapter 76 Kristin Newby, Pamela Douglas.

4. http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-full-story/index.html

“I can’t believe I’m having more heartburn,” I said to my wife as she lay beside me in bed. “I’m going to go downstairs for a bit and take some Tums.” Here it was flaring up again I thought. Just like last weekend when we walked five blocks to the drugstore and picked up all sorts of “remedies” - antacids, Pepto-Bismol and whatever else, thinking it would give me some relief.

“Are you going be okay?” she asked.

“Sure, no problem," I replied, but in actuality, I was feeling a bit nauseous. “I’m just going to go downstairs and watch a little bit of TV. It helps to sit up while the Tums takes effect.”

It didn’t get any better. The heartburn just didn’t seem to go away and even caused me enough nausea that I had to get up from the couch and go to the bathroom. That was the way it went for the whole night. The burning pain kept me up all night. When my wife came down in the morning, I immediately said that I’m going to our family doctor in Owasso for a checkup. This is just not right.

So I made an appointment for early morning and drove to Utica Park Clinic in Owasso to see Dr. MoneyPenny. After a few questions, he said, “we have to get an EKG to rule some things out.” I got an EKG - a mere formality to what I thought. Dr. Moneypenny said that I was having a heart attack and I need to go immediately to the emergency room at Bailey Medical Center.

I thought it was a mistake. I just could not wrap my head around what was going on. I had no history of heart disease in my family. My blood pressure was always normal. I was 20 or 30 pounds overweight, but nothing I thought was a big deal. I was an active 55 years old.

“Yes, you are having a heart attack and we need to get you over to the emergency room as quickly as possible,” I remember Dr. Moneypenny saying.

“Couldn’t I just take a few more Tums?” I asked. My wife looked at me with a strange disbelief - like we were both having a nightmare and were going to wake up any second and laugh about the strange dream we had. Next thing I know, I’m being loaded into an ambulance with the lights and siren going, on my way to Hillcrest in Tulsa and the Oklahoma Heart Institute.

I remember vividly the rain pouring down and hitting the roof of the ambulance as we rode on the highway – a constant pinging on the metal roof as I laid on the gurney inside. My only thought was that this was going to be the last sound I hear before I die.

When I arrived at the hospital in Tulsa, I was wheeled straight into surgery. There, I was told that they will image my heart and proceed depending on what the images indicated. It could be stents or it could be something even more intensive, perhaps surgery. I’m thinking, “just great - open heart surgery.”

Fortunately, I only needed stents and as I was awake the whole time, the team explained exactly what the problem was and what they were going to do. I had 100 percent blockage and they were going to go through my leg to the area and insert a stent to get the blood flowing. Still awake, I watched on the imaging monitor fascinated by the whole thing. The one thing that I remembered most of all about the experience in the operation was the coordination of everyone. For some reason, and this may sound a bit off, but I thought of an Indy pit crew - few words spoken and extremely fast. It just seemed all so coordinated. I really can’t describe it beyond that. Just so coordinated - like a ritual that has been taken to absolute perfection in movement and efficiency.

I had two stents put in and was in my room before my wife was even able to drive our car from Bailey Medical Center in Owasso to Tulsa. I stayed in the hospital three days and the care was absolutely first rate. Within a few hours, the doctor came in and explained just what had happened in more detail and I was even given a sketch by the doctor showing just what had happened and what had been done.

I had 100 percent blockage in the left anterior descending (LAD), which apparently is considered a major heart attack. My first thought was that it seemed I was lucky even to have made it to my initial doctor’s appointment. Yet, here I was and feeling better than I had in quite a while - almost euphoric like I had been at 10,000 feet for months and suddenly here I was at sea level and breathing oxygen again. It is hard to describe really. I was almost giddy.

During those three days, as I mentioned before, my care was excellent. Even the food wasn’t so bad. But one particular caregiver comes to mind as giving her time above and beyond. She answered every single question that I came up with, telling me what to expect and how to improve. The last two days she would come by and even give me a impromptu “class” on what drugs I would be taking, how they were named and how to distinguish which drugs did what towards my recovery. Her professionalism, concern and care made those three days go by very quickly.

Here she is on my last day just before I was discharged.

It has been several weeks since that dramatic day. My recovery continues and I’ve had several people mention they are amazed at my recovery. Some even say that I look a few years younger. So far so good as with every new day I know is a good one.

What can I say about the experience? Really, how can you thank those who saved your life? No words can do justice really but here it is anyway.

Thank you, Dr Moneypenny.

Thank you to all those exceptional professionals at Oklahoma Heart Institute.

And thank you Beth, RN.

Please visit Utica Park Clinic at uticaparkclinic.com or by calling (918) 579-DOCS to find a provider near you.

Edward J. Coleman, MD, is a cardiovascular surgeon who specializes in cardiac, thoracic and vascular surgery. He completed his residency in cardiothoracic surgery at State University of New York at Buffalo in Buffalo, New York. He was Senior & Chief Resident at Mary Imogene Bassett Hospital/Columbia University College of Physicians & Surgeons in Cooperstown, New York. Dr. Coleman performed his Internship and Residency in general surgery at the University of Rochester School of Medicine & Dentistry in Rochester, NY. He earned his medical degree from State University of New York at Buffalo School of Medicine, Buffalo, New York. Dr. Coleman received his Bachelor of Arts degree from Norwich University in Northfield, Vermont.

I Know I Should Exercise, But…
By Wayne N. Leimbach, Jr., MD, FACC, FSCAI, FCCP, FAHA

Everybody knows they should exercise, but most of us feel we don’t have the time, or think we can’t do the exercise activity level needed to get any benefit. To further confuse us, the recommendations in the media vary greatly and often reflect a particular sales pitch for exercise equipment, a workout program or a health club membership.

So what does the scientific data say regarding how much someone should exercise to lead a healthier life?

First, some people question how much benefit someone actually gains from routine exercise. Wouldn’t living longer be a good incentive to exercise?

Dr. Steven Blair at the Cooper Clinic in Dallas, Texas, has evaluated greater than 70,000 individuals with maximal exercise treadmill testing since 1970. Maximum exercise treadmill tests were performed at baseline on all patients, and the majority had follow up exercise treadmill tests over the subsequent years. He divided the subjects into three categories: the “unfit” (lower 20 percent based on time on the treadmill adjusted for gender and age), the “moderately fit” (the next 40 percent of patients based on time on the treadmill), and the “high fitness” group (which included the top 40 percent based on time on the treadmill). He collected the mortality rates during the 18 years of follow up for both men and women based on whether they were initially found to have a low, moderate, or high level of fitness on the initial treadmill testing.

He found a greater than 50 percent reduction in mortality for women by just being in the moderately fit group as compared to the low fit group, and moderately fit men had an even greater reduction as compared to the low fit group.

In addition, people who initially tested as “unfit” on the first exam and remained in the “unfit” category at follow up exams had a two-fold higher mortality rate than those who initially tested as unfit on the first exam, but then tested moderately fit on the follow up exams.

For those subjects who tested fit on both the initial and follow up treadmill tests, there was a 60 percent lower mortality rate as compared to the unfit group, so exercising even to a moderate level of fitness can substantially decrease all cause mortality.

Many people think you have to jog or run a marathon to make a difference. The real question for them is, “How little can I do to make a difference in my health and my life?”

Dr. Timothy Church, Director of the Pennington Biomedical Research Center at Louisiana State University measured the effects of different doses of physical activity on cardiopulmonary fitness among sedentary, overweight, or obese postmenopausal women. Women were randomly assigned to one of four groups. The first group was a non-exercising group, which served as a control. The second group was a low exercise group that walked 72 minutes a week. The third group was a moderate level exercising group that walked 136 minutes per week, and the fourth group was a high level exercise group that walked 192 minutes per week. After six months, the control, non-exercising group experienced a 1.7 percent decrease in physical fitness as compared to a 3.8 percent, 6.7 percent, and 9.1 percent improvement in fitness for the low, moderate, and high exercise level groups respectively.

These findings showed that just a 10 minute walk seven days a week not only prevented the deterioration in fitness that was seen in the non-exercising group, but the 10 minute a day walk produced a measurable increase in fitness in just six months.

So, the smallest amount of exercise time to produce a measurable benefit in health is a 10-minute walk seven days a week.

The United States Government has produced a Physical Activity Guideline similar to what the government has done in regards to nutritional recommendations. The guideline recommends that adults accumulate two hours and 30 minutes a week of moderate intensity exercising, which includes walking. So, 30 minutes of walking five days a week produces a significant improvement in health.

There have been several studies, which show that a person doesn’t have to be a marathon runner to gain benefits from exercise. Studies have shown that simple strategies to increase one’s daily activity produce long term benefits. Such strategies include walking more than 10,000 steps a day or simply doubling the number of steps a person walks each day. People who consistently use the stairway in their workplace instead of the elevator also showed benefit over time.

Most everyone knows they should exercise, but most don’t realize that even a 10-minute walk once a day produces a substantial benefit. So, there is no need to buy any special exercise equipment or join a health club unless you want to do more.

It is important to remember that it is far better and easier to maintain good health than try to regain it once it is lost.

Reducing Stroke in Atrial Fibrillation
By Gregory A. Cogert, MD, FACC, FHRS

WHAT IS ATRIAL FIBRILLATION?
Atrial fibrillation (AF) is the most common heart rhythm problem in America, with over 4 million people who carry the diagnosis of AF and many more yet to be diagnosed. Normally, every beat of the heart is initiated by the upper chamber (atrium) contracting. This atrial impulse sets the heart rate and facilitates the flow of blood in the heart. With atrial fibrillation, there is continuous chaotic electrical activity in the atrium with no atrial contraction and no atrial control of the heart rate. The loss of normal atrial blood flow can result in clotting of blood in the heart. The loss of heart rate control can result in symptoms of fatigue, weakness, loss of exercise tolerance, and potentially a dangerously fast or slow heart rate.

Atrial fibrillation can result in a dramatic reduction in quality of life, physical condition, mental health, and social functioning, as well as cause congestive heart failure, stroke, dementia and death.

WHO IS AT RISK FOR ATRIAL FIBRILLATION?
There is an increasing incidence with age and it is estimated that 25% of adults over 40 will develop AF during their lifetime. In addition to age, common risk factors for AF include high blood pressure, obesity, and obstructive sleep apnea. Patients with any chronic medical problem are also at an increased risk for AF, especially problems of the heart, lungs, kidney, thyroid and diabetes.

HOW IS ATRIAL FIBRILLATION TREATED?
The first step in the treatment of AF is to evaluate the risk of stroke and initiate a treatment plan to minimize that risk. There are 5 classic risk factors for stroke in AF. They are the “CHADS risk factors”
C = Congestive Heart Failure
H= Hypertension
A= Age over 75 years old
D= Diabetes
S= prior Stroke or TIA

The risk for stroke in AF with none of these risk factors is under 2%, whereas, in the presence of all 5, the annual stroke rate approaches 20%. Stroke risk is also increased in women, patients over 65 years old, and the presence of vascular disease.

There are currently four approved anticoagulant medications (blood thinners) used to minimize stroke in AF:

Coumadin (warfarin): Blocks the liver’s production of clotting factors. Warfarin was the only option prior to 2010. Warfarin is a once daily medication that is affordable. An individual’s dose is highly variable and frequent blood tests are required to confirm the correct dosing. Negatives include multiple food and drug interactions resulting in frequent dose changes and blood tests.

Pradaxa (dabigatran): Direct Thrombin Inhibitor. Approved by the FDA in October, 2010. In a large research trial it was found to be superior to warfarin. If kidney function is stable, the dosing is reliable and no blood tests are required. There are significantly less food and drug interactions than with warfarin. It is more expensive and there are less long-term safety data than warfarin. Negatives include the cost, twice daily dosing, and >10% of patients do not tolerate due to stomach irritation.

Xarelto (rivaroxaban): Clotting factor (Xa) inhibitor. Approved for treatment of AF in November, 2011. Similar to dabigatran with stable dosing and minimal food and drug interactions negating the need for frequent blood tests in patients with stable kidney function. Cost is similar to dabigatran. In the large research trial that led to approval, its effectiveness was found to be equivalent to warfarin (as opposed to superiority seen with dabigatran). Advantages include once daily dosing and an improved side effect profile.

Eliquis (apixaban): Clotting factor (Xa) inhibitor. Approved for treatment of AF in December, 2012. Similar to rivaroxaban with stable dosing and minimal food and drug interactions negating the need for frequent blood tests in patients with stable kidney function. In the large research trials that led to approval, its safety and effectiveness was found to be superior to warfarin with a bleeding profile comparable to aspirin. Disadvantages include twice daily dosing.

BLOOD THINNERS FOR EVERYONE?
In all but the lowest risk for stroke patients (CHADS>2), anticoagulant medications have shown clear superiority in reducing the risk for stroke in AF. This conclusion has been validated in long-term research studies of over 100,000 patients. Importantly, the risk for stroke does not follow the quantity of AF a patient has, and even patients who spend the majority of time in normal rhythm warrant the same treatment as those in continuous atrial fibrillation.

There is, however, a subgroup of patients in whom the risk of bleeding conferred by taking blood thinners outweighs their benefits. These are patients who are at a high risk for bleeding, many of whom have had previous life threatening bleeding in the head or have required blood transfusion. In this subgroup of patients who cannot safely take blood thinners, we consider an invasive approach to stroke reduction.

Over 90% of strokes in AF are felt to originate from the left atrial appendage (LAA). For years cardiac surgeons have sought to mitigate stroke risk in patients undergoing cardiac surgery by removing the LAA. The AtriClip was approved in 2010 for surgical closure of the LAA to prevent stroke in AF. Less invasive procedures to exclude the LAA from the circulation without heart surgery are currently being developed.

The best-studied implantable device to occlude the LAA is the Watchman device. The Watchman is a plug inserted from within the heart to occlude the LAA without requiring heart surgery. This device remains under active investigation, but is yet to be approved by the FDA.

Recently the FDA has approved the LARIAT suture delivery device to close the LAA. The LARIAT procedure is performed under general anesthesia. The LARIAT is a pre-tied suture that is delivered from one puncture in the right groin and another below the rib cage. Once the suture is advanced to the base of the LAA, the loop is tightened down permanently, sealing the LAA off from the rest of the heart. Once tied off, the appendage shrivels into scar tissue. A successful LARIAT eliminates the main source of stroke in AF, while avoiding the potentially serious bleeding risks of blood thinners, as well as the need for heart surgery. In the trial that led to its approval, the LARIAT procedure took on average 45 minutes to complete and had a 95% success rate at 3 months of follow up. Although this is a new technology lacking long-term results, surgical research has not found any negative effects from removing the LAA. While the preponderance of research data currently supports taking lifelong blood thinners, the hope is that future studies will show that procedures like LARIAT will eliminate the need for blood thinners.

SUMMARY
Atrial fibrillation is the most common heart rhythm problem in America. In addition to its known associations with decreased quality of life, congestive heart failure, dementia, and death, AF confers a 5x increased risk for stroke. The first step in the management of AF is to minimize stroke risk. This is done primarily by taking one of the four approved blood thinners: Coumadin (warfarin), Pradaxa (dabigatran), Xarelto (rivaroxiban), or Eliquis (apixaban). In patients who are unable to tolerate blood thinners due to bleeding risk, the left atrial appendage is targeted as the culprit for over 90% of stokes in AF. Cardiac surgery and LARIAT suture delivery are the two approved methods to seal off the LAA from the rest of the heart.

Our Advanced Practice Provider Team:  The Physician Assistant

What is a Physician Assistant?

A physician assistant (or PA) is a nationally certified and state-licensed medical professional.

They practice and prescribe medication in all 50 states, the District of Columbia and all U.S. territories, with the exception of Puerto Rico.

What can a Physician Assistant Do?

PAs can: take your medical history, conduct physical exams, diagnose and treat illnesses, order and interpret tests, develop treatment plans, counsel on preventive care, assist in surgery, write prescriptions, make rounds in hospitals and nursing homes.  Often, the PAs’ specific duties depend on the setting in which they work, their level of experience, their specialty and state laws.

How are PAs educated and trained?

Most programs are approximately 26 months (3 academic years) and require the same prerequisite courses as medical schools. Most programs also require students to have about three years of healthcare training and experience.

Students take courses in basic sciences, behavioral sciences and clinical medicine across subjects such as anatomy, pharmacology, microbiology, physiology and more.  They then complete a total of more than 2,000 hours of clinical rotations.

In order to maintain certification, PAs must: complete a recertification exam every 10 years and complete 100 hours of continuing medical education (CME) every 2 years.  The “PA-C” after a PA’s name means they are currently certified.

Our Advanced Practice Provider Team:  The Advanced Practice Nurse 

What is an Advanced Practice Nurse?

Advance Practice Nurses (or APN) are divided into four categories: Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, & Nurse Anesthetists.  These are nationally certified and state-licensed professionals who have the right to practice autonomously with prescriptive authority in the state of Oklahoma.  

OHI employs both Nurse Practitioners and Clinical Nurse Specialists. The predominant difference is with the focus on their education with one track being specific to adults, acute care, or family practice.  

What can an Advanced Practice Nurse Do?

APNs can: take your medical history, conduct physical exams, diagnose and treat illnesses, order and interpret tests, develop treatment plans, counsel on preventive care, coordinate services, write prescriptions, make rounds in hospitals and nursing homes.  Often, the APNs’ specific duties depend on the setting in which they work, their level of experience, their specialty and state laws.

How are APNs educated and trained?

APNs' programs are Masters' of Science and usually are populated by baccalaureate prepared nurses in search of expanding their knowledge and abilities.  The programs involve a mixture of clinical rotations as well as a core curriculum involving anatomy, physiology, pathophysiology, pharmacology, mathematics, and a mixture of social sciences to expand their skills and knowledge base to allow them to provide evidence-based medicine following nationally recognized guidelines to achieve optimal patient outcomes.  

In order to maintain licensure, APNs must complete 45 hours on ongoing general medical education and those with prescriptive authority are required for 15 more hours of ongoing medical education specific to pharmacology.  

National recertification requirements vary depending on which certifying body is used.  It can involve continuing education, preceptorship and examinations.

Dr. Weber is a Peripheral Vascular Surgeon at Oklahoma Heart Institute who specializes in complex vascular disease.  He offers both open and endovascular treatment of arterial and venous disease.  Areas of interest include open and endovascular treatment of aortic pathology, cerebrovascular surgery, limb salvage surgery, vascular access and complex venous therapies.

He completed his residency in Vascular Surgery at the Cleveland Clinic in Cleveland, Ohio. Dr. Weber earned his medical degree at the University of Oklahoma College of Medicine.  He also completed his undergraduate degree at the University of Oklahoma.

Phyllis received her Master’s degree from Maryville University as a Family Nurse Practitioner after completing a Bachelor of Science degree in Nursing from Oklahoma Wesleyan University. She began her career as a Registered Nurse in the operating room with experience as a circulating and scrub nurse. She began her career as an advanced practice provider specializing in pediatrics before joining the OHI team. Phyllis maintains her certification with the American Association of Nurse Practitioners.

Gini received her Master’s degree from the University of South Alabama as an Adult-Gerontology Acute Care Nurse Practitioner with a cardiovascular subspecialty. She completed a Bachelor of Science degree in Nursing from the University of Oklahoma Health Science Center. Gini began her career as a Registered Nurse in intensive care specializing in cardiovascular nursing and holds her certification through Oklahoma State Board of Nursing as a registered nurse. She is a member of the American Association of Critical Care Nurses Tulsa Chapter and a volunteer with the Oklahoma Medical Reserve Corps. Gini also has a degree in Communications/Public Relations.

Rachael received her Master’s degree from the University of Oklahoma and the University of Tulsa, School of Community Medicine as a Physician Associate after completing a Bachelor of Science degree in Nutritional Sciences from Oklahoma State University. She began her career working in Family Medicine. Rachael maintains her certification with the National Commission of Certified Physician Assistants.

Kassandre received her Master’s degree from the University of Oklahoma at Tulsa in Physician Assistant studies after completing a Bachelor of Science degree in Radiologic Science from Midwestern State University. She began her career working in Emergency Medicine specializing in Cardiology. Kassandre maintains her certification with the National Commission of Certified Physician Assistants. 

Joan received her Master’s degree from the University of Oklahoma Health Science Center as a Physician Associate after completing a Bachelor of Arts degree in Psychology from the University of Oklahoma. She began her career as a nursing assistant at Hillcrest Medical Center. Joan maintains her certification with the National Commission of Certified Physician Assistants. She is a current member of Oklahoma Academy of Physician Assistants and American Academy of Physician Assistants.

In recognition of treating more than 100 Transcatheter Aortic Valve Replacement (TAVR) patients at Oklahoma Heart Institute, a reception was held October 16, 2014. Some patients shared their own stories.