Atrial Fibrillation Causes, Triggers, and Prevention

Reducing Afib risk factors with Dr. Aseem Desai.

Dr. Aseem Desai calls atrial fibrillation the Afib epidemic, as 1 in 4 people over age 40 will develop the disease. In today’s podcast, we discuss Afib causes and risk factors, Afib triggers, and how early intervention and detection can improve outcomes.

In This Episode

Dr. Desai’s Background … 00:05:40
What is Atrial Fibrillation? … 00:06:49
Are EMFs an Afib Risk Factor? … 00:09:19
Afib Causes and Triggers … 00:15:44
Afib Early Detection & Diagnosis … 00:24:02
Afib & Heart Rate Variability Relationship … 00:30:15
Gut-Heart Connection … 00:36:12
Dr. Desai’s New Book … 00:47:28

Atrial Fibrillation Causes, Triggers, and Prevention -

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Atrial Fibrillation

  • Atrial fibrillation is “arthritis of the electrical systems of the body”.
  • 1 in 4 people over the age of 40 will get Afib.
  • Afib is a progressive disease. Early intervention is key because “Afib begets Afib.”

Primary Risk Factors

  • High blood pressure
  • Diabetes
  • Heart valve abnormalities
  • Sleep Apnea
  • Obesity
  • Thyroid abnormalities

Primary Triggers

  • Alcohol, even one drink a day increases risk 8%
  • Sleep apnea
  • Stress

Sponsored Resources

Hi everyone. I want to thank Doctor’s Data who helped to make this podcast possible and who I’m very excited to say has now released a profile called the GI 360 which is finally a validated microbiota mapping measure.

Atrial Fibrillation Causes, Triggers, and Prevention - ddi logo centered 2col 300

If you remember back, I’ve discussed numerous times the only lab that is really validating a mapping of the microbiota to have clinical significance is the GA map out of Norway. Well, turns out that Doctor’s Data is not only using the same methodology but also in collaboration with this group in Norway using their parameters to adjust what we call normal, abnormal or dysbiotic and normal. So great news, we finally have a validated measure.

Now this test also offers, in addition to the microbiota dysbiosis index, a PCR assessment for bacteria, virus and pathogens, a comprehensive microscopy for a parasite, a MALDI-TOF bacteria and yeast culture. And as you would imagine, because of the rigorous validation they’ve gone through, they also have approval from the CE, which is equivalent to the European FDA.
So great test, please check them out. Doctor’s Data is offering 50% off a practitioner’s first GI 360 test kit. Go to doctorsdata.com/Ruscio to claim your first kit, limit one per provider. The offer ends October 31st, 2020.


Early Detection and Prevention is Key

  • Afib is a muscle memory disorder. The more frequently it occurs, the more it will occur.
  • Wearables, like an Apple watch, Live Core, or fitness wearables can help with early detection and diagnosis.

There is a Gut-Heart Relationship

  • Vagus nerve innervates both the heart and the gut, so they are connected by the nervous system.
  • Esophagus is right behind the heart, bad acid reflux can trigger Afib
  • Afib can trigger reflux
  • Heavy fatty meals may trigger Afib
➕ Full Podcast Transcript

Intro:

Welcome to Dr. Ruscio radio providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, please make sure to subscribe in your podcast player. For weekly updates, DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking to your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hi everyone. Today I spoke with Dr. Aseem Desai and we discussed atrial fibrillation, which apparently is a topic shrouded in confusion, quite similar to gut health. We talked about causes, treatments, triggers, and actually the fact that this is somewhat prevalent, somewhat more prevalent than I was anticipating. One in four in their lifetime will experience Afib or atrial fibrillation. His new book provides people with kind of an anecdote to the misinformation, or just lack of highly robust information currently in existence. So I do hope that you will listen to this episode, especially if you are someone that is impacted by Afib. Also, I want to remind you of a piece that I recently wrote. It was a rebuttal to 60 Minutes television show’s exposition on probiotics, which unfortunately really seem to kind of misrepresent what the science on probiotics says. I’m quite aware that I could be labeled as someone who’s biased in this area, although it’s extremely difficult for me to discern how someone could label my opinion here, biased when you look at the body of evidence. I try to check my own bias and there’s been no accusation of me being biased. I’m just acknowledging the fact that I am refuting what a major television and seemingly reputable source is citing, which is a number of experts who are essentially concluding that probiotics have no evidence for IBS or antibiotic associated diarrhea. There have literally been Journal of the American Medical Association systematic reviews of meta- analyses concluding that there is merit for probiotics in IBS or antibiotic-associated diarrhea. So I just want to acknowledge that. Uunfortunately, while I try to give people the benefit of the doubt as much as possible. This was one area where my jaw kind of proverbially hit the floor. When I saw how discordant the conclusions there were with the actual science. Again, sorry, I don’t mean to kind of obfuscate from today’s podcast on Afib, but I just want to make sure that you’re aware of that. Also, if the podcast has been helpful to you, please head over to iTunes and leave us a review. That’s really helpful to make sure that we reach more people and also helps us to procure bigger names and guests for you. With that, we will go into the interview with Aseem.

DrMR:

Hi everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio today. I’m here with Dr. Aseem Desai and we are going to be talking about atrial fibrillation amongst other things. Definitely a topic that I am interested in as one of my good friends, I was actually the best man at his wedding, so you can tell how terrible of a wedding that must’ve been, was diagnosed with Afib a few years back. This is something that’s become a personal interest of mine since he informed me that he was not to drink caffeine or alcohol. Which made me wonder – Is there a way to get someone in more robust shape to where they can have those things? So Aseem, I’m really looking forward to digging into this topic today.

DrAseemDesai:

Thank you, Michael. Thank you for having me on the podcast. I’m very excited to be here and would love to impart some of my thoughts to the listeners. Things that could help them in everyday life. The Afib epidemic, we actually call it an electrical epidemic, is so common, so widespread. When you start talking to people at a cocktail party, for example, someone always has Afib or someone knows someone who has Afib and one of the biggest reasons is the aging population. Over the age of 60 or 65, the incidence of Afib goes up significantly, mainly due to scarring of the electrical system. Just as you would get arthritis in your joints, you get arthritis, in a sense, of the electrical system. So that’s a big mechanism. There’s high blood pressure and diabetes. Sleep apnea is an enormous unrecognized and underappreciated trigger for Afib. What’s interesting is we’re seeing a lot more athletes and younger people getting Afib typically in the 40 to 50 year old age group. And there are some definite mechanisms behind that, that we can touch upon. But to your point in the beginning, it’s really about not just treating a disease. It’s about treating the body as an entire unit in a functional medicine approach, treating all aspects of someone’s health because that’s really what helps this disease. It’s almost as if the disease is a symptom of underlying imbalance in the body.

Dr. Desai’s Background

DrMR:

I want to define for people what Afib is, just in case they’re not familiar with exactly what that means, but first why don’t you give people the short synopsis on your background.

DrAD:

Yeah. So I grew up in Chicago and attended Northwestern University for college and med school. I was part of this program where they encourage you to do a liberal arts major in conjunction with your premed. So I became a philosophy major and I ended up through medical school and training at Stanford, bringing that education into my cardiology practice, which you wouldn’t imagine. The field of work that I’m in is cardiac electrophysiology. So we deal with a lot of logical reasoning, which is why the philosophy background helped. We try to diagnose and treat heart rhythm problems. Your heart is an engine and it has a pump and valves and plumbing, and has an electrical system, and the challenge there is that problems can come and go. So if you go for an office checkup, you may not detect anything. And then that night, your heart rate goes to 180 beats a minute, and you’re out of rhythm in something called an arrhythmia.

What is Atrial Fibrillation?

DrAD:

So atrial fibrillation is the most common heart arrhythmia worldwide. In the US about 6 million Americans have it and that’s projected to go up significantly over the next few decades. The three principal catastrophic events that occur are stroke, heart failure, and significant reduction in quality of life. Those three. Afib is an often unrecognized cause of stroke. It can be silent, you may have it and not realize it. So the best way to think about a Afib is arthritis of the electrical system. We also think of it almost as like an electrical cancer. Every time you have an episode, the electrical system changes, the heart muscles. So it develops a muscle memory for having more Afib, making it a progressive disease. We use the term Afib begets Afib.

DrMR:

I’m not sure if you mentioned there and I may have missed it, but what is the prevalence of this US population, if you have that, or the world population if you have that.

DrAD:

Yeah, I mean, as far as in the US, up to 6 million people have Afib right now. It’s estimated that will be upwards of 10 to 15 million in a few decades. Worldwide it’s at least 30 to 40 million. It is, again, felt to be a combination of aging population, the medical issues that I mentioned being much more pervasive, like obesity, and then also better recognition of Afib. Apple, I think really helped the medical industry by coming up with the wearable watch that can diagnose Afib.

DrMR:

As a percentage of the population, do you happen to know offhand? Just to try and get people to understand how likely they are to be affected by this?

DrAD:

Yeah, I would say about one out of every four people, the statistics show, over the age of 40 are going to get Afib at some point in their life. It is more common than many cancers.

DrMR:

Yeah. Okay. So that’s actually quite a bit more prevalent than I was anticipating. Definitely something I’m glad that we’re having the conversation regarding.

Are EMFs an A-Fib Risk Factor?

DrMR:

So one of the theories I’ve heard posited as to why this condition is becoming more prevalent, is EMF, electromagnetic frequency, electrical pollution, so to speak. Wifi, Bluetooth. I’m open to that, although I think this is an area where the science is compelling. But I also wonder, and this is perhaps my own circumspect bias, but I wonder if some who have gotten on the EMF train or are looking to establish causality where it may not yet be supported. Regarding EMF, what are your thoughts in terms of the role it plays in causality?

DrAD:

It is highly unlikely to be a cause. I mean, I’ve been doing this for about 20 years and looking at the research over time and our own experiences. The risk factors for Afib are well known, well documented and are the primary causes of the disease. I’m not dismissing EMF as a possible contributor where we just haven’t discovered the link yet. What we do know is the brain and the heart are intimately connected through what’s called the autonomic nervous system. And that is a trigger for Afib. That’s some exciting work that’s being done more recently in figuring that out. But to what you’re saying, I’m not aware of any studies that have found a causal link or even in association.

DrMR:

Okay. So I guess my intuition there is not too far off then. To play the devil’s advocate for maybe someone here who has read up on EMF and feels like it’s a major causal factor, and by the way, I am completely neutral on this. Have you gone through the data here? Is it fair to say that there is data disproving? How would you kind of give a bit more of a nuanced answer there. Again, just thinking about the person who maybe has read a lot about EMF.

DrAD:

Yeah. That’s a great question. So I have not come across any literature. I have not done literature searches on EMF and Afib, and I will definitely do that after this podcast to see if there’s anything out there. You know, we have the international heart rhythm society meetings every year. That’s literally all about Afib. I have been going to that for the last 15 years and I’ve never seen anything in the programs or any of the topics, any of our major journals about EMF and Afib. Obviously EMFs are not a good thing. I mean, it is associated with a lot of health issues. I just can’t even imagine a mechanism in which it could contribute to Afib. I think the challenge is that we often are trying to look for things that we can control. And if there are other health concerns with things like EMF to maybe try to add Afib to build the evidence that EMFs are bad. But like I said, the number one risk factor for Afib is age. I mean, you could be completely free of EMF or any other kind of impact and age is the number one risk factor. Also high blood pressure, all those common medical problems.

DrMR:

Sure, sure. Yeah. I mean, this is why I ask. If you do have a moment and you do any kind of followup query and you want to shoot me an email, let me know. I’m kind of curious because Dr. Joe Mercola was on the podcast a while back. He hypothesized, or the going hypothesis here is that membrane potentials are altered by EMF impacting calcium, magnesium, sodium potassium pump balance and therefore electric conductivity of the heart. But, again, I’m suspicious of a lot of claims, which is why I asked you. I know we’re all busy, but if you do have a moment and you poke around and you find a consensus one way or the other, let me know, and we’ll make a note in the transcript and the summary of this, just so we can give our audience an opinion there. As EMFs are an emergent topic, I’m trying to really arm our audience with the most rational evidence-based and reasonable knowledge possible. So I appreciate your candidness here. And again, if you have any follow up commentary on that, I’d be curious to see it.

DrAD:

Absolutely. I would be happy to do that. I mean, I’m continuously learning. And so if there’s any way we can help our patients with Afib and things that we can control or identify those ssues, I’m all for that. I understand the concept of the ion channels in the heart and the electrical system. We know, for example, that there is heart rate variability and nervous system connections between the brain and the heart that are involved in arrhythmias. People do postulate these different electromagnetic fields through the body and have implicated the heart as part of that. So from a mechanism standpoint, you could probably align some kind of logic there. As I said though, I’m not aware of any thing that’s been published, but I am, I’m very interested in that so I’ll circle back with you on that.

DrMR:

Great, great. You make a fantastic point, which is one of the kind of key principles we really try to inculcate in this podcast, which is that it is one thing to show a mechanism. It’s another thing to show outcome data. So someone could point as you’re aluding to, that EMF may impact this mechanism. But the impact there may be so minute that it never has an appreciable impact. Conversely, and I’m totally open on this., perhaps there is some data there that’s been a bit swept under the rug because this topic is somewhat ensconced in tinfoil hat conspiracy theory. And so it may not have been given its just attention. So, yeah, I’d be curious to get your thoughts there and follow up.

DrAD:

Well, you know, I think one of the biggest concerns we have is if we start tracking down too many other things, we ignore what are actually very well established, causal links such as the risk factors that I mentioned. What we would hate to see happen is for people who have Afib issues and it’s tied to the fact that they’re overweight or that their blood pressure is uncontrolled but they focus on this fringe things that may be proposed as a cause. You know, I think, I think it’s important to look at all of these different factors and definitely be open to it. We can always just learn more. I think the most important thing is that we listen to each other, even if it doesn’t make sense to us. We don’t know what we don’t know. So I’m definitely going to check into that.

Afib Causes and Triggers

DrMR:

Awesome much, much appreciated there. Maybe to shift us to the things that the evidence and your finding to be the most impactful, you hit on a few of those, but let’s give people a rundown of the items that seem to be the primary drivers of A Fib.

DrAD:

It’s good to think about Afib in terms of the disease and the risk factors for it, and then the triggers for an actual Afib episode. So the risk factors, again, the top ones are age over 65, high blood pressure, diabetes, valvular heart disease, thyroid abnormalities, sleep apnea, and obesity. The triggers for Afib episodes. The big one is alcohol. It’s an enormous trigger for Afib. And in fact, one glass of alcohol has an increased risk of an Afib episode of 8%. So alcohol is something that people think, you know, one drink a day or a few drinks a week, it’s good for my heart. When it comes to the electrical system, it’s not, and we can go into detail if you’d like about the different mechanisms behind that. But alcohol is a big one. Sleep apnea is not only a risk factor, but a trigger because when your oxygen levels drop at night with sleep apnea, when you stop breathing, that actually has a direct effect on the electrical properties of the conduction system of the heart. That drop in oxygen facilitates Afib. And then other triggers. Stress is a big trigger.

DrAD:

We see it all the time where people who have Afib can be very well controlled. They’ve had different treatments, something called catheter ablation, or they’re on a medication. And then out of nowhere, they start getting all this Afib. We are seeing it now in the pandemic, we have so many patients who have well-controlled Afib and the episodes are just popping up left and right. And the changes are that they’re less active, they’ve gained weight with the “COVID-19 weight gain”. People are drinking more alcohol, as we know, and stress is pervasive now. Also, lack of sleep is another big trigger. So you have the risk factors, like I said, age, high blood pressure, hypertension, diabetes, obesity, obesity is a really big one. And then you have the triggers, alcohol, people ask about caffeine which is also a trigger, dehydration, lack of sleep. So it’s useful to kind of think of it in those two terms.

DrAD:

I have a book that’s going to be coming out in just a few weeks about Afib. In that book, I have a worksheet which actually allows you to go through all of these risk factors and triggers to check off if you have them or not and how that increases your risk. It also has a treatment plan in place on how to get started on helping modify those risk factors and triggers and making commitments to yourself and to other people to achieve certain milestones and reduce the risk of Afib. I’d love to give you more information about that offline, if you’d like for your listeners.

DrMR:

Even a bit online would be nice just to kind of give people direction. One question I want to pose, just while it hits me here before I forget, keeping in mind that a good chunk of our audience is exercising regularly, attending to healthy sleep hygiene and timing, eating a very healthy diet, probably managing their body composition. So they probably are otherwise a healthy population. Actually that kind of describes my friend, who,at the time of diagnosis, I believe 31 or 32. Healthy weight, no comorbidities. What do you suspect are the drivers in that population?

DrAD:

Yeah, it’s probably a combination of factors. The perfect storm analogy is mentioned a lot in Cardiology for Afib. It’s a combination of nature and nurture. So there’s so much about the electrical system of the heart. There are five or six major ion channels and genetic mutations that we’re still learning about. There a lot of research that’s coming into play for risk of Afib in terms of genetics. And it’s not just like one gene or two genes, it’s multiple genes in combination. So that’s definitely a part of it. If you see someone who has Afib less than age 40, there’s almost certainly a genetic component. Oftentimes you take a history and there are other family members that may have had it, or people have other arrhythmias that lead to Afib. So real common one we see in younger patients is something called SVT or supraventricular tachycardia. There’s a strong association between SVT and Afib. So a lot of times we’ll hear stories from young people about how they had racing heartbeat or skipping heartbeats since they were young. And no one really thought much of it. They were told that it was benign. They had monitors done. Well it turns out that over time that actually can predispose you to Afib. There’s a strong link there. We mentioned earlier the issue of the autonomic nervous system. So I can touch on that a little bit more specifically.

DrAD:

Many athletes are now being found to have Afib. A lot of athletes have low resting heart rates and anyone who’s athletic, who’s well conditioned, the heart rate tends to run low and that is a sign of cardiac conditioning. Well, the big driver behind that is the vagus nerve and the vagus nerve is part of what we call the autonomic nervous system, which controls all the major bodily functions. So your fight or flight response is the sympathetic nervous system. And the vagus nerve is the counterbalance, what we call the rest and relax or rest and digest as another way to describe it. It’s now found that that low resting heart rate may not be good in some patients. The lower your heart rate, the easier it is for premature beats, skipping beats, which people get commonly, to actually trigger an episode of Afib. So we’ll actually see people who start getting a lot of palpitations and then when they get up and they move around, the palpitations actually go away. So in someone as young as your friend, almost certainly some genetics involved. I didn’t ask, but if your friend was athletic, that definitely can be a contributor. And then the last piece is if your friend had any kind of history of even skipping beats or palpitations, he may have had something called SVT, which can be a trigger for him.

Sponsored Resources:

Hi everyone. I want to thank Doctor’s Data who helped to make this podcast possible and who I’m very excited to say has now released a profile called the GI 360 which is finally a validated microbiota mapping measure. If you remember back, I’ve discussed numerous times the only lab that is really validating a mapping of the microbiota to have clinical significance is the GA map out of Norway. Well, turns out that Doctor’s Data is not only using the same methodology but also in collaboration with this group in Norway using their parameters to adjust what we call normal, abnormal or dysbiotic and normal. So great news, we finally have a validated measure. Now this test also offers, in addition to the microbiota dysbiosis index, a PCR assessment for bacteria, virus and pathogens, a comprehensive microscopy for a parasite, a MALDI-TOF bacteria and yeast culture. And as you would imagine, because of the rigorous validation they’ve gone through, they also have approval from the CE, which is equivalent to the European FDA. So great test, please check them out. Doctor’s Data is offering 50% off a practitioner’s first GI 360 test kit. Go to doctorsdata.com/Ruscio to claim your first kit, limit one per provider. The offer ends October 31st, 2020.

A-Fib Early Detection & Diagnosis

DrMR:

Where do you want to go next from here? My mind goes to what are the most viable treatments, or is there anything else that you think we should touch on first?

DrAD:

Yeah, I think, the theme here is really early detection, early intervention. With Afib, it’s a progressive disease. So you want to be able to detect it early. How do you detect it? What are the symptoms? So Apple has the Apple watch. There’s another company called AliveCor that has the KardiaMobile device. You can get it on Amazon. It’s very inexpensive. These are devices that allow you to record an EKG. An EKG is a test that we do often in the office to record the electrical rhythm of the heart. Now there are wearable devices that can do that. So if someone is having an episode of symptoms: Rapid heartbeat, irregular heartbeat, uncertain. These devices actually have relatively good algorithms. They’re not perfect, but relatively decent algorithms to pick up atrial fibrillation. Stanford is actually doing a very large study with Apple, the Stanford/Apple Heart Study looking at some of these outcomes and detecting Afib. So that’s the diagnosis component. There are lots of different ways we make the diagnosis that we could talk about. But the intervention part is critical in that every episode of Afib changes the cellular architecture of the heart. That is why we say Afib begets Afib. It’s a muscle memory thing. I think those are two really critical messages to get to people. And I think the other part is the impact of other health problems on developing Afib. You know, we talked a little bit about the fact that younger people are getting it. There are a lot of people in the news. Kenley Jansen, a pitcher for the Dodgers is probably most recent. He went into Afib during a game in Denver, and he actually had to be pulled out of the game. And I had an opportunity to chat with him a little bit, and it turned out that a lot of his episodes were being triggered actually by uncontrolled high blood pressure. He had multiple Afib treatments, but once that high blood pressure was gotten under control, things got a lot better. And we do have a lot of young people that can get high blood pressure as well because of genetics and other factors. If you start looking at the sort of pop culture, Barry Manilow has Afib, Billie Jean King has Afib, Larry Bird has Afib, Howie Mandel, Kevin Nealon.

DrAD:

These are all people that have been vocal about the condition and are trying to spread some of that information out to the public. No one is really immune. As I mentioned, one out of four people over age 40 have it. And the challenging thing about this disease is it’s just so hard to diagnose. I mentioned earlier that stroke is a big part of Afib and many times people don’t feel it. What’s fascinating about it is that the only symptom that they feel could be just profound fatigue, just not feeling well. There are so many things that cause that so people don’t immediately think, Oh, I should check my pulse because maybe my heartbeat is irregular. A lot of times with Afib you don’t actually feel heart symptoms, the classic ones we think about like chest pain or shortness of breath. You may just feel fatigued. We see this more in older patients. A lot of times people will show up to surgery for gallbladder surgery or a colonoscopy, and they get their preop and they’re in Afib. We see that so commonly. You don’t know that someone is actually having symptoms until you restore the rhythm back to normal, and all of a sudden they feel a lot better. And the hypothesis is the atria, the two top chambers of the heart, contribute about 20 to 30% of the pump efficiency of the heart. So when you lose the function of those chambers, and that’s what Afib is, those chambers don’t be properly, you lose 20 to 30% of the pump performance of your engine. So it makes sense that you can have a whole host of different symptoms.

DrMR:

Now, I believe what you’re saying, if I’m interpreting correctly, is someone wearing a device or wearable device, like an Apple watch that will monitor their heart rate to be able to indicate to them that the episode they are in is critical because there aren’t always these classic cardiac symptoms. So them identifying that they are having an episode as early as possible, so they can seek treatment as early as possible, is a foundational and critically important aspect of Afib. Right?

DrAD:

Absolutely. Number one: Learn how to check your pulse. It’s a simple maneuver, but that’s often how you can get a tip off to Afib that it’s irregular and chaotic. But as you said, Michael, the wearable devices we have now, even Fitbits, they can provide some insight. When they give you the reports, they don’t tell you the rhythm. They tell you heart rate fluctuations. They don’t tell you the actual rhythm, the beat to beat changes in your rhythm, but they can sometimes be a clue. I have a gentleman for example, that got a new Apple watch and he wasn’t having any symptoms of Afib and he noticed when he was checking out the heart health app, that he was having these spikes in his heart rate in the middle of the night that he wasn’t even feeling. Then we put an external rhythm monitor on him and low and behold, it was actually Afib. So that can be a clue. I mentioned that the Apple watch and this other device, KardiaMobile they actually have a feature where you can actually record an EKG rhythm. So you can actually make a diagnosis of Afib that will actually tell you: Yes – Afib, No – Afib or unclassified. Your doctor can actually look at EKG strip. So there are two levels of how someone can And help diagnose that issue. There are the symptoms that we mentioned. Checking your pulse. Using these devices to look for these sort of random fluctuations in heart rate. And then there’s also the ability to EKGs is off these devices.

A-Fib & Heart Rate Variability Relationship

DrMR:

One of the things I wanted to kind of tie into this, but there there’s a measure of heart rate variability that, as I understand it, is most typically done in the morning as an indicator of how stressed you are, how well you slept. Is this something that’s made its way into this body of research and assessment? And if so, is there any merit to doing something like a morning heart rate variability measure when you’re wearing a heart rate monitor around your chest. Doing the 60 second HRV assessment in the morning and looking to see, or is there any connection between HRV scores in the morning and risk of going into an episode?

DrAD:

That’s such a great question, and I’m really glad you brought it up because I’m actually doing a lot of work in this area. So heart rate variability is basically the beat to beat variation in your heartbeat. So 60 beats per minute, isn’t 60 beats per minute. There are subtle variations beat to beat. Those variations occur as a result of a balance of these two parts of the nervous system that I mentioned, the fight or flight, the sympathetic and the rest and relax or the parasympathetic. What impacts heart rate variability the most is your parasympathetic, the vagus nerve. So when you’re stressed, one of the first things that happens is your heart rate goes up. The amount of variability goes down. So your heart rate variability drops and the vagus nerve has less effect when you’re relaxed, the opposite occurs, and that’s an emotional representation, but the physical occurs too. When your body’s under chronic stress studies have shown a lower heart rate variability. So it’s important to kind of understand what does that parameter actually measure? It turns out that that actually was born out of what I do for a living in terms of heart rhythm monitors. So the Holter monitor was the original heart rhythm monitor. That’s worn for 24 hours to record each beat of the heart. That’s where heart rate variability was born as a principal, out of the field of cardiac electrophysiology and Holter monitors. Now companies and the fitness industry have realized that this can actually be a good measure of the state of stress that your body is in mentally and physically. You can actually not only look at it, you can assess the effect of interventions on it. There’s a company called Heart Math that a lot of functional medicine physicians, around here at least, use. They actually have a set of products that measures heart rate variability in a much more detailed, comprehensive fashion than what you would get on an Apple watch or a Fitbit, which are great devices to have. The point being is that you actually can do special breathing work and meditation exercise. Just simple breathing work actually can have a huge impact on the heart rate variability over time, and with your stress management over time.

DrAD:

In the book that I have coming up, I actually have a whole chapter dedicated to the connection between the brain and heart rate variability and how that metric can be used in terms of just your overall health. Connecting it back to Afib, the autonomic nervous system is really what’s represented by the heart rate. Variability is what is connected to Afib. We don’t use heart rate variability as a way to figure out if someone’s going to have an Afib episode, we don’t see that connection yet. It is used to predict congestive heart failure hospitalizations. So heart failure is where the heart is not pumping right. Body fills up with fluid. And so one of the first things that actually happens is the heart rate variability drops. But for your audience, for people out there, you know, depending if you’re totally healthy, I think heart rate variability is extremely helpful for managing stress, which everyone is under. You can use these products, including your Apple watch, to look at your baseline heart rate variability. What happens when you’re stressed? What happens when you’re relaxed? And then doing different interventions. Whether it’s having a social connection or going out for a walk or meditation and see what it does to your heart rate variability. So I’m glad you brought it up.

DrMR:

There’s at least a general tie in for people as kind of a predictive measure. Sounds like the HRV is giving you more of a rough global assessment, but certainly it would make sense and correct me if I’m misrepresenting this, but if you see your HRV kind of going lower and lower and lower, it’s probably obvious that you haven’t been sleeping well, or maybe you’re under too much stress. There also may be some subtle benefit there where perhaps you’re staying up 45 minutes later, or you’re working a bit more and you’re perhaps not tying into the fact that you’re putting your body over this kind of stress recovery precipice. And now the first indicator you get is the HRV score declining. I would hope that person could then make changes and preempt themselves from going into a full blown episode. Yeah, that’s exactly right. HRV is really a kind of a subclinical thing that changes prior to the clinical presentation, as you mentioned. So you’re stressed or you have have some other kind of issue, then it’ll give you a clue of what do you need to change. What do you need to do differently when you track it? Because it’s one of the first things that changes before you actually have the full blown stressor, or physical problem.

Gut/Heart Connection

DrMR:

Now we we’ve touched on heart/brain and also mindfulness, which I know are two things that we discussed offline. What about the gut/heart connection? That’s another area that I’m sure our audience is keen to hear more about.

DrAD:

Yeah. And I first kind of thought about that with our Afib patients. It has actually been well reported that the GI system can be a trigger for Afib. So if you start with the esophagus. The esophagus sits right behind the left atrium, the left atrium is the source of Afib, they’re literally right next to each other. So people who had that acid reflux, that’s been a trigger for their Afib. Interestingly, when people have Afib it can actually trigger acid reflux. It’s right there, they’re next to each other. They also share the similar autonomic nervous system input for the vagus nerve. When you look at the lower GI system, we definitely see where if someone eats a really heavy fatty meal that it can trigger Afib. Again, it’s all through the vagus nerve. So what we know so far with regards to the heart and the brain, I’m just talking about the AFib right now now, but there’s a whole host of other things. I know you’re aware of the risk of high blood pressure and atherosclerosis and other things related to gut health, but with regards to Afib, it’s interesting. I think we’re really seeing that connection between the two, between what you eat and what happens with your rhythm. There is some data on the gut microbiome and dysregulation of that and how that impacts certain patients. I came across a couple of studies in preparation for this podcast today, knowing that you are a leader in the area of gut health. There are studies that have actually shown the changes in the actual bacterial species and the metabolites in paroxysmal and persistent Afib patients. These are two kinds of Afib that aren’t present in people without Afib. So the thinking here is that those metabolites have kind of a more systemic effect and by causing increased inflammation through the body, and there’s so much about inflammation and how it relates to so many different medical problems and ties into food.

DrAD:

Inflammation is involved with the heart, it is involved with Afib, it is involved with coronary artery disease. So, yeah, it was interesting. The study actually showed that the dysregulated bacteria actually seemed to have a connection to the size of the left atrium, that the left atrium can get bigger, or you can get more scar in the left atrium. So the two big driving forces behind the risk of Afib and the progression of Afib, it’s the size of the left atrium and the amount scar tissue in it and it’s all tied into inflammation. So, you know, that’s really interesting. And then you look at the bigger picture of stuff that’s well established about the connection between TMA (trimethylamine) and atherosclerosis, short chain fatty acids and how they connect to vascular health that people can have issues with regards to. When you’re eating too much of a protein diet you get too much of that TMA, which then produces other components that can lead to problems with your vascular health. There’s tons of stuff out there which talks about issues with the gut causing problems with the cardiovascular system. I haven’t come across a lot with that look at the reverse, like, does the heart actually cause a problem with the gut. I can tell you in clinical practice that it’s interesting. We have these cases of cardiac issues triggering GI symptoms. I have a patient who gets episodes of Afib and it triggers her reflux. So I think there may be a connection there. And I think that’s more through the nervous system. So I think the gut/heart connection, of the gut affecting the heart and cardiovascular has to do with the bacteria, dysregulation, the metabolites and the effect on inflammation. But I think that the, the heart probably has an impact on the gut and it may be more through the shared autonomic nervous system component.

DrMR:

Sure. And it would make sense there’s some degree of biodirectionality there. Absolutely. Also I love the point that you make about inflammation. One of the things I often explain to patients is that your gut ostensibly the primary source of inflammation in your body. I can’t say there’s an airtight case for that. But if we look at the small intestine, having the highest density of immune cells in the entire body and just the immense degree of immunoregulation has to occur in the gut. Then that selectively permeable membrane , I think we can safely say, that the gut is a fairly sizeable source of inflammation. And it seems that inflammation kind of exposes one’s weak link. If they’re more prone to have some sort of rheumatic reaction or a dermatological reaction, some sort of inflammatory bout seems to expose that. So it would make sense that the heart would also be amenable to that influence. Regarding my friend, using him as the avatar here, he definitely has gut health that is in disarray and hopefully, when he listens to this podcast, we’ll kind of light a fire under his butt to take his gut health a little bit more seriously. Cause that is something he’s suffered with fairly markedly for a number of years. I couldn’t help but wonder if there were some kind of connection there.

DrAD:

Absolutely. I mean, I can tell you just anecdotally, having practiced for a long time, I see cases and patients teach me this. When they’ve cleaned up their diet, when they’ve gone vegan, their arrhythmia episodes go down. I mean, there’s definitely a lot of stuff already about cardiovascular health and atherosclerosis and the connection. There are many people out there such as Dr. Mark Hyman and so many other leaders in their area of food’s impact on the body and on health. I think the common language that all of us speak you, me, any organ system doctor is inflammation, inflammation, inflammation. Your immune system helps until it hurts. We see that with COVID. We see people who have overactive immune systems that are causing massive COVID infection. And we see the same thing in human body. You know, the immune system was designed for specific purposes. But when you overload it and you have these different metabolites and chemicals out of balance, chronic inflammation causes scar tissue to develop. That happens in the heart and when scar tissue develops in the heart, it can predispose you to all sorts of problems. Most common are arrhythmias. Scar tissue almost creates a short circuit in the heart’s electrical system, it’s like a break in the insulation around a wire. Kind of around what we are talking about – the heart, the brain and the gut – I kind of like think about the relationship of those three organs. It really is fascinating. The lungs are a big part of it too because the lungs help to impact breathing exercises to help, to impact so many of these other organ systems. So this tie in is really amazing. The brain though. You have the blood brain barrier, this layer of tissue around the brain that kind of separates it from the rest of the body in so many different ways. You mentioned anything from your mouth down to your lower intestines can affect your risk of heart disease, including valve infections and everything else. I just wonder about the brain and these other organs and how the brain gets affected. I don’t know about you, but I’ve come across this fascination with the brain as the origin of the nervous system, but there are two other “brains” in the body. One is the brain in the gut called the enteric nervous system. The other is the brain that’s in the heart, the part of the nervous system that’s in the heart. And so you have a two way street, you have messages from the brain going up to these organs, and then you have messages from these organs going to the brain.

DrAD:

Just as a quick example, there are studies that have shown that when people get exposed to a visual stimulus, like a really graphic picture of something, you will see changes in the heart rate and blood pressure first. We call it evoked potentials in the electrical system, you see changes there first before you see changes in the brain, I mean, it may be a very brief period of time, but before your brain even has a chance to process. So that’s a sign that your heart connects to you brain in that direction, not just the other way around. I defer to you, but I imagine the same kind of thing happens with the gut. This connection of the nervous system in the gut with the brain.

DrMR:

I would speculate that while you’re mentioning that kind of circulatory and cardiac changes, it’s probably having a micro effect on circulation to the amount of blood in the gut, because I’m assuming it’s getting the system geared up to go into this kind of acute response. I haven’t seen anything that documents that, but it would certainly physiologically make sense.

DrAD:

Yeah. Yeah. I agree.

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Dr. Desai’s New Book

DrMR:

You mentioned your book. Can you tell us a little bit about the book. I’m hoping that we’ve hit some of the main foundational points for people who need to learn more in this area. What can they expect when they dive into your book?

DrAD:

Yeah. So thank you. So I wrote the book as a personal story. My mom passed away unexpectedly and it was pretty traumatic and in dealing with the grieving process, I wrote because that’s what I do. She died of something related to the heart. So I was familiar with all aspects of that. The experience also caused me to go into a fairly significant depression as a result and I started looking at like what tools I could use to just help me process all of this. So I came up with the idea of creating a playbook or a toolbox of how to help me get through it and my own health. So I’m at work and I’m dealing with patients every day who have Afib and they really struggle. People with Afib really struggle. There are treatments, but the drugs don’t work in 50% of cases. We have great strides in the technology to treat Afib with something called ablation. But they still really struggle. And there’s so much misinformation about Afib. I can’t even begin to tell you. People talk to other people, even healthcare providers, people are not up to date on Afib. People are being told that their Afib can’t be cured. Their Afib can’t be treated. There’s nothing else that can be done. In so many cases now we’ve been able to cure the people who have been in Afib for 10 years and now they are in normal rhythm. It would be unheard of before.

DrAD:

I’m very grateful for you having me on the podcast today so I could share that that really important piece of news. We have so many options nowadays for people with Afib. My book is a playbook. It’s called Restart Your Heart, The Playbook for Thriving with Afib. Just as I needed a toolbox and a playbook to kind of get back on my feet and process everything, I felt like I should give something to people written from a place of credibility. Because I live and breathe Afib every day, that’s what I do. And so I wrote it in a way that is easy to follow and it’s filled with a lot of different patient stories. People that I’ve taken care of over the years that have met these challenges and overcome them in different ways. There’s a lot to glean from that. So the things that I love about the book are the personal component, my own story, and then kind of leading into stories about my patients and then also the science. A lot of the things that you and I have talked about today. Also the mindfulness of overall health and wellness, nutrition, what I call the resilience toolbox and how it’s important to have all of those things in place. September is national Afib Awareness Month. So the book came out September 1st and it’s available on all the major bookseller websites. My website is draseemdesai.com. It’s got a lot more information on there about the book, but also I talk quite a bit on my blogs about many of the topics that you and I have covered today, especially in regards to stress management. So I’m proud of it. It’s my first attempt at writing and I wasn’t sure where it was gonna go. It started from a place of, of sadness and loss and I feel like it’s really gonna help a lot people, I hope.

DrMR:

That’s fantastic. Congratulations on your first book. And I’ll just share that I have one book out and I feel like there’s a kinship between our perspectives because in gut health, there’s also an alarmingly high amount of misinformation out there and it’s been so motivating to hear all of the readers who’ve sent in their stories about how they saw two gastroenterologists and a naturalopath and a chiropractor and an acupuncturist, and no one was able to help them. And then they went through the book and were finally able to resurrect their health. I would be inclined to think you’re going to have a similar experience. So I’m excited for you. And I’m glad that you undertook that project cause it’s certainly not the easiest thing to accomplish and I hope anyone in our audience who is intersted will go to this resource for more information.

DrAD:

Maybe the next book is a joint venture between you and me. I mean, it’s interesting you mention being told by people that they were told by so many different doctors that nothing could be done. I mean, this one gentleman, I distinctly remember the day that I chose the topic of the book. I was walking this gentleman out. He had been in Afib continuously for five years, shocked multiple times, multiple medicines, multiple different procedures told by two cardiologists, nothing could be done. Because I live and breathe this every day and I was up to date on the science and the technology and the skillset, we were able to get him in a rhythm and he walked out of our office in normal sinus rhythm, the normal electrical rhythm of the heart. He just turned to me and he said something that’s so simple, but so profound just said “Dr. Desai, Thank you for being with me on this journey. I was told that nothing could be done about this and you really changed my life”. I mean, you being a physician, you know what impact we can have on people, but my patients are my best teachers.

DrMR:

Absolutely. I couldn’t agree more. And, you know, if we are being a little candid at the moment, sometimes as a doctor, the volume of people that you see can kind of desensitize you, but then every once in a while you have one of those cases that really strikes you and reminds you of how important the work is that you’re doing. How vulnerable I like to think that it is, and it kind of humbles you and just makes you grateful for what you’re doing. So fantastic story. Thank you for sharing. Is there anything else you want to leave people with as we transitioned to a close.

DrAD:

You know, we covered so many of the great points. My theme is really all about connection. That in our body all of the organ systems are connected. So we have to treat our health that way. We talked about heart/gut and heart/brain and inflammation. That thinking of the body in a certain way and an integrative medicine, functional medicine perspective is really important. The same goes true for what I do for living for Afib and for other heart-related issues, we treat it that way. Something that we didn’t really touch upon, but I just wanted to impart as we finished this up is the heart is the center of compassion and that’s what we need for each other right now during the stresses of what’s going on in our society. There’s a science to it and people can learn that science of how to be compassionate for others. There’s actually techniques through mindfulness that are done to do that. And I invite people to take a look at an article I wrote on Thrive Global, Arianna Huffington’s website called Make Compassion Go Viral. So a sort of a play on words, but the idea is that if one person’s compassionate for another and trying to step into that person’s shoes, instead actually do something about it, not just be empathetic, but do something about it even in a very small way. It has a snowballing effect. We need that now more than ever. So I wanted to just make that plug for the heart, not just as an organ, but as the source of compassion for each other.

DrMR:

I love it. And that’s a great note for us to close on. Aseem, thanks so much for taking the time and for writing the book.

DrAD:

Thank you, Michael. Be well.

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