1 billion. That's the number of times a human heart beats in a lifetime. Whether it's due to the resilience of a heart that beats 1 billion times or not, we always find ourselves running alongside our hearts in a competitive society. However, unfortunately, humans are not robots. The law of action and reaction inevitably applies.

With a 'lup-dup' sound, the heart kept its rhythm until, one moment, it broke down. The heart is a very honest organ. It cannot be deceived about who you like, whether you are stressed, slept well, or told lies. Atrial fibrillation is no exception.

Atrial fibrillation is an arrhythmia that occurs when the atria (upper chambers) of the heartbeat are irregular. The heart sends blood from the right atrium to the lungs through the pulmonary artery and receives oxygenated blood from the lungs into the left atrium through the pulmonary veins. Atrial fibrillation is mainly caused by rapid and irregular electrical signals originating from the pulmonary veins connected to the left atrium.

Mainly atrial fibrillation primarily occurs in individuals aged 60 and above, with both the incidence and prevalence increasing with age. While bodily aging is one contributing factor, it could also be seen as a warning signal from the heart that has tirelessly been running without rest.

Above all, as South Korea faces the imminent challenge of an aging society, appropriate measures are crucial. According to the Health Insurance Review & Assessment Service, the number of patients with atrial fibrillation stood at approximately 259,052 as of 2022, marking a staggering 125% increase over the past decade. Considering that atrial fibrillation can progress into chronic arrhythmia, leading to blood clot formation and potentially causing strokes, early diagnosis and treatment are paramount.

Fortunately, advancements in medical technology have alleviated the suffering caused by diseases. Treatment methods that were once limited have now become more diverse. Not only surgery but various procedures can now be used to treat atrial fibrillation. I had the opportunity to discuss atrial fibrillation treatment with Professor Kim Donghyuk from the Department of Cardiology at Yonsei University Severance Hospital.

Atrial fibrillation is associated with a 5-fold higher risk of stroke.

Arrhythmia refers to an irregular heartbeat. If there are issues with blood circulation, blood clots can form. When these clots travel to the brain, they cause ischemic strokes. It's common to observe narrowed blood vessels in elderly patients. However, among patients in their 40s to 50s with unexplained narrowing of blood vessels, atrial fibrillation is often the cause. Approximately 25% of cases of cryptogenic strokes (strokes with an unknown cause) are reported to be attributed to atrial fibrillation.

Atrial fibrillation is one of the cardiovascular diseases affecting the heart and brain. Due to the nature of cardiovascular diseases, diagnosis may be delayed.

Less than 30% of patients with symptoms of atrial fibrillation are diagnosed, meaning that approximately 70% of cases are asymptomatic and therefore diagnosed later. In reality, many elderly patients with atrial fibrillation are often incidentally diagnosed during health screenings through electrocardiogram tests.

The national health examination in South Korea does not include electrocardiogram (ECG) testing.

Early diagnosis and treatment of cardiovascular diseases are crucial. Therefore, there is an issue advocating for the inclusion of ECG testing in the national health examination for early detection. Global guidelines, including those from Europe and the United States, recommend ECG testing for individuals aged 65 and above.

What is the rate of early diagnosis of atrial fibrillation?

Atrial fibrillation is termed "paroxysmal" when first detected. If it persists for over a year, it is termed "persistent." The rate of diagnosis for paroxysmal atrial fibrillation varies among datasets. Simply looking at the prevalence itself, it has historically been reported at around 1-2%. Due to population aging, it is projected to exceed 5% by 2050-2060. In fact, over the past decade alone, the prevalence has nearly doubled. The majority of atrial fibrillation is explosively increasing.

Who are High-risk patients for atrial fibrillation?

High-risk patients for atrial fibrillation include Elderly individuals, those with hypertension and diabetics, and patients with a history of elevated cholesterol levels. Additionally, individuals who have previously experienced conditions such as myocardial infarction, angina pectoris, or heart failure are also considered to be at high risk.

What are the diagnosis process and treatment methods for atrial fibrillation?

Generally, atrial fibrillation is diagnosed using an electrocardiogram (ECG). Following a diagnosis of atrial fibrillation, medications for arrhythmia are typically prescribed. Medical procedures may be considered if medications do not yield the desired response. One key difference in South Korea compared to other countries is the requirement to use medicines for at least six weeks following diagnosis. If atrial fibrillation persists despite medication usage, medical procedures may be pursued. The strict guidelines are enforced because the government supports 95% of the procedure costs.

Whether there are differences from global treatment guidelines.

Medications for arrhythmia only control symptoms and are not considered a fundamental cure. Procedures can be described as fundamental treatment from the outset. Nowadays, guidelines from countries like the United States and Europe show a trend towards performing procedures concurrently with diagnosis, as medication usage alone may delay the timing of procedures. Nearly all data consistently suggest that earlier procedures lead to better outcomes. However, this approach is not allowed in South Korea due to differences in national healthcare expenditures. Nevertheless, in cases where there is a risk of ventricular arrhythmia or sudden cardiac death, procedures may be performed immediately.

Two main procedures for treating atrial fibrillation are radiofrequency catheter ablation (radiofrequency ablation) and cryoballoon ablation.

Atrial fibrillation originates from the pulmonary veins in the left atrium, and the procedure aims to eliminate this signal. The main difference between radiofrequency ablation and cryoballoon ablation lies in the energy used; radiofrequency ablation utilizes heat energy, while cryoballoon ablation utilizes energy below minus 89 degrees Celsius. It's important to note that neither procedure is 100% effective, and each has its own advantages and disadvantages. Additionally, both procedures are covered by insurance. Global guidelines treat radiofrequency ablation and cryoballoon ablation equally. However, it is noted that cryo balloon ablation is preferred for initial procedures.

I'd like more detailed information about cryo balloon ablation.

Before performing cryoballoon ablation, a CT scan of the patient is taken to predict whether cryoballoon ablation is feasible. The procedure method varies depending on whether the atrial fibrillation is chronic or acute. In practice, both procedures are more effective when performed early. From the patient's perspective, cryoballoon ablation is much more convenient. Radiofrequency ablation takes longer, and there is a risk of perforation and death if a hole is created during the procedure. However, cryoballoon ablation typically takes less than 2 hours, resulting in less discomfort for the patient. The hospitalization period is also shorter. Therefore, in elderly patients, cryoballoon ablation is preferred over radiofrequency ablation. Cryoballoon ablation is performed more frequently in elderly patients, as it has fewer complications and a shorter procedure duration, resulting in less burden.

Interesting research findings were presented at the 2019 Asia Pacific Heart Rhythm Society.

It indicated the effectiveness of cryoballoon ablation in reducing the burden of atrial fibrillation occurrence and improving the quality of life in patients with early persistent atrial fibrillation. According to the study, cryo balloon ablation reduced disease burden in patients with early persistent atrial fibrillation by 10.1±25.7% (n=115) 12 months after the procedure. Moreover, the proportion of patients experiencing significant burden from atrial fibrillation (80% or more) also continuously decreased following cryoballoon ablation. In summary, radiofrequency and cryoballoon ablation's therapeutic effects are considered equivalent.

Which patient population may find cryoballoon ablation challenging?

Cryoballoon ablation involves using a tool shaped like a round balloon to ablate the pulmonary veins. Therefore, it is necessary to examine the structure of each patient's veins using CT or MRI scans to confirm the procedure's suitability. The procedure may be challenging to perform if the openings are too small or the shape is unsuitable for the balloon.

Can atrial fibrillation be cured through procedures or surgeries?

Generally, when discussing diseases like cancer, the term "cured" is often used to indicate that the condition has not recurred for at least five years. This implies that the likelihood of recurrence in the future is less than 5%. The same concept applies to procedures. Even after undergoing a procedure, recurrence can still occur. For paroxysmal atrial fibrillation, the recurrence rate is around 10-20%, while for chronic cases, it's around 40-50%. On average, the recurrence rate is approximately 30%. In younger individuals, the recurrence rate tends to be lower when procedures are performed promptly. However, since there is always a possibility of recurrence, using the term "cured" in this context is not accurate.

Ultimately, is preventive care through regular check-ups important?

Guidelines have been established regarding this matter. Sometimes, when a patient visits after experiencing recurrence just one-month post-procedure, it may appear to be atrial fibrillation. However, it's not a recurrence. Typically, the first three months after the procedure are considered a "blanking period," during which the heart may become more activated. This is because specific forces are applied to the blood vessels during the procedure, causing them to swell. During the blanking period, even if atrial fibrillation is observed, the decision on recurrence is made after three months. Subsequently, a Holter monitor (24-hour electrocardiogram) is conducted annually at home.

What guidelines should patients follow in their daily lives after the procedure?

The most important rule after the procedure for atrial fibrillation is abstinence from alcohol. According to research findings, alcohol can have an extreme impact, so it's strongly advised to avoid alcohol entirely for at least three months. The exercise follows a similar recommendation. Instead of muscle exercises, patients are encouraged to engage in aerobic activities such as jogging for 30 minutes three times a week and are advised to maintain a moderate diet.

What areas need improvement in the treatment environment for atrial fibrillation?

I hope that an environment where atrial fibrillation can be treated proactively before it becomes chronic will be established. In the United States, if a patient is in their 40s or 50s, physicians tend to proceed with the procedure promptly after diagnosis. However, in Korea, patients often have to wait for six weeks while taking medication. For patients in their 40s and 50s, allowing for prompt procedures in the early stages would be socially beneficial. Therefore, there is a need to relax insurance standards to facilitate this.

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