February 25, 2025 • 33 mins
Advancements in arrhythmia care are transforming patient outcomes and reshaping clinical practices. Join Dr. Sanjiv Narayan, Professor of Medicine at Stanford University, and Dr. Paul Wang, Professor of Medicine and of Bioengineering at Stanford University, as they explore the evolving field of electrophysiology, highlighting the importance of early detection and best practices in the management of common electrical abnormalities. Discover how a patient-centered approach can enhance care and outcomes for those with irregular heart rhythms.
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Episode Transcript
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(00:00):
(upbeat music)
- Welcome to Stanford Medcast,
the podcast from Stanford CME
that brings you the latest insights
from the world's leadingphysicians and scientists.
If you're joining us for the first time,
be sure to subscribe andApple Podcast, Amazon Music,
(00:20):
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to stay updated with our newest episodes.
I am your host, Dr. Ruth Adewuya.
In this episode, I will be chatting
with Dr. Sanjiv Narayan and Paul Wang.
Dr. Narayan is a professor of medicine,
the Director of the StanfordComputational Medicine
in the Heart Integrated Program
and co-founder of theStanford Arrhythmia Center.
(00:43):
He directs the ComputationalArrhythmia Research Lab,
which operates at the intersection
of cardiovascular medicine,
bioengineering, and data science.
He earned his MD in Neuroscience
from the University of Birmingham
and completed his residencyat Cambridge, Massachusetts
and his cardiology fellowships
at Washington University in St. Louis.
(01:03):
Dr. Narayan is the recipient
of the Distinguished Scientist Award
of the Heart Rhythm Society
and the Top Doctor Award fromCastle Connolly, among others.
Dr. Paul Wang is the Director
of the Stanford Cardiac Arrhythmia Service
and Professor of Medicineand Bioengineering.
He is an expert in thetreatment of cardiac arrhythmias
(01:23):
including atrialfibrillation, atrial flutter,
ventricular andsuperventricular arrhythmias,
and sudden cardiac death.
He was a co-inventor ofcatheter cryoablation,
which has been used to treatover a million patients
with atrial fibrillation
and has pioneered new techniques
in the management ofheart rhythm problems.
(01:44):
He earned his medical degreefrom Columbia University,
completed his residencyat New York Presbyterian
Medical Center and his cardiovascular
and Cardio Electrophysiology fellowship
at Brigham and Women's Hospital.
Thank you both for chatting with me today.
- It's really a pleasure to be here.
- Great to be here, thank you.
- I'm thrilled to have the chance
(02:04):
to speak with both of youabout electrophysiology,
arrhythmias, and theincredible advancements
happening in this field.
To start, I'd love to hear aboutyour journey as clinicians.
What inspired you tospecialize in electrophysiology
and how has this focus shapedyour clinical practice?
Dr. Narayan?
- I really love what Ido, I think we all do,
(02:27):
everyone here at Stanfordand in the profession.
For me, the heart just seems such a
incredibly intricate organ.
At one level, it's justa pump, on the own level,
it causes so many problems,
and of course at the other level,
it's so essential to health.
I'm fascinated by it,how something so simple
can be so critical
and yet could causeproblems in so many people.
(02:49):
I also was fascinatedbecause at some level,
it seemed pretty simple to me,
that's what led to myfascination with the research.
It's incredible howsomething like the ECG,
which has been around for 120 years
can still be giving us insights.
Of course, we don't just stickwith the body surface ECG,
we do it inside the heart,
but it's fascinating how wecan understand complex rhythms,
(03:11):
atrial fibrillation,ventricular tachycardia,
and fibrillation, and treat them
based on looking essentiallyat just those ECGs.
- Turning to you, Dr. Wang.
- I was attracted to cardiology
because I viewed it asa mainstream problem
that many people have.
We view it as a potentiallyserious condition
(03:31):
where you're thinking,
oh, this might have bigimpact on their life.
I decided when I started medical school,
how can I approach this?
I look for mentors in cardiology
and it happened to be thefirst mentor that I found
was a specialist in cardiac arrhythmias.
I always tell my students,that can happen to you,
it's often self-fulfilling
(03:52):
what you end up thinking you want to do,
you have a great experience
and then that's somethingthat gets your attention
and continues as part of your career.
- I enjoyed hearing the pivotal role
that your mentor playedin shaping your career.
It highlights just howimportant mentorship is
in setting students up for success
and helping them discover anddevelop their own passions.
(04:15):
Dr. Narayan, to kick off ourconversation on arrhythmias,
could you talk about
some of the most commonelectrical abnormalities
that you encounter in your practice
and how they typicallypresent in patients?
- This is a broad spectrum.
Some people see us because askip beat was picked up in ECG
and they didn't feel it.
Other people have arrhythmias diagnosed
(04:37):
because they presentwith a variety of things
across the gamut ofmedicine, feeling tired,
feeling a bit lightheadedwhen they stand up,
which of course could be normal,
but could also be
the beginnings ofbradycardia, for instance.
The arrhythmias we seecould span many of those.
This gets into the exquisiteness of it
that you've got simple thingslike premature atrial beats
(05:00):
that can make you feel prettylousy, but they're benign
and they're easy to treat,
all the way through toatrial fibrillation,
which can cause problemslike stroke, fatigue,
hospitalization, even heart failure.
Even worse in the most extreme cases,
yet often is not picked upearly and people go undiagnosed.
It's this breadth that makesit so fascinating to me.
(05:21):
We don't understand much ofwhat causes those difference
in presentations betweenpeople, we just don't know why.
- Thank you forhighlighting the complexity
and the nuance in diagnosingand managing arrhythmias
and how the same underlyingissue can manifest
so differently across patientsfrom something as benign,
(05:42):
as premature atrial beat
to something that is reallypotentially life altering
and a consequence of atrial fibrillation.
As a follow-up, could you discuss
how early detectionimpacts patient outcomes
and the potential long-term risks
of untreated electrical abnormalities?
(06:02):
- We live our lives withbillions of heartbeats
and the heart is an incredible organ.
Occasional abnormalitiesare not a problem,
we all have an occasional skip beat
when we're doing our SATsor running a marathon,
but of course, early detection is good.
Without being paranoid, a simplemeasure is check your pulse
the same way you check your weight,
(06:22):
you check your blood pressure,
people could just check their pulse.
People then get used to the idea
of regular versus irregular.
Moving forwards beyond that,
many people are wearing wearables,
it's an increasing part of our daily lives
all over the world, andthis is a phenomenal tool
for cardiology and heart rhythm.
You don't really knowwhat symptoms people have
(06:45):
and people may not have symptoms,
but on the other hand,
Apple Watch and otherdevices is easily available,
so early detection is great.
Without getting alarmist, Ithink it's just good for us
to build into our dailylives, teaching our patients,
that's worth doing.
If one sees an irregular rhythm,
then kick that up to the next notch.
Speak to your family care provider,
(07:06):
speak to someone in the team,
we're always available in thearrhythmia service to help.
- Dr. Wang, building on that,
can you discuss the keyrisk factors and triggers
for arrhythmias thatclinicians should be aware of
in their patient populations?
- I tend to think about triggers
and then different factorsthat may contribute
to the disease process.
(07:28):
Acquire diseases, our aging process,
other things about our overall health.
Arrhythmias often are manifest by
things that can lead tosymptoms like palpitations
that patients actually feel,
they're the signal thatsomething is gonna happen.
That's not true of manyof the problems we have.
Many of the medicalconditions, we don't feel
(07:48):
until a very late stage,whereas arrhythmias,
you could feel from the very beginning.
Similarly, they're prettystraightforward to diagnose.
We don't need any fancy kind of machine,
it's called electrocardiogram.
These patients identifythemselves what might cause it.
Lifestyle, various comorbidities,diabetes, hypertension,
and other things related to aging.
(08:09):
The same things that wecounsel our patients about
specifically for arrhythmiasare often those same things
we tell people for getting good health
and good cardiovascular overallcondition and lifestyle.
The other things we talkabout is more triggers.
Patients will always ask me,is there anything I'm doing
that might be resultingin these arrhythmias?
(08:30):
We go through this listthat's pretty standard
of common triggers like caffeine,
physical, emotional stress,physical exhaustion,
systemic metabolic problems, dehydration,
sleep disorders,
there's so many things that overlap
that affect the heart, inparticular, heart rhythms.
Patients also often come withthe information themselves.
(08:53):
Oh, when I do certain kinds of activities,
it actually will result in it,
but we generally don't tellpeople, oh, don't exert yourself
or do certain things unless wecan identify pretty clearly.
There are some situationsthat are more medical,
such as an operation, a colonoscopy,
a colon prep, things like that,
they can be pretty common triggers,
(09:14):
so they'll get postoperative arrhythmias.
There are many differentpossible triggers.
- What I'm hearing you sayis that arrhythmias can act
as both a signal of broader health issues
and a condition influenced
by such a diverse range oftriggers from lifestyle factors
to specific medical events.
Given this complexity and variability,
(09:36):
how does these breadthof factors influence
how you as a clinician managethe diagnostic process?
- It has many great ramifications.
One, sometimes it'll lead patients to us.
They may have symptomsthat are pretty general,
that is shortness of breath or fatigue.
Sometimes, I think we miss the diagnosis.
No one thought it's an arrhythmia,
(09:58):
they went off and looked for other causes.
The opposite can happen,someone can be referred
because, oh, I think itmust be an arrhythmia.
In actuality, they have atotally, another problem.
I had a patient gotreferred for exactly this,
the shortness of breathand anemia and fatigue.
Turned out they had colon cancer
and they really were anemic.
What's great about arrhythmia
is that as long as we cancatch the episode happening,
(10:21):
we can pretty reliably andvery safely make the diagnosis
and interpreting, as you said,
these variety of differentsymptoms that people can have.
One of the first messagesis symptom awareness.
We do encourage patients tobring forward their symptoms,
and then it's on us to make the diagnosis,
is it arrhythmic or not arrhythmic?
And simply as long as we can capture it,
(10:43):
the challenge is thatwhen we can't capture it
because they're so transientand maybe even infrequent,
that can be the difficulty
and that can be veryfrustrating for patients.
We do have other strategies,
it's something very specificcalled an implantable recorder
loop recorder, that allowsfor situations like,
oh, I have severe symptoms,
(11:04):
but they only occur three times a year
with a two week monitor,
where we're gonna begenerally pretty unsuccessful.
But if one wants to really capture it,
that's something we verymuch might want to do
is to implant such a monitor.
- There has been an increasein arrhythmia diagnoses
in recent years.
In your experience,
what factors arecontributing to this trend
(11:26):
and how should clinicians respond?
- We are seeing many more arrhythmias,
it's increasing rapidly.
Part of its recognition, whichwe're very pleased about,
it means that patients are more aware
that we as cliniciansalso are much more aware
because we see so much of arrhythmia.
Finally, the diseaseprocesses are increasing.
We all accept that we'rein an aging population.
(11:49):
The most of the acquiredarrhythmias are increasing with age
and the other associatedfactors, metabolic syndrome,
diabetes, hypertension,
they get more prevalent with age also,
and perhaps other factorssuch as obesity increasing,
et cetera, they may bealso contributing to
our increased awareness andfrequency of these arrhythmia.
(12:10):
We're seeing truly anexplosion in arrhythmia.
- Dr. Narayan, you mentioned wearables
earlier in our conversation.
I'm curious about yourthoughts on wearables
and how they've become suchan integral part of our lives.
Are you noticing a trend whereself-diagnosis of arrhythmias
has increased because peopleare constantly tracking
(12:31):
their activity with devices?
Are you seeing more patientswith benign conditions
as a result of this increased monitoring?
- We have, people are self diagnosing.
I actually think the ideal would be
we have full disclosure all the time.
If you're the kind of person
that doesn't wanna know, switch it off.
If you do wanna know, fine, it's up to us
to then sort out what'sreal from what isn't.
(12:54):
It's one of the fascinatingareas that arrhythmias,
electrophysiology so wellsuited to auto sensors,
artificial intelligence, computer models,
that over time, is beginningto help us sort out
what is important for whatcould be just reassured.
We're not there yet, there'sstill a lot of false positives,
(13:14):
but I don't think it's bad,
I think it is betterto have full disclosure
and then sort it out later.
- One of the great things is that
as those devices become more prevalent,
I think that'll beavailable for more people,
it's fundamentally a consumer product,
yet there are abilities
to help us make thediagnosis of arrhythmias.
Yes, I think we're all a bitfearful that we'll be deluged,
(13:37):
but we think of that as animportant step for healthcare,
et cetera, because we dothink of it as a way that
people with previouslyundiagnosed arrhythmias
might be detected
in a very kind of comfortable,safe way for patients.
As a society, we havetrouble screening people
for any condition andjust the healthcare costs
and the need for educationand dissemination
(13:59):
can be very daunting, but ifthe public becomes more aware
and have these accessible,then it allows us this entree.
We're excited about the promise
that people with undiagnosed arrhythmias
might be able to be diagnosedin an earlier stage.
- That's such an excellent way to frame it
as a supportive toolthat empowers patients
(14:19):
to take greater control of their health
and become more aware of their wellbeing.
Ideally, of course,
it also helps streamlinethe screening process,
making it more accessible and effective.
Dr. Wang, what are thecurrent best practices
for managing patients withirregular heart rhythms?
- It's the sub classification.
What is exactly the arrhythmia
(14:40):
and what treatment is required and why?
Sometimes it's gonna betreatment for symptoms,
the other situation is,are the arrhythmias signal
for something more serious?
That's at the forefront of our minds,
that does tend to use resources,
because we will typicallydo an echocardiogram
and other testing to figure out,
(15:01):
well, why does this person have this?
Why would that occur?
We do also, one interestingkind of observation
and one of my colleagues,
Dr. Marco Perez is an expert in this area
is for younger patients,
people in their twenties and thirties
developing arrhythmias that otherwise,
you should develop when you're 60 or 70,
those are largely genetic abnormalities.
(15:21):
We're very early now
to direct those patientsfor genetic testing
because that can have great implications
for them and their future.
There are many different approaches
to evaluation and treatment.
When we think about treatment,
some of it's gonna be preventative,
the big one is stroke
anticoagulation for atrialfibrillation, stroke prevention.
Whenever we see somebodywith atrial fibrillation,
(15:42):
that's one of the veryfirst things we address.
Being in the arrhythmia area,we try to identify your risk,
is it high sudden cardiac death?
That's another aspect we wantto tailor for the patient,
the correct treatment plan.
Those are the things we thinkabout, why do they have this?
What is the underlying condition
and what is their overall risk?
And then we pivot for you,what are we gonna do for you
(16:04):
in terms of treatment, et cetera.
Treatment also has evolved significantly
for some conditions,for atrial fibrillation,
we're treating people muchearlier than previously.
particularly largestudies that show benefit
of earlier treatmentof atrial fibrillation,
so that could be arrhythmic drug therapy,
that could be catheter ablation,
so these are definitely on the move.
(16:26):
For a number of years, we werereally heavily symptom driven
and didn't consider so muchthe natural history, et cetera.
Now that we have more dataabout the natural history,
that's one area we'refocusing on much, much more.
- I'd like to focus
on your mention of catheter cryoablation,
especially as someone who is aco-inventor of the technique,
(16:49):
could you share your insightson when this treatment
should be considered and how it compares
to other modalities interms of effectiveness
and patient selection?
- The journey towards new technologies
is an interesting one.
For many years, the radiofrequency energy
was the only real sourcefor catheter ablation.
Cryoablation is something that
(17:10):
was introduced shortly thereafter.
The one big differenceis that cryoablation
is particularly useful forcritical or delicate areas
where you're concerned aboutdamage to the structure.
As a good example of thatare pediatric colleagues
who deal with small patients
and patients that are lookingto have a lifetime ahead,
they will overwhelminglyuse catheter cryoablation
(17:32):
compared to radiofrequencybecause of the concern
that if they have damage,
that will result in their whole lifetime
of having a consequence of that,
and that's one of the areas
that I think has stood the test of time,
that continues to be a go-to technology.
In the last six to 12 months,
there's a new technologycalled pulse field ablation,
which is a new energysource that's very similar
(17:56):
to what our benchscientists colleagues use
called electroporation,
forming little kind ofopenings in the cell membrane.
That has been shown tobe a very effective way
of treating patients with arrhythmia.
That's probably the latest
of the shift in terms of technology.
I don't doubt that we'llsee more advances though
in that area and a lot more new technology
(18:17):
that'll benefit patients.
- It's fascinating to hear how
technologies like cryoablation
and the newer pulse fieldablations have evolved
and found their place in patient care,
it's a great reminder ofhow innovation continues
to shape the field of electrophysiology.
Dr. Narayan, this brings me to your work
at the ComputationalArrhythmia Research Lab.
(18:40):
I'd love to hear more about
how you integrate interdisciplinaryresearch in this space.
Could you share an overviewof your current research
and how clinicians canapply these insights
to improve the management ofarrhythmias in their patients?
- I'm really privileged to be at Stanford
where we are the hub ofso many great things,
one of which is computer science.
(19:01):
I have a lab which buildsbetween engineering,
a little bit of devices and hardware,
but mostly computer science,data science, analytics,
through the data we collect in patients.
There's a lot that one can collect,
you've got demographics,you've got the ECG,
then you can go deeper.
How do we put that all together?
(19:21):
Recently, we've been very excited
about putting thesetogether into AI models.
Moving forward, what aboutif you took that and said,
there's this patternthat's really interesting
and it's a certain kind of ECG signal
coupled with an electrical signal
from this part of the heartin atrial fibrillation,
but not this part.
You get an even better prediction,
(19:42):
then, okay, this bit is abnormal,
could we actually treat that?
We're using that as a wayto actually guide treatment,
not just to predict
who will do better and who will do worse.
We work increasinglywith people in genetics,
so I could list a few, butmy colleagues, Marco Perez
and Michael Snyder, just phenomenal people
across the med school ecosystem.
Engineering, a quick plugfor a wonderful bioengineer
(20:05):
I work with Allison Marsden
with whom we have a training program.
I'm very passionate aboutblending engineering and medicine
and then everybody across medical school.
That's what we try to do
with a focus on atrial fibrillation,
ventricular arrhythmias,but a bit of everything.
- First of all, that'sabsolutely incredible,
I think the work you're doing is amazing.
I can't even imagine the scaleof data you're working with
(20:29):
to create such a comprehensive approach,
not just to target and treatpatients, but to push beyond
current practices and elevatecare to the next level.
From what you've shared,
it sounds like you're leveraging AI models
to manage these massive computations
and integrate data in a waythat drives meaningful insights.
(20:50):
How has the integration ofAI and large language models
impacted the way youconduct your research?
- The short answer is enormously,and it's just beginning.
On the other hand, it's not that smart
in the sense that whena kid is growing up,
it'll learn to recognizea train from a car
or a book from a carafter five or 10 times.
(21:12):
We have to train our AI modelsa hundred thousand times
before they can figure that out.
A medical student understandsan ECG pretty well
after a couple of hundredsinus rhythm, heart block,
things like that, and an AI algorithm
may need a hundred thousandor a million examples.
They're not that smart,but once they are trained,
they are unbelievable.
The biggest challengeis getting that data,
(21:34):
just as you said, how dowe get the right data?
And the right data isn'tjust always more data.
More data isn't always better
because if you had amillion recordings of ECGs
with slow heartbeats of40 and 50, et cetera,
you can't assume that everyslow heartbeat is a problem.
Some of those people will be athletes,
(21:55):
some of those people will be sleeping,
some of these people aregoing to be on beta blockers.
How do you figure it out?
It's all a question ofcurating that data set right.
This is where the field is going,
getting exactly the right data sets built
that will allow us to answer,
will this individual do better
from this chemotherapy ornot, or this ablation or not?
(22:16):
- That's an important nuancefor people to understand,
highlighting the complexities
of utilizing machinelearning and research.
It's not just a magic solution,
but something that requires
significant effort and expertise.
You touched on this earlierwhen discussing the intersection
of engineering and medicine,
I believe you were referring to
(22:36):
the Stanford ComputationalMedicine in the heart program
and its educational goals.
Could you share more about this program
and how it prepares clinicians
for the evolving landscapeof electrophysiology?
- The program's calledCHIP, Computational Medicine
in the Heart Integrated Program,
I run it with my friend andcolleague, Dr. Allison Marsden
(22:57):
in mechanical engineeringand the school of medicine.
The goal is basicallyto just bridge this gap
between biology, cardiovascular research,
medicine and engineering.
This is critical becauseit's obvious all around us,
we're getting more techy,the whole world is,
smart watches, databases,early warning systems,
there's so many things youcould think of yet people,
(23:18):
including myself, get a littleintimidated by the methods,
what is AI, what's a neural network?
We don't all have to be experts,
I'm not, but I do understand a bit
and I think if we did, we'dbe able to read the papers
and really move the field forward.
That's the goal, that we have a tagline
to teach engineers aboutclinically important questions
and to teach physicianshow to write Python
(23:40):
to speak the same language.
- As we wind down our time together,
I'd like to shift the focus
to your experiences with patients.
In your view, what are the key elements
of patient-centered care inthe treatment of arrhythmias
and how can cliniciansapply these principles
to enhance their approachand improve patient outcomes?
(24:02):
- I love those conceptof patient-centered care
and many times, we'll say it's
shared decision making as well.
That's engaging thepatient and their families.
That's where, as we talkedabout decision making,
many of the factorsthat we're going to want
to help patients with,comorbidities, et cetera,
we try to encouragepatients not to think that
(24:23):
they're coming in fora so-called solution,
that they don't really haveto change their lifestyle
and do other modifications,
but rather, it's a plan
that we're going to come forward together
that may have thesedifferent ramifications.
Certainly, we're goingto give them treatment
directly for what they have,
but we're gonna wanna workwith them to figure out,
well, what kind of contributed to this?
(24:44):
What could be contributing in the future?
It may lead to not as goodoutcomes in the future.
We really wanna engagepatients and their families
in this decision making process.
That could be challenging for patients,
sometimes patients, theycome with this idea that
just tell me what to do kind of thing,
and that's not as beneficialto the patient rather than,
(25:04):
yeah, I understand what you're saying,
I really absorb the reasoning
so I can take that homewith me and then really,
hopefully that'll motivate metowards making these changes,
whereas otherwise sometimes,it just seems very
transactional, oh, dothis, and okay, I'm done,
and they don't really think about
what they need to do in termsof their overall health.
(25:24):
Hopefully we try topresent a bigger approach
to various arrhythmias.
We're trying to do that moreand more overall at Stanford.
- What I heard you emphasizing
is the importance of developing tools
and treatment plans in truecollaboration with patients,
ensuring that they have allthe information they need
to make the best decisions for themselves.
(25:45):
It's really about co-creatingthe plan with them,
which is such an empowering approach.
Dr. Narayan how do socio economic factors
influence patient accessto electrophysiology care,
and what can clinicians do
to mitigate these barriersin their practice?
- That's such an important question,
and I think we're alsowell positioned to help.
(26:06):
There's disparities in arrhythmia care,
like with everything, it goesthrough the standard triad,
less detection, less treatment,
and worse outcomes even when treated.
That's true for AF, for stroke prevention,
which of course is related to AF
and for ventriculararrhythmias or sudden death.
I've been lucky to be on a committee
at the American Heart Association,
(26:27):
we are just actually puttogether a position statement
on trying to address disparities of care,
which is socioeconomic,it's health literacy,
it's physical access, butit's also digital things.
So many people have smartphones,
you can imagine a smartphoneapp can get everywhere.
You don't need tophysically leave your job
(26:48):
and schlep an hour into clinic,
you could do it on a 15 minute break.
Algorithms could help diagnose.
You could imagine extendingthis to parts of the world,
I'm Indian, so Asia,Africa, all over the world,
rural parts of the US, digitalmedicine across the board,
not just cardiology arrhythmia,
could massively level the playing field.
Despite that potential leveling,
(27:09):
there is actually a digitaldivide that's opening.
On one hand, these toolscould really close that divide
and narrow it, provide the evidence base
across diverse communities,
including underrepresented minorities,
on the other hand, isn't happening yet.
Some of it is that an AppleWatch is really expensive,
so there's economic,
but it's also the resources like internet
(27:29):
isn't widely and uniformly accessible.
We wrote this paper withsome really notable people
who are very interestedin the aspect of equity,
health equity, digital equity,
to try and speak about possible solutions.
- Looking ahead, wheredo you both see the field
of electrophysiologyheading in the next decade
(27:50):
and what should cliniciansbe prepared for?
- We've seen so much change,
it's probably gonna slow down or stop,
but we're pleasantly surprised
that there's a significantamount of change.
I'll tell my trainees or example,
if I reflect back on what wedid three to five years ago,
I could say every six months,
there's something new that's happened.
(28:11):
That's one of the thingsthat we look forward to
as well as reflecting on that.
In recent years, we've had thisexplosion of new approaches
and different ways andbetter ways to treat things.
We're very optimistic thatrate of change will continue,
it's a very robust area of development
and new arrhythmia treatments.
One area that has been a bit slower
(28:32):
for the heart rhythmareas is drug therapy.
We haven't had a new drugfor a number of years
and we're hearing moreabout that acceleration.
There's a lot of areas we need to work in,
but I'm very excitedabout the rate of change.
- We're heading into an integrated future
where we don't break thingsdown by heart, lung, brain,
(28:53):
but in terms of syndromes,because we'll have wearables,
your watch will measureyour blood pressure,
but also your temperature
and it'll give you a variety of activity.
Because of that,
there'll be a convergenceof the specialties.
There's already communicationbetween specialties
in disease management and inresearch, that will continue,
and because of that,
(29:13):
we're gonna make headwayat the intersections
as we already are,
cardio neuro cardiorenal,oncology with cardiology.
I think that the technology evolution
as we get more comfortablewith, it'll become seamless
and that will furtherblur the distinction.
I really welcome patient participation.
We have to deal with the work overload,
(29:33):
but I really welcome that andthat is likely to continue
and improve overall outcomes as well.
We won't just be waiting
for that clinic visitevery three to six months,
there'll be continuous recordings.
- You've both been inthis field for a while
and have witnessed thetrends and changes over time,
yet as I'm speaking with both of you,
it's clear that yourpassion and excitement
(29:55):
for this field remains strong.
I'm curious, what have you found
to be the most rewarding aspects
of working in electrophysiology
and how this perspective could benefit
practicing clinicians?
- We're all clinicians.
We see the promise of helping patients
and fundamentally changing andimproving how we treat them.
(30:15):
That's really what we're excited about,
and as we've seen so muchprogress, we see the potential,
particularly in academic environments,
we are very aware of thelimitations that we have,
so we are certainly awareof the accomplishment
and what progress we've made,
but at the same time, we'reequally aware of the gaps.
One of the big gaps Idiscussed with my colleagues
(30:37):
is we don't have enoughscience going on in our area.
One of the reasons we don'thave so much drug therapy,
for example, we'verelied on more mechanical
and engineering basedsolutions, which are great,
but fundamentally, weneed better drugs to use
and other different forms of treatment.
Similarly, because a large partof our mission is training,
we need to train thebest and the brightest
(30:59):
and attract them.
I think we need to doa better job of that.
I feel like the most importantthing is human health
and how can we improve it.
I want the rest of theworld to feel the same way.
Everybody really wants to work with us
and develop new things,
that's one of the greatestpromises of places like Stanford
where we can bring various people
with engineering,computer science together
(31:19):
and really do things thatreally can't be done on our own,
and we need collaboratorsthat can do that,
that's the exciting part ofdifferent places like Stanford
that have that capability
and have the vision to be able to
see what we can do in the future
and solve these problemsthat still are massive.
As I mentioned, atrialfibrillation, for example,
the rate of increase is astronomic.
(31:42):
Patients still die suddenly,or hundreds of thousands.
We still have yet to make a huge dent.
We need to have new strategies,
we're working on those all the time.
That's one area we
are both really passionateabout and excited about.
We've got a big mountain to climb,
we need a lot of help doing that.
- It's the patients, it's just fantastic.
(32:02):
I've done basic research in my time,
and although I loved it,
I just wanted to comeback to patient care.
There's nothing morerewarding than that patient
who at the end of the day says,
you've really changed my life.
It can be as simple astaking away a palpitation,
as well as something reallydramatic that's lifesaving.
I also love our environment,
I love the fact that we havesuch incredibly talented
(32:23):
trainees coming throughwho are fun to work with
and who keep us on our toes,
and I love the fact that it's changing.
We're always learning and moving,
in what I think is a very valuable
and worthwhile direction,
it's human health reduction in disease,
you can't get much better than that.
- Thank you for sharing both the promise
and the challenges within this space.
It's inspiring to see how these elements
(32:45):
continue to motivateindividuals like both of you
to push boundaries and drivethis important work forward.
Thank you both for joiningme on this podcast episode,
it's been an insightful conversation
and I truly appreciateyour time and expertise
in sharing your perspectiveson this important topic.
(33:05):
- It was really fun, thank you, Ruth.
- Delightful, thank you.
- This episode was broughtto you by Stanford CME.
To claim CME forlistening to this episode,
click on the claim CME link below
or visit Medcast.stanford.edu.
Check back for new episodes
by subscribing to Stanford Medcast
(33:26):
wherever you listen to podcasts.
(dramatic music)
(upbeat music)
- Welcome to Stanford Medcast,
the podcast from Stanford CME
that brings you the latest insights
from the world's leadingphysicians and scientists.
If you're joining us for the first time,
be sure to subscribe andApple Podcast, Amazon Music,
(00:20):
Spotify, or YouTube
to stay updated with our newest episodes.
I am your host, Dr. Ruth Adewuya.
In this episode, I will be chatting
with Dr. Sanjiv Narayan and Paul Wang.
Dr. Narayan is a professor of medicine,
the Director of the StanfordComputational Medicine
in the Heart Integrated Program
and co-founder of theStanford Arrhythmia Center.
(00:43):
He directs the ComputationalArrhythmia Research Lab,
which operates at the intersection
of cardiovascular medicine,
bioengineering, and data science.
He earned his MD in Neuroscience
from the University of Birmingham
and completed his residencyat Cambridge, Massachusetts
and his cardiology fellowships
at Washington University in St. Louis.
(01:03):
Dr. Narayan is the recipient
of the Distinguished Scientist Award
of the Heart Rhythm Society
and the Top Doctor Award fromCastle Connolly, among others.
Dr. Paul Wang is the Director
of the Stanford Cardiac Arrhythmia Service
and Professor of Medicineand Bioengineering.
He is an expert in thetreatment of cardiac arrhythmias
(01:23):
including atrialfibrillation, atrial flutter,
ventricular andsuperventricular arrhythmias,
and sudden cardiac death.
He was a co-inventor ofcatheter cryoablation,
which has been used to treatover a million patients
with atrial fibrillation
and has pioneered new techniques
in the management ofheart rhythm problems.
(01:44):
He earned his medical degreefrom Columbia University,
completed his residencyat New York Presbyterian
Medical Center and his cardiovascular
and Cardio Electrophysiology fellowship
at Brigham and Women's Hospital.
Thank you both for chatting with me today.
- It's really a pleasure to be here.
- Great to be here, thank you.
- I'm thrilled to have the chance
(02:04):
to speak with both of youabout electrophysiology,
arrhythmias, and theincredible advancements
happening in this field.
To start, I'd love to hear aboutyour journey as clinicians.
What inspired you tospecialize in electrophysiology
and how has this focus shapedyour clinical practice?
Dr. Narayan?
- I really love what Ido, I think we all do,
(02:27):
everyone here at Stanfordand in the profession.
For me, the heart just seems such a
incredibly intricate organ.
At one level, it's justa pump, on the own level,
it causes so many problems,
and of course at the other level,
it's so essential to health.
I'm fascinated by it,how something so simple
can be so critical
and yet could causeproblems in so many people.
(02:49):
I also was fascinatedbecause at some level,
it seemed pretty simple to me,
that's what led to myfascination with the research.
It's incredible howsomething like the ECG,
which has been around for 120 years
can still be giving us insights.
Of course, we don't just stickwith the body surface ECG,
we do it inside the heart,
but it's fascinating how wecan understand complex rhythms,
(03:11):
atrial fibrillation,ventricular tachycardia,
and fibrillation, and treat them
based on looking essentiallyat just those ECGs.
- Turning to you, Dr. Wang.
- I was attracted to cardiology
because I viewed it asa mainstream problem
that many people have.
We view it as a potentiallyserious condition
(03:31):
where you're thinking,
oh, this might have bigimpact on their life.
I decided when I started medical school,
how can I approach this?
I look for mentors in cardiology
and it happened to be thefirst mentor that I found
was a specialist in cardiac arrhythmias.
I always tell my students,that can happen to you,
it's often self-fulfilling
(03:52):
what you end up thinking you want to do,
you have a great experience
and then that's somethingthat gets your attention
and continues as part of your career.
- I enjoyed hearing the pivotal role
that your mentor playedin shaping your career.
It highlights just howimportant mentorship is
in setting students up for success
and helping them discover anddevelop their own passions.
(04:15):
Dr. Narayan, to kick off ourconversation on arrhythmias,
could you talk about
some of the most commonelectrical abnormalities
that you encounter in your practice
and how they typicallypresent in patients?
- This is a broad spectrum.
Some people see us because askip beat was picked up in ECG
and they didn't feel it.
Other people have arrhythmias diagnosed
(04:37):
because they presentwith a variety of things
across the gamut ofmedicine, feeling tired,
feeling a bit lightheadedwhen they stand up,
which of course could be normal,
but could also be
the beginnings ofbradycardia, for instance.
The arrhythmias we seecould span many of those.
This gets into the exquisiteness of it
that you've got simple thingslike premature atrial beats
(05:00):
that can make you feel prettylousy, but they're benign
and they're easy to treat,
all the way through toatrial fibrillation,
which can cause problemslike stroke, fatigue,
hospitalization, even heart failure.
Even worse in the most extreme cases,
yet often is not picked upearly and people go undiagnosed.
It's this breadth that makesit so fascinating to me.
(05:21):
We don't understand much ofwhat causes those difference
in presentations betweenpeople, we just don't know why.
- Thank you forhighlighting the complexity
and the nuance in diagnosingand managing arrhythmias
and how the same underlyingissue can manifest
so differently across patientsfrom something as benign,
(05:42):
as premature atrial beat
to something that is reallypotentially life altering
and a consequence of atrial fibrillation.
As a follow-up, could you discuss
how early detectionimpacts patient outcomes
and the potential long-term risks
of untreated electrical abnormalities?
(06:02):
- We live our lives withbillions of heartbeats
and the heart is an incredible organ.
Occasional abnormalitiesare not a problem,
we all have an occasional skip beat
when we're doing our SATsor running a marathon,
but of course, early detection is good.
Without being paranoid, a simplemeasure is check your pulse
the same way you check your weight,
(06:22):
you check your blood pressure,
people could just check their pulse.
People then get used to the idea
of regular versus irregular.
Moving forwards beyond that,
many people are wearing wearables,
it's an increasing part of our daily lives
all over the world, andthis is a phenomenal tool
for cardiology and heart rhythm.
You don't really knowwhat symptoms people have
(06:45):
and people may not have symptoms,
but on the other hand,
Apple Watch and otherdevices is easily available,
so early detection is great.
Without getting alarmist, Ithink it's just good for us
to build into our dailylives, teaching our patients,
that's worth doing.
If one sees an irregular rhythm,
then kick that up to the next notch.
Speak to your family care provider,
(07:06):
speak to someone in the team,
we're always available in thearrhythmia service to help.
- Dr. Wang, building on that,
can you discuss the keyrisk factors and triggers
for arrhythmias thatclinicians should be aware of
in their patient populations?
- I tend to think about triggers
and then different factorsthat may contribute
to the disease process.
(07:28):
Acquire diseases, our aging process,
other things about our overall health.
Arrhythmias often are manifest by
things that can lead tosymptoms like palpitations
that patients actually feel,
they're the signal thatsomething is gonna happen.
That's not true of manyof the problems we have.
Many of the medicalconditions, we don't feel
(07:48):
until a very late stage,whereas arrhythmias,
you could feel from the very beginning.
Similarly, they're prettystraightforward to diagnose.
We don't need any fancy kind of machine,
it's called electrocardiogram.
These patients identifythemselves what might cause it.
Lifestyle, various comorbidities,diabetes, hypertension,
and other things related to aging.
(08:09):
The same things that wecounsel our patients about
specifically for arrhythmiasare often those same things
we tell people for getting good health
and good cardiovascular overallcondition and lifestyle.
The other things we talkabout is more triggers.
Patients will always ask me,is there anything I'm doing
that might be resultingin these arrhythmias?
(08:30):
We go through this listthat's pretty standard
of common triggers like caffeine,
physical, emotional stress,physical exhaustion,
systemic metabolic problems, dehydration,
sleep disorders,
there's so many things that overlap
that affect the heart, inparticular, heart rhythms.
Patients also often come withthe information themselves.
(08:53):
Oh, when I do certain kinds of activities,
it actually will result in it,
but we generally don't tellpeople, oh, don't exert yourself
or do certain things unless wecan identify pretty clearly.
There are some situationsthat are more medical,
such as an operation, a colonoscopy,
a colon prep, things like that,
they can be pretty common triggers,
(09:14):
so they'll get postoperative arrhythmias.
There are many differentpossible triggers.
- What I'm hearing you sayis that arrhythmias can act
as both a signal of broader health issues
and a condition influenced
by such a diverse range oftriggers from lifestyle factors
to specific medical events.
Given this complexity and variability,
(09:36):
how does these breadthof factors influence
how you as a clinician managethe diagnostic process?
- It has many great ramifications.
One, sometimes it'll lead patients to us.
They may have symptomsthat are pretty general,
that is shortness of breath or fatigue.
Sometimes, I think we miss the diagnosis.
No one thought it's an arrhythmia,
(09:58):
they went off and looked for other causes.
The opposite can happen,someone can be referred
because, oh, I think itmust be an arrhythmia.
In actuality, they have atotally, another problem.
I had a patient gotreferred for exactly this,
the shortness of breathand anemia and fatigue.
Turned out they had colon cancer
and they really were anemic.
What's great about arrhythmia
is that as long as we cancatch the episode happening,
(10:21):
we can pretty reliably andvery safely make the diagnosis
and interpreting, as you said,
these variety of differentsymptoms that people can have.
One of the first messagesis symptom awareness.
We do encourage patients tobring forward their symptoms,
and then it's on us to make the diagnosis,
is it arrhythmic or not arrhythmic?
And simply as long as we can capture it,
(10:43):
the challenge is thatwhen we can't capture it
because they're so transientand maybe even infrequent,
that can be the difficulty
and that can be veryfrustrating for patients.
We do have other strategies,
it's something very specificcalled an implantable recorder
loop recorder, that allowsfor situations like,
oh, I have severe symptoms,
(11:04):
but they only occur three times a year
with a two week monitor,
where we're gonna begenerally pretty unsuccessful.
But if one wants to really capture it,
that's something we verymuch might want to do
is to implant such a monitor.
- There has been an increasein arrhythmia diagnoses
in recent years.
In your experience,
what factors arecontributing to this trend
(11:26):
and how should clinicians respond?
- We are seeing many more arrhythmias,
it's increasing rapidly.
Part of its recognition, whichwe're very pleased about,
it means that patients are more aware
that we as cliniciansalso are much more aware
because we see so much of arrhythmia.
Finally, the diseaseprocesses are increasing.
We all accept that we'rein an aging population.
(11:49):
The most of the acquiredarrhythmias are increasing with age
and the other associatedfactors, metabolic syndrome,
diabetes, hypertension,
they get more prevalent with age also,
and perhaps other factorssuch as obesity increasing,
et cetera, they may bealso contributing to
our increased awareness andfrequency of these arrhythmia.
(12:10):
We're seeing truly anexplosion in arrhythmia.
- Dr. Narayan, you mentioned wearables
earlier in our conversation.
I'm curious about yourthoughts on wearables
and how they've become suchan integral part of our lives.
Are you noticing a trend whereself-diagnosis of arrhythmias
has increased because peopleare constantly tracking
(12:31):
their activity with devices?
Are you seeing more patientswith benign conditions
as a result of this increased monitoring?
- We have, people are self diagnosing.
I actually think the ideal would be
we have full disclosure all the time.
If you're the kind of person
that doesn't wanna know, switch it off.
If you do wanna know, fine, it's up to us
to then sort out what'sreal from what isn't.
(12:54):
It's one of the fascinatingareas that arrhythmias,
electrophysiology so wellsuited to auto sensors,
artificial intelligence, computer models,
that over time, is beginningto help us sort out
what is important for whatcould be just reassured.
We're not there yet, there'sstill a lot of false positives,
(13:14):
but I don't think it's bad,
I think it is betterto have full disclosure
and then sort it out later.
- One of the great things is that
as those devices become more prevalent,
I think that'll beavailable for more people,
it's fundamentally a consumer product,
yet there are abilities
to help us make thediagnosis of arrhythmias.
Yes, I think we're all a bitfearful that we'll be deluged,
(13:37):
but we think of that as animportant step for healthcare,
et cetera, because we dothink of it as a way that
people with previouslyundiagnosed arrhythmias
might be detected
in a very kind of comfortable,safe way for patients.
As a society, we havetrouble screening people
for any condition andjust the healthcare costs
and the need for educationand dissemination
(13:59):
can be very daunting, but ifthe public becomes more aware
and have these accessible,then it allows us this entree.
We're excited about the promise
that people with undiagnosed arrhythmias
might be able to be diagnosedin an earlier stage.
- That's such an excellent way to frame it
as a supportive toolthat empowers patients
(14:19):
to take greater control of their health
and become more aware of their wellbeing.
Ideally, of course,
it also helps streamlinethe screening process,
making it more accessible and effective.
Dr. Wang, what are thecurrent best practices
for managing patients withirregular heart rhythms?
- It's the sub classification.
What is exactly the arrhythmia
(14:40):
and what treatment is required and why?
Sometimes it's gonna betreatment for symptoms,
the other situation is,are the arrhythmias signal
for something more serious?
That's at the forefront of our minds,
that does tend to use resources,
because we will typicallydo an echocardiogram
and other testing to figure out,
(15:01):
well, why does this person have this?
Why would that occur?
We do also, one interestingkind of observation
and one of my colleagues,
Dr. Marco Perez is an expert in this area
is for younger patients,
people in their twenties and thirties
developing arrhythmias that otherwise,
you should develop when you're 60 or 70,
those are largely genetic abnormalities.
(15:21):
We're very early now
to direct those patientsfor genetic testing
because that can have great implications
for them and their future.
There are many different approaches
to evaluation and treatment.
When we think about treatment,
some of it's gonna be preventative,
the big one is stroke
anticoagulation for atrialfibrillation, stroke prevention.
Whenever we see somebodywith atrial fibrillation,
(15:42):
that's one of the veryfirst things we address.
Being in the arrhythmia area,we try to identify your risk,
is it high sudden cardiac death?
That's another aspect we wantto tailor for the patient,
the correct treatment plan.
Those are the things we thinkabout, why do they have this?
What is the underlying condition
and what is their overall risk?
And then we pivot for you,what are we gonna do for you
(16:04):
in terms of treatment, et cetera.
Treatment also has evolved significantly
for some conditions,for atrial fibrillation,
we're treating people muchearlier than previously.
particularly largestudies that show benefit
of earlier treatmentof atrial fibrillation,
so that could be arrhythmic drug therapy,
that could be catheter ablation,
so these are definitely on the move.
(16:26):
For a number of years, we werereally heavily symptom driven
and didn't consider so muchthe natural history, et cetera.
Now that we have more dataabout the natural history,
that's one area we'refocusing on much, much more.
- I'd like to focus
on your mention of catheter cryoablation,
especially as someone who is aco-inventor of the technique,
(16:49):
could you share your insightson when this treatment
should be considered and how it compares
to other modalities interms of effectiveness
and patient selection?
- The journey towards new technologies
is an interesting one.
For many years, the radiofrequency energy
was the only real sourcefor catheter ablation.
Cryoablation is something that
(17:10):
was introduced shortly thereafter.
The one big differenceis that cryoablation
is particularly useful forcritical or delicate areas
where you're concerned aboutdamage to the structure.
As a good example of thatare pediatric colleagues
who deal with small patients
and patients that are lookingto have a lifetime ahead,
they will overwhelminglyuse catheter cryoablation
(17:32):
compared to radiofrequencybecause of the concern
that if they have damage,
that will result in their whole lifetime
of having a consequence of that,
and that's one of the areas
that I think has stood the test of time,
that continues to be a go-to technology.
In the last six to 12 months,
there's a new technologycalled pulse field ablation,
which is a new energysource that's very similar
(17:56):
to what our benchscientists colleagues use
called electroporation,
forming little kind ofopenings in the cell membrane.
That has been shown tobe a very effective way
of treating patients with arrhythmia.
That's probably the latest
of the shift in terms of technology.
I don't doubt that we'llsee more advances though
in that area and a lot more new technology
(18:17):
that'll benefit patients.
- It's fascinating to hear how
technologies like cryoablation
and the newer pulse fieldablations have evolved
and found their place in patient care,
it's a great reminder ofhow innovation continues
to shape the field of electrophysiology.
Dr. Narayan, this brings me to your work
at the ComputationalArrhythmia Research Lab.
(18:40):
I'd love to hear more about
how you integrate interdisciplinaryresearch in this space.
Could you share an overviewof your current research
and how clinicians canapply these insights
to improve the management ofarrhythmias in their patients?
- I'm really privileged to be at Stanford
where we are the hub ofso many great things,
one of which is computer science.
(19:01):
I have a lab which buildsbetween engineering,
a little bit of devices and hardware,
but mostly computer science,data science, analytics,
through the data we collect in patients.
There's a lot that one can collect,
you've got demographics,you've got the ECG,
then you can go deeper.
How do we put that all together?
(19:21):
Recently, we've been very excited
about putting thesetogether into AI models.
Moving forward, what aboutif you took that and said,
there's this patternthat's really interesting
and it's a certain kind of ECG signal
coupled with an electrical signal
from this part of the heartin atrial fibrillation,
but not this part.
You get an even better prediction,
(19:42):
then, okay, this bit is abnormal,
could we actually treat that?
We're using that as a wayto actually guide treatment,
not just to predict
who will do better and who will do worse.
We work increasinglywith people in genetics,
so I could list a few, butmy colleagues, Marco Perez
and Michael Snyder, just phenomenal people
across the med school ecosystem.
Engineering, a quick plugfor a wonderful bioengineer
(20:05):
I work with Allison Marsden
with whom we have a training program.
I'm very passionate aboutblending engineering and medicine
and then everybody across medical school.
That's what we try to do
with a focus on atrial fibrillation,
ventricular arrhythmias,but a bit of everything.
- First of all, that'sabsolutely incredible,
I think the work you're doing is amazing.
I can't even imagine the scaleof data you're working with
(20:29):
to create such a comprehensive approach,
not just to target and treatpatients, but to push beyond
current practices and elevatecare to the next level.
From what you've shared,
it sounds like you're leveraging AI models
to manage these massive computations
and integrate data in a waythat drives meaningful insights.
(20:50):
How has the integration ofAI and large language models
impacted the way youconduct your research?
- The short answer is enormously,and it's just beginning.
On the other hand, it's not that smart
in the sense that whena kid is growing up,
it'll learn to recognizea train from a car
or a book from a carafter five or 10 times.
(21:12):
We have to train our AI modelsa hundred thousand times
before they can figure that out.
A medical student understandsan ECG pretty well
after a couple of hundredsinus rhythm, heart block,
things like that, and an AI algorithm
may need a hundred thousandor a million examples.
They're not that smart,but once they are trained,
they are unbelievable.
The biggest challengeis getting that data,
(21:34):
just as you said, how dowe get the right data?
And the right data isn'tjust always more data.
More data isn't always better
because if you had amillion recordings of ECGs
with slow heartbeats of40 and 50, et cetera,
you can't assume that everyslow heartbeat is a problem.
Some of those people will be athletes,
(21:55):
some of those people will be sleeping,
some of these people aregoing to be on beta blockers.
How do you figure it out?
It's all a question ofcurating that data set right.
This is where the field is going,
getting exactly the right data sets built
that will allow us to answer,
will this individual do better
from this chemotherapy ornot, or this ablation or not?
(22:16):
- That's an important nuancefor people to understand,
highlighting the complexities
of utilizing machinelearning and research.
It's not just a magic solution,
but something that requires
significant effort and expertise.
You touched on this earlierwhen discussing the intersection
of engineering and medicine,
I believe you were referring to
(22:36):
the Stanford ComputationalMedicine in the heart program
and its educational goals.
Could you share more about this program
and how it prepares clinicians
for the evolving landscapeof electrophysiology?
- The program's calledCHIP, Computational Medicine
in the Heart Integrated Program,
I run it with my friend andcolleague, Dr. Allison Marsden
(22:57):
in mechanical engineeringand the school of medicine.
The goal is basicallyto just bridge this gap
between biology, cardiovascular research,
medicine and engineering.
This is critical becauseit's obvious all around us,
we're getting more techy,the whole world is,
smart watches, databases,early warning systems,
there's so many things youcould think of yet people,
(23:18):
including myself, get a littleintimidated by the methods,
what is AI, what's a neural network?
We don't all have to be experts,
I'm not, but I do understand a bit
and I think if we did, we'dbe able to read the papers
and really move the field forward.
That's the goal, that we have a tagline
to teach engineers aboutclinically important questions
and to teach physicianshow to write Python
(23:40):
to speak the same language.
- As we wind down our time together,
I'd like to shift the focus
to your experiences with patients.
In your view, what are the key elements
of patient-centered care inthe treatment of arrhythmias
and how can cliniciansapply these principles
to enhance their approachand improve patient outcomes?
(24:02):
- I love those conceptof patient-centered care
and many times, we'll say it's
shared decision making as well.
That's engaging thepatient and their families.
That's where, as we talkedabout decision making,
many of the factorsthat we're going to want
to help patients with,comorbidities, et cetera,
we try to encouragepatients not to think that
(24:23):
they're coming in fora so-called solution,
that they don't really haveto change their lifestyle
and do other modifications,
but rather, it's a plan
that we're going to come forward together
that may have thesedifferent ramifications.
Certainly, we're goingto give them treatment
directly for what they have,
but we're gonna wanna workwith them to figure out,
well, what kind of contributed to this?
(24:44):
What could be contributing in the future?
It may lead to not as goodoutcomes in the future.
We really wanna engagepatients and their families
in this decision making process.
That could be challenging for patients,
sometimes patients, theycome with this idea that
just tell me what to do kind of thing,
and that's not as beneficialto the patient rather than,
(25:04):
yeah, I understand what you're saying,
I really absorb the reasoning
so I can take that homewith me and then really,
hopefully that'll motivate metowards making these changes,
whereas otherwise sometimes,it just seems very
transactional, oh, dothis, and okay, I'm done,
and they don't really think about
what they need to do in termsof their overall health.
(25:24):
Hopefully we try topresent a bigger approach
to various arrhythmias.
We're trying to do that moreand more overall at Stanford.
- What I heard you emphasizing
is the importance of developing tools
and treatment plans in truecollaboration with patients,
ensuring that they have allthe information they need
to make the best decisions for themselves.
(25:45):
It's really about co-creatingthe plan with them,
which is such an empowering approach.
Dr. Narayan how do socio economic factors
influence patient accessto electrophysiology care,
and what can clinicians do
to mitigate these barriersin their practice?
- That's such an important question,
and I think we're alsowell positioned to help.
(26:06):
There's disparities in arrhythmia care,
like with everything, it goesthrough the standard triad,
less detection, less treatment,
and worse outcomes even when treated.
That's true for AF, for stroke prevention,
which of course is related to AF
and for ventriculararrhythmias or sudden death.
I've been lucky to be on a committee
at the American Heart Association,
(26:27):
we are just actually puttogether a position statement
on trying to address disparities of care,
which is socioeconomic,it's health literacy,
it's physical access, butit's also digital things.
So many people have smartphones,
you can imagine a smartphoneapp can get everywhere.
You don't need tophysically leave your job
(26:48):
and schlep an hour into clinic,
you could do it on a 15 minute break.
Algorithms could help diagnose.
You could imagine extendingthis to parts of the world,
I'm Indian, so Asia,Africa, all over the world,
rural parts of the US, digitalmedicine across the board,
not just cardiology arrhythmia,
could massively level the playing field.
Despite that potential leveling,
(27:09):
there is actually a digitaldivide that's opening.
On one hand, these toolscould really close that divide
and narrow it, provide the evidence base
across diverse communities,
including underrepresented minorities,
on the other hand, isn't happening yet.
Some of it is that an AppleWatch is really expensive,
so there's economic,
but it's also the resources like internet
(27:29):
isn't widely and uniformly accessible.
We wrote this paper withsome really notable people
who are very interestedin the aspect of equity,
health equity, digital equity,
to try and speak about possible solutions.
- Looking ahead, wheredo you both see the field
of electrophysiologyheading in the next decade
(27:50):
and what should cliniciansbe prepared for?
- We've seen so much change,
it's probably gonna slow down or stop,
but we're pleasantly surprised
that there's a significantamount of change.
I'll tell my trainees or example,
if I reflect back on what wedid three to five years ago,
I could say every six months,
there's something new that's happened.
(28:11):
That's one of the thingsthat we look forward to
as well as reflecting on that.
In recent years, we've had thisexplosion of new approaches
and different ways andbetter ways to treat things.
We're very optimistic thatrate of change will continue,
it's a very robust area of development
and new arrhythmia treatments.
One area that has been a bit slower
(28:32):
for the heart rhythmareas is drug therapy.
We haven't had a new drugfor a number of years
and we're hearing moreabout that acceleration.
There's a lot of areas we need to work in,
but I'm very excitedabout the rate of change.
- We're heading into an integrated future
where we don't break thingsdown by heart, lung, brain,
(28:53):
but in terms of syndromes,because we'll have wearables,
your watch will measureyour blood pressure,
but also your temperature
and it'll give you a variety of activity.
Because of that,
there'll be a convergenceof the specialties.
There's already communicationbetween specialties
in disease management and inresearch, that will continue,
and because of that,
(29:13):
we're gonna make headwayat the intersections
as we already are,
cardio neuro cardiorenal,oncology with cardiology.
I think that the technology evolution
as we get more comfortablewith, it'll become seamless
and that will furtherblur the distinction.
I really welcome patient participation.
We have to deal with the work overload,
(29:33):
but I really welcome that andthat is likely to continue
and improve overall outcomes as well.
We won't just be waiting
for that clinic visitevery three to six months,
there'll be continuous recordings.
- You've both been inthis field for a while
and have witnessed thetrends and changes over time,
yet as I'm speaking with both of you,
it's clear that yourpassion and excitement
(29:55):
for this field remains strong.
I'm curious, what have you found
to be the most rewarding aspects
of working in electrophysiology
and how this perspective could benefit
practicing clinicians?
- We're all clinicians.
We see the promise of helping patients
and fundamentally changing andimproving how we treat them.
(30:15):
That's really what we're excited about,
and as we've seen so muchprogress, we see the potential,
particularly in academic environments,
we are very aware of thelimitations that we have,
so we are certainly awareof the accomplishment
and what progress we've made,
but at the same time, we'reequally aware of the gaps.
One of the big gaps Idiscussed with my colleagues
(30:37):
is we don't have enoughscience going on in our area.
One of the reasons we don'thave so much drug therapy,
for example, we'verelied on more mechanical
and engineering basedsolutions, which are great,
but fundamentally, weneed better drugs to use
and other different forms of treatment.
Similarly, because a large partof our mission is training,
we need to train thebest and the brightest
(30:59):
and attract them.
I think we need to doa better job of that.
I feel like the most importantthing is human health
and how can we improve it.
I want the rest of theworld to feel the same way.
Everybody really wants to work with us
and develop new things,
that's one of the greatestpromises of places like Stanford
where we can bring various people
with engineering,computer science together
(31:19):
and really do things thatreally can't be done on our own,
and we need collaboratorsthat can do that,
that's the exciting part ofdifferent places like Stanford
that have that capability
and have the vision to be able to
see what we can do in the future
and solve these problemsthat still are massive.
As I mentioned, atrialfibrillation, for example,
the rate of increase is astronomic.
(31:42):
Patients still die suddenly,or hundreds of thousands.
We still have yet to make a huge dent.
We need to have new strategies,
we're working on those all the time.
That's one area we
are both really passionateabout and excited about.
We've got a big mountain to climb,
we need a lot of help doing that.
- It's the patients, it's just fantastic.
(32:02):
I've done basic research in my time,
and although I loved it,
I just wanted to comeback to patient care.
There's nothing morerewarding than that patient
who at the end of the day says,
you've really changed my life.
It can be as simple astaking away a palpitation,
as well as something reallydramatic that's lifesaving.
I also love our environment,
I love the fact that we havesuch incredibly talented
(32:23):
trainees coming throughwho are fun to work with
and who keep us on our toes,
and I love the fact that it's changing.
We're always learning and moving,
in what I think is a very valuable
and worthwhile direction,
it's human health reduction in disease,
you can't get much better than that.
- Thank you for sharing both the promise
and the challenges within this space.
It's inspiring to see how these elements
(32:45):
continue to motivateindividuals like both of you
to push boundaries and drivethis important work forward.
Thank you both for joiningme on this podcast episode,
it's been an insightful conversation
and I truly appreciateyour time and expertise
in sharing your perspectiveson this important topic.
(33:05):
- It was really fun, thank you, Ruth.
- Delightful, thank you.
- This episode was broughtto you by Stanford CME.
To claim CME forlistening to this episode,
click on the claim CME link below
or visit Medcast.stanford.edu.
Check back for new episodes
by subscribing to Stanford Medcast
(33:26):
wherever you listen to podcasts.
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