Controversies and Consensus with Atrial Fibrillation: An Experts' Roundtable

Join a roundtable with two prominent Central Ohio electrophysiologists, Dr. Ralph Augostini from The Ohio State University, and Dr. Anish Amin from OhioHealth, as they discuss current practices, controversies, and management strategies for patients with atrial fibrillation. They address risk factor management, the rationale for early rhythm control, and the role of left atrial appendage exclusion in these challenging patients.

This episode is dedicated to the memory of Dr. Albert Waldo, master clinician, educator, researcher, and mentor.

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Transcript

0:11

This is Canny Gral, president of the Ohio Chapter of a c c. Before we present the new podcast episode dealing with cutting edge therapy of atrial arrhythmias, I just wanted to take a moment to recognize the very unfortunate passing of a giant in the field of cardiology and electrophysiology, both here in Ohio and known throughout the. Cardiovascular community. We unfortunately just learned that Dr. Al Waldo passed away after, uh, short illness. Dr. Waldo was a master clinician, he was a researcher, he was a master educator, and he was a mentor to so many of us in the cardiovascular community around Ohio. I have fond memories of Dr. Waldo as a clinician in Cleveland when I was a fellow. Reading EKGs with him, uh, accompanying him on rounds and I still refer to so many of his pearls for e k G interpretation. Dr. Waldo was originally from New York State, and after spending some time training at Columbia and Johns Hopkins, he joined the university hospital's medical staff in 1986, basically to establish the division of electrophysiology there. He ended up as a professor at Case Western and clinician at, uh, all the way until 2022 when he just retired a year ago at the age of 85. We all have fond memories of him as a master clinician educator researcher as well in addition to all of his excellence clinically. He actually was instrumental in the founding of the Ohio chapter of a c c in the late 1980s, and he also served as our second president. Uh, and so many of us who have, uh, contributed or, or benefited from the our state chapter really walk in his footsteps. Therefore, we think it's very fitting that for a podcast episode, talking about the latest treatment of arrhythmias that we dedicate this. Episode to our clinician, mentor, educator, and teacher Dr. Al Waldo. And now for today's episode.

Kanny: 2:31

So welcome back to the Cardio Ohio podcast. Today we're gonna have a discussion about atrial fibrillation, a condition you probably occasionally see in your own practice. Before I introduce our two eminent central Ohio electrophysiologist that are gonna enlighten us on all things af I do wanna introduce a, a special co-host I'd like to welcome also from here in central Ohio at Ohio State University. Third year fellow Andrew Hornick.

Andrew: 3:00

Thanks, DRAL. I'm honored to be here tonight filling in the big shoes of your usual co-host, Ben Allen Cherry, to introduce myself. My name is Andrew Hornick. I'm a third year cardiology fellow at Ohio State University. Here in Columbus. I'm pursuing a career in general cardiology with an interest in sports cardiology and

Kanny: 3:17

imaging.

Andrew: 3:18

I'm excited to introduce one of our guests tonight, Dr. Ralph Augustini, who's one of our EP faculty here at Ohio State. We've been in the trenches of inpatient consults together, actually a few times now. Dr. Augustini, do you mind just telling us briefly about where you're from and your training pathway to get to O SS U currently?

Ralph: 3:35

Sure. I'm originally from Western New York. I grew up about an hour south of Buffalo in a large family. I wound up making my way through state University of New York at Buffalo, now the Jacobs School of Medicine and did my residency at the University of Michigan during my residency. Dr. Topel had moved from Michigan to the Cleveland Clinic and I followed him there thinking I was gonna go into intervention. And once I got into fellowship, I really found the intellectual and variability of EP procedures to be more enticing. And I chose to do EP there at the Cleveland Clinic. I joined The practice Mid Ohio, cardiology at Ohio Health or Riverside coming outta fellowship and then transitioned to Ohio State now for 17 years.

Andrew: 4:46

Thanks, Dr. Augustini. We're we're glad that you've joined the, the good side over at Ohio State after starting off Michigan.

Kanny: 4:55

Yeah, so I would echo that. Welcome, Ralph. Thanks for joining us and it's it's been great to know you over the years and, and practice with you as well. Our second guest is also a eminent electrophysiologist from here in central Ohio. I'd like to welcome Dr. Anish Amin. He's currently the chief of electrophysiology here at Ohio Health. He did do his medical school. And fellowship at Ohio State. I think finishing approximately in 2015, and I believe he is just about to receive an endowed chair in electrophysiology here at Ohio Health as well. So Anish congratulations on that and welcome and just let us know a little bit about your current clinical

Anish: 5:34

interests. Absolutely. Thank you, Dr. Gral for inviting me. And thanks Ralph for agreeing to. With me. As Dr. Gral mentioned, I trained at Ohio State. In fact, Ralph trained me. And so it's quite humbling to be here with him tonight. We've had, you know, since coming over since finishing Fellowship and, and starting at Ohio Health, we've had tremendous opportunities are mostly related to. Novel energy therapies in managing atrial fib and as well as novel device therapies for left atrial appendage occlusion. So to both topics that are consistent with tonight's conversation.

Andrew: 6:25

Awesome. Well welcome both Dr. Augustinian and Dr. Amin. It's great to have you both with us. I think to start off this conversation, we probably should just dive right into one of the core things that we always discuss with, with atrial fibrillation, and that is when you have a patient who's coming to your office, it's a new diagnosis of atrial fibrillation, how do you make a decision about pursuing either a rate control or a rhythm control strategy? Dr. Augustinian, maybe we can start with you and, and then toss it over to Dr. Amin.

Ralph: 6:54

Number one, I think a, a good history. From the patient is helpful in particular if they're aware of the AFib or not and also how long it's been present. From there, generally I would take a workup including an echocardiogram an E C G and some blood work to really look to see. If the AFib itself has had a substantial impact on the structural components of the heart,

Kanny: 7:33

Ralph does the pre, does the fact that the patient might be, inpatient versus outpatient affects, maybe how aggressive you would be. the incidental clinical AFib c in the office. Do, would you treat that different than maybe someone admitted with, with rapid ventricular response and acute symptoms?

Ralph: 7:50

I think there's a definite value to making sure that if someone is symptomatic and or if they have a rapid ventricular response, that they get treated quickly. One of the, one of the most important components is. Is making sure that their rate does not exceed 130 beats per minute regularly, or an average rate of 110 beats per minute on, on a surveillance monitor such that they would potentially develop a, a dilated cardiomyopathy from tachycardia. So, and also if, if they're quite. Be more aggressive at getting that patient back to normal rhythm.

Andrew: 8:42

I think that makes a lot of sense. And Dr. Amin, anything else you would kind of add as, as part of your practice when you approach, the patient who has new AFib and how to manage them

Anish: 8:51

and work them up? Yeah, I, I, I generally agree, I think that most programs are gonna approach patients with a primary consideration for hemodynamic stability. And so those patients that Dr. Gral, mentioned that are inpatients admitted acutely for atrial fibrillation with rapid rates, we wanna find ways to restore sinus rhythm for those individuals. I would add that in after we've addressed the acute needs of the patient. I think we have taken an approach that really begins to lay the groundwork for patients and caregivers in identifying atrial fibrillation as a chronic progressive disease. So a disease state that. May manifest both with intermittent, symptomatic and asymptomatic episodes and lead to downstream heart failure events, valvular events all of which we'll need management after the initial workup is completed with structural heart assessment, as Dr. Augustini referred to we also. Want to assure that we've addressed stroke risk reduction with you know Diligent conversation with the patient about risk factors for stroke. And I think we're all familiar with the CHADS two vast scoring system which is what we use. We ask patients to actually identify their own score so they understand where their risk is coming from, and then make recommendations about both short term and long term anticoagulation strategies as they're applicable or downstream. Left atrial strategies if that's more appropriate. I will say that, as if we are thinking about patients who if we're thinking about rate and rhythm control, which I think was the original question that you asked. I think for the newly diagnosed patient, most of us are probably going to at least ask patients and Care teams to consider rhythm control when it's clinically appropriate. So certainly patients in an ambulatory setting on a general medicine ward, it's very appropriate to consider rhythm strategies. Maybe in an I C U setting, we may say, you know, let's visit with these folks in an when they're discharged and Consider rhythm control strategies as an outpatient when it's more elective. And the reason that we ask folks to to more consistently consider rhythm based strategies today than maybe five years ago, 10 years ago, or 15 years ago, is an increasing set of data that would suggest that rhythm patients who undergo rhythm. Control, whether they're asymptomatic or symptomatic, do demonstrate reductions in heart failure, heart failure, hospitalization, stroke, and potentially cardiovascular mortality.

Ralph: 12:15

we, we wind up seeing the full spectrum of what patients present with in terms of symptoms or associated. Comorbidities. And sometimes you'll see someone who looks perfectly fine and they're in AFib, but they're unaware of it. And you get an echo and their ejection fraction is 15% and you just say, how could it come to this point? And so at a minimum I try even a, even a what is patient claims? They're completely asymptomatic. I at least try to do a cardioversion to restore sinus rhythm to see if they feel a, a clinical improvement. So whether that be a short term episode of AFib, Or an AFib that's been persisting for 12, 15 months even. I think they deserve a shot at sinus rhythm. So yeah, we're being much more aggressive at rhythm control because of the data that's emerging with composite death cardiovascular events and stroke.

Anish: 13:31

Yeah, Ralph, you're highlighting that classic patient that comes in with, you know, tachy cardio induced cardiomyopathy with persistent AF that's unaware of it until their heart failure symptoms warrant the presentation. And I think we also want to make folks aware, Andrew, you know, as you move into clinical practice, patients who will present with heart failure with preserved ejection fraction, which is decompensated by af. Which we know is one of the leading causes of HFpEF decompensation. So for the paroxysmal population, certainly recognizing the symptoms of heart failure, de decline HFpEF exacerbation when they have parms of atrial, atrial fib is also important. And then I'll, I'll throw out one more consideration and maybe get your thoughts and Dr. Al's thoughts even on this. Is that with the increasing prevalence of valvular disease and the awareness that atrial functional Mr. Mitral regurgitation, which is in fact driven by atrial fibrillation. Recognizing that early and understanding that patients who have atrial functional Mr. Also benefit significantly from rhythm based strategies is increasingly important. Yeah.

Kanny: 14:58

Thanks Anisha. That's appreciate your insight on that. Do you think that since you talked about you both elucidated the, the benefits of early rhythm control, is there a classic kind of patient profile you think the general cardiologist should be looking for and, and saying, this is a patient even though this is their index presentation of af, this is a patient I might think of, you know, more early considering ablation or getting, electrophysiologists involved to at least kind of start leading'em down that pathway towards more aggressive therapy.

Anish: 15:34

Well, I, I think it's a little bit of a loaded question, if I'm honest with you. I, I mean, I think that as a community in electrophysiology, we wanna recognize that ablative interventions are more effective earlier in the disease state. It makes sense that they would be more effective earlier in the disease state because an ablation is, Mechanistic and focal. And so if we go back to what we think the current model of atrial fibrillation is, which is something that's driven by independent triggers arising from specific structures in the left atrium, namely the pulmonary veins and the posterior wall, then intervention towards those structures early in the disease state, think. Diagnosis to intervention time that's less than two years is gonna be much more approachable than seeing patients who have long histories of atrial fibrillation refractory to multiple therapies. Just because of the inherent remodeling that occurs and the diffuse fibrosis that occurs in the atrium for patients that have long histories of atrial fib. So yes, we want to, we want to educate both our electrophysiology community clinical cardiology communities, PCPs. That early referral is important. Does that mean that we want to take patients who are presenting with their first episode of atrial fibrillation or two episodes in two years and ask them to consider ablation? Most people will tell you probably not. I mean, we want to help folks understand that there we do have to reach a burden of events that will. That will give us the opportunity to elicit a benefit from the therapy. And AFib ablation even in today's day and age is not without risk. And so we have to recognize that, you know, a one to 2% procedural risk, which is what is, you know, what we are seeing in our practice in, in Columbus and in fact in most of Ohio, but, Even higher reported procedural risks in, in published studies is not something to take necessarily lightly for a single or two or three episodes of atrial fib. So I think the message is, you know, this is a chronic progressive disease and we want to intervene on the early end. Ideally, when events are starting to become increasingly frequent. And the diagnosis to intervention time is, you know, let's say less than two years. And by diagnosis, I mean, not that first episode, but when the, when the episodes are really starting to accumulate. I don't know. What do you think, Ralph? Yeah, I, I,

Ralph: 18:48

I totally agree. I think one of the other things to think about too is that Early intervention might not necessarily be ablation. It might be particularly here in central Ohio weight loss so such that you know, it, it will reduce their blood pressure, it will reduce their sleep apnea and it will make any form of therapy more effective. And so if it's an infrequent atrial fibrillation, Event, I'm more likely to wait on that patient and try to work on the risk factors. And then when things do progress or if they are failing, for instance, an antirrhythmic drug then move on to ablation at that point, we don't like to see them progress from paroxysmal to persistent simply because we know. That that implies that there's enough fibrosis and remodeling that's occurred that is causing them to have that progression, that natural progression of disease.

Anish: 20:11

Yeah. I can't agree more with Ralph about the role of risk factor modification. It's taken us several years in our Heart Rhythm society guidelines to incorporate. And strenuously identify risk factor modification as a key element of treating. Atrial fibrillation. And so weight loss is the number one thing we can ask our patients to consider. Remember that we, we want to give them achievable targets. So if in our program we tend to be very discreet to patients, we ask'em to consider a 10% weight loss. So, you know, we're trying to make it so that it's approachable. It's achievable. It's not you know, something that we're, that has a negative connotation to it. And that number is born out of the data outta Adelaide, Australia where some of the early work on weight loss and atrial fibrillation regression was completed. Ralph, you also mentioned sleep apnea, and I think you, you know, maybe you're gonna bring this up a little bit later, Andrew, I know that we had sort of discussed this before the, the podcast recording about, Specifically for young patients who are otherwise healthy, the workup. And very often, you know, we complete the structural heart evaluation, we complete an an endocrine evaluation. We will often ask patients to be, you know, acute aggressively monitoring and managing hypertension. Ralph, you're an expert in sleep apnea as well as electrophysiology. What do you think about. Occult sleep apnea. Are stereotypes about obstructive sleep apnea, the role of central sleep apnea in arrhythmic populations? Well,

Ralph: 22:05

you, you know, there's definitely a significant number of patients who have atrial fibrillation that have sleep disorder breathing. And so in our clinics we've pretty much established that anyone who's coming in with a new diagnosis of of AFib gets at least a screening questionnaire to determine if they have any, any possible risk factors for sleep apnea or if they've had any clinical symptoms of it. And our referral rate. Virtually every patient that I see will get at least a screening home sleep study to determine if they, if they need more aggressive treatment. And so

Anish: 23:02

Our, our hit rate,

Ralph: 23:03

so to speak, for, for sleep apnea is about 80% for, for AFib patients. And so it's a virtual no brainer. I, I, I think it's just so much overlap between the disease processes with, with obesity, hypertension, AFib, and sleep apnea. And in patients who have heart failure in particular central sleep apnea is quite prevalent and upwards of 50% of heart failure patients will have some form of sleep disorder breathing. And there's more than half of those will be central apnea rather than obstructive apnea. So there's a. A bit subgroup that really we try to be aggressive with screening tests in the heart failure patients as well for an assessment for any type of sleep disorder breathing.

Anish: 24:11

And I think you mentioned this, so so patients who have untreated sleep apnea, If we were to intervene with either drug or ablation their downstream one year success rates are about half the population that's treated. Is that right, Ralph? That's right. And I think this is why it's so important. Weight and sleep apnea have clear data for the success of intervention, whether it's drug or ablation.

Kanny: 24:48

Yeah, thanks Anisha. Thanks for highlighting that. I, I think that's a good take home point is that basically weight management and screening for sleep disorder breathing is almost a mandatory part of the initial assessment and it's gonna guide future success as well. So thanks for calling that out. I will also add Anish that we did have Andrea on our podcast last month actually, we were highlighting, the role of apps with innovative. Clinics, and she's talked about the AFib Walk-in AFib clinic that you've established Ohio Health. Several years ago she talked about, the success rate, but she also highlighted how the visits are, 50 minutes long and allow for more in-depth discussion about risk factor modifications. So perhaps that's gonna be a trend. And AF management is to highlight those issues from the, from the beginning. We have about five to 10 minutes left, so I wanted to make sure we saved some room to talk a little bit about, left atrial appendage occlusion therapy since, this has become widespread over the last 15 years or so. So I thought I'd just ask Ralph. I think most of our clinicians are familiar with, left atrial appendage occlusion as a kind of a commonplace now therapy for patients who are intolerant or have other reasons to not take anticoagulation. But as, as you know, the devices evolved as we now have multiple devices on the market. I wanted to maybe start with you, Ralph, and then transition to a niche and just ask, you know, can you like let our clinicians know, like kind of what is the typical patient profile where they should be thinking about referral for, device therapy versus ongoing anticoagulation? Certainly.

Ralph: 26:34

So we really follow the publish guidelines on this. And so we look at a CHADS VASc risk of three or higher, or score of three or higher, and a has blood risk of two or higher. And also in particular patients who have had any form of bleeding problem. Any form of issues with anemia particularly in, in cancer patients where they're intermittently having their cell counts dropped with therapy. We look at patients who have had the use of warfarin with fluctuating levels of I n r. And difficult management because those patients tend to be at higher risk than those patients who are on the, the novel agents because they can go high or low. And with just diet dietary changes sometimes they're quite difficult to control. And there are patients who simply do not want to take an anticoagulant. And so those patients would also qualify provided that their risk score was high enough. So we've all had the patient that comes into clinic and said, I will not take rat poison. Which has become less so with the doac. But still out there and the association of, of anticoagulants they, they may have a family member or somebody that was close to them that died from an intracranial hemorrhage and they just absolutely will, will not accept an anticoagulant. And so those patients are, are very good candidates for device occlusion of the appendage. We do exclude patients who have significant mitral valve related atrial fibrillation.

Kanny: 28:51

Anish how, how's the practice at Ohio Health? Is that similar in terms of patient selection?

Anish: 28:58

Absolutely. I think that the indications for left atrial appendage have been well described and, and as a point of sort of logistics, I think some of this is mandated by C M s and the need for shared decision making, which I think is why it's so important that referring clinicians recognize the risks and benefits of left atrial appendage closure because we often ask for those individuals to. Participate in the shared decision making with patients. The procedures certainly have become increasingly safer more convenient for the patients and, you know, in many centers completed with same day discharge. And so there is a an in a, there's progression in the number of patients that are referred. I think there. Two clinical trials that will be upcoming. One is called watch option, another one is called Champion with Watchman. And a third called Catalyst with amulet that are gonna be looking to actually broaden the indication for left atrial appendage closure. So looking to do closure with at the time of atrial fibrillation ablation, which is watch option. And then looking at. Left atrial appendage occlusion as an alternative to anticoagulation in patients that wouldn't today qualify for closure. So people that are tolerating anticoagulation without issue. Randomizing those patients to continue anticoagulation versus complete closure. That that was the premise behind Champion and Catalyst. Those are, they have five-year follow-up. Those results will take, you know, seven plus years to be in practice at this point. But the future looks like closure may be a primary option for stroke risk management. I'll 0.11 thing out about closure that I, it, and maybe you were gonna ask this, it's what are the unresolved issues? And, and there are several, so the, some of the unresolved issues are what should we be utilizing for peri procedure imaging? What should we be doing with patients that have leaks of their device? What should we be doing with device related thrombosis? The rates of thrombosis are, are quite low, thinking like the three to 5% range, but do represent increased stroke rates for individuals who have device related thrombosis. And the last question, and probably the most pressing one is how do we manage short-term anticoagulation for patients on rhythm control strategies after they've had a closure? So somebody gets a. Watchman or an amulet, they have atrial fib. They're on aspirin as their long-term stroke risk reduction with combined with the closure, and you do a cardioversion or an ablation, what type of anticoagulation do those patients need? So those are four big kind of issues for downstream management of patients with closure. As we move beyond the population that's persistent AF with a bleeding indication.

Andrew: 32:21

I think that remains one of the biggest challenges that we see still in fellowship at, at Ohio State. We use both CT and d e E to assess the occlusion devices. I guess maybe for the sake of time, if you both could just briefly touch on what your current practices in regards to, you know, both imaging these devices and then making decisions on anticoagulation. Thereafter

Ralph: 32:43

So we just published a manuscript Anish on anticoagulation strategies around cardioversion in patients with left atrial appendage occlusion, and whether that be from surgical atrial clip or ligation. Whether it was from a Lariat, an amulet, or a Watchman device, all of these patients were included. And we found that we had a very low risk of events with a four week strategy. Anticoagulation of the patient following the cardioversion if they're, if they're sent for cardioversion. So, so it, it was a limited anticoagulation scheme with good tolerance and low neurologic event rates. So that, that's something that, that we practice regularly now. Regardless of how the appendage is occluded,

Anish: 33:59

I was teeing you up, brother. Thank you.

Ralph: 34:03

I forgot to mention if, if the patient does have an indication for chronic anticoagulation other than AFib, for instance, if they've had recurrent D V T or they have a, a thrombogenic genetic disorder Those patients are probably not the best. They're not the good candidates for an occlusion device as their sole form of thrombotic protection, that they should remain on an oral anticoagulant if possible.

Anish: 34:35

N now, I think Andrew, most of the time, the short-term an Anticoagulation and platelet therapies. The, the individual doing the cardioversion, maybe the implanter or the electrophysiologist is gonna own that. I think the question you asked about imaging modalities pre and post is relevant too. You know, we want to try to minimize the amount of imaging and the strain on the system for patients who are coming through with closure. So We do a CT for all the patients that can tolerate it from a perspective of renal function. And then we essentially do about 50 50 implant with either T guidance or intracardiac ultrasound guidance. And then we try to duplicate the imaging technique for the 45 day follow up. So if they, if we did a ice closure, we'll do a ct. At the 45 day, if we did a TE closure, we'll do a te at five day. You know, there are, it's a big conversation around what to do with leaks.'cause leaks are present and the more resolute the imaging technique in this case ct, the more likely you are to see him. We don't necessarily extend the anticoagulation scheme past 45 days. If we do see a small leak, less than five millimeters although Ralph can speak to the data that they've presented about leaks less than three if he wishes to. But I think the, at the end of the day, if folks, if you do see a device related thrombus, that patient should be put on at least short term anticoagulation. So, Regardless of the imaging modality, if you see a device related thrombus, that person should be put on at least short-term anticoagulation. We generally will suggest three to six months in repeat imaging.

Ralph: 36:37

We're, we're very similar in that approach. We pretty much have adopted CT imaging for both pre and post testing more than t e e at this point. It gives you the dimensions. Of the left atrial appendage. It avoids sedation for the patient, and I think it's a more comfortable and, and more there's, there's more information that you gather from the ct. Aside from the t e e, there are some operators that choose to use only in echo. With no preceding imaging. I have not adopted that pattern myself at this point. But I am using ICE with some of the cases where intraoperative, t e e has increased risk.

Kanny: 37:37

Thanks. Thank you both for the insight. It's been very interesting to see device therapy evolve into the mainstream. There's so many aspects of AF we could keep talking about. I, I just want to finish with one final topic because we're up against our time and I'll throw it out to Aish first. We, we don't have time to talk about all the aspects of wearables and implantable loopers. That could be an entire. Podcast by itself. But my specific question for you, an is, is as we've had a proliferation of, of loop recorders and patients with home, you know, E K G devices, whether it's Apple Watch, et cetera, do we yet know whether the incidental AF that shows up on these monitors and devices incidentally carries the same, you know, kind of prognostic significance? Clinically presenting AF does. Is that something we still have to figure out? And do you have any advice for clinicians, you know, who are dealing with the, with these results from these devices?

Anish: 38:36

Well, it's a great question. I, I will tell you that last year, I think at European Society of Cardiology, the question about symptomatic AF versus asymptomatic AF on loop recorders and stroke, cryptogenic stroke patients was described in two different trials with different results. So basically saying that, These asymptomatic episodes maybe didn't increase the e the the risk of stroke like the symptomatic episodes did, and I don't know if that's going to be true for wearables as well. I, I think that for the patient that has a known diagnosis of atrial fib, the wearable devices do provide us with a nice longitudinal. Mechanism to communicate with the patient beyond their symptoms. So to have patients transmit ECGs when they're having episodes, confirming a diagnosis before we instruct'em to go to utilize acute care pathways, whether that's the emergency department in our office, AF clinic, et cetera. So I think they're valuable from that perspective. I also think that, you know, the next generation of devices, including the current Apple Watch, which allows AF burden. Detection lets us talk to patients about that longitudinal history of atrial fib. So looking at somebody and saying, Hey, when we saw you six months ago, you had a 3% burden of AFib. Now we're seeing you, it's a 10% burden. So your, whether your symptoms are changing or not, the disease is changing in the background and we should be managing that. So, There is value from that perspective. I certainly do empathize with everybody who has to look at all the tracings because it, it, it is a little bit of a data overload and we don't have great ways yet to not only manage the data describe it, you know, in a usable format but also to. Recognize the time that we're putting in for it evaluating it. So those are all things that I think we're, we're gonna have to face, especially because this is just the pinnacle. The, I think that e c G on a wearable format is easy to do and most of us would agree with that. And the, you know, the evolving devices and we've all seen'em, whether it's sleep metric, VO two. You know, there are devices, especially on our implantable loops that can monitor heart failure. The list is almost endless of what's coming, so we're gonna have to look at how to manage this stream of information.

Kanny: 41:24

Thanks, Anish. That's insightful. I think we've had an amazing discussion. It's just amazing how complex this one condition is and how it affects so many aspects of cardiovascular care. And I think Andrew and I have both. We've been texting each other with so many additional questions and topics that we'd like to cover. So I would hope that maybe you guys would be willing to come back. At some point in the future and educate us a little further, not just on af but perhaps some other EP topics as well. And until then, I just wanna thank you both for taking the time to educate us and and our listeners. So Ralph thanks for joining us.

Ralph: 42:02

Thank you Canny. Thank you Andrew and Anish as well.

Anish: 42:06

Yeah. Thank you guys. It's a pleasure.

Ralph: 42:08

Yep.

Kanny: 42:09

And thanks Andrew for co-hosting and until our next episode we'll be in touch.

42:14

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,