Western AF Symposium 2023: Session 2 Roundtable

After EAST AFNET and CABANA, Do I Ablate or Use AAD in My AF Patients?

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Featured is the Session 2 Roundtable entitled “After EAST AFNET and CABANA, Do I Ablate or Use AAD in My AF Patients?” from WAFib 2023. 

Western AF Symposium: Session 2 Roundtable 
After EAST AFNET and CABANA, Do I Ablate or Use AAD in My AF Patients?

Moderator: Hugh Calkins, MD – Johns Hopkins 
Discussant: John Mandrola, MD 
Discussant: Christine Albert, MD 
Discussant: Thomas Deneke, MD 
Discussant: Michael Riley, MD

Michael Riley, MD: Good morning, everyone. I'm very excited to be here. Thank you to Nassir for the invite. I’m Michael Riley. I'm an electrophysiologist with the WellStar Health System in Atlanta, Georgia. I will start by saying that ever since the EAST AFNET study was published, my threshold for offering ablation early on in the process has certainly decreased. It's harder to know how to incorporate the results of the CABANA trial because of the problems with crossovers and everything like that. But I think that the EAST AFNET study certainly added to the wealth of data from other trials that supports an early rhythm control strategy, so I tend to ablate early on in the process.

Thomas Deneke, MD: I think what we have to consider when we talk about EAST AFNET is that it's not an ablation trial. Only a minority of patients were ablated. So, I think it's really hard to draw conclusions in regard to indications for ablation from that specific trial. Nonetheless, I think we tend to ablate earlier than 10 years before. I don't usually ablate asymptomatic patients who do not have heart failure. I think it's worthwhile considering that in EAST AFNET, approximately one-fourth of patients, or 30%, were asymptomatic at the beginning. So, I think this is the cohort of patients where EAST AFNET may really imply a different approach now. We've heard a lot of the discussion about when is early. I think within the first 12 months after the first atrial fibrillation (AF) episode is a good time frame. I would not ablate a patient who has had a single episode of AF. So, for the first initial episode, I would always cardiovert if it's persistent. But then, I'm starting to get earlier and earlier in the process of evaluating patients for ablation. The question that comes up for me is, are there patients who would benefit or in whom we would consider strictly rate control only? I don't know that. I guess there are many more questions than answers in EAST AFNET 4.

Christine Albert, MD: I think that we still have to individualize it a bit. As you mentioned, EAST AFNET was not an ablation trial, and so, the majority of patients were treated with drugs. Interestingly, they were older patients with a lot of risk factors—the patients that we usually would have started with rate control. So that is a paradigm shift. I think the important thing that we learned is that it is important to try to get people into sinus rhythm if we can, and the way we do it needs to be individualized. If there is heart failure, then obviously moving towards ablation makes sense. Even if you look at CABANA, the younger patients did much better with ablation. Also, speaking with patients about the benefit of ablation over drugs. We know that there's sort of equipoise with respect to side effects and complications. The risk of recurrence after ablation is so much lower than it is with an antiarrhythmic drug. So again, it really will depend upon the patient's mindset a little. I still have young patients who choose to try an antiarrhythmic drug first, and it's been successful. They're not enthused to go ahead and go for an ablation. So, I think these trials give us choices but tell us that we should probably think about trying to even get those elderly patients, which, sometimes it's hard thinking about having them go on drugs to get into sinus rhythm.

Hugh Calkins, MD: John, we look forward to your comments. 

John Mandrola, MD: I'm glad that Christine and I agree. One thing I've thought about with that the question about EAST AFNET and CABANA is, “do I use ablation or drugs?” The obvious answer is you use both. One of the things that I've been struck with looking at these trials is that they seem overly reductive to me. We have ablation versus drugs, we have rhythm control versus rate control, but that's really not what we see in our clinic. In our clinic, we might have to use both. We might use drugs for a while to cool things off and see how a patient does. We might use rate control for a while just to see if a patient tolerates it, and then we can move back and forth. But this reductive sort of one versus the other I don't think is advancing the field anymore. PFA is exciting, it's safer. But what is it? It's just a way to destroy heart tissue. Does that really advance the field? I wonder if you put your scientific hat on, would we be of more benefit? Would we get more benefit from following more of Dr Schotten’s work and really going upstream to the basic science, because of PVI and ablation? I'm not sure.

Hugh Calkins, MD: Let me make a few comments and pose some questions to the audience. What is amazing in this field is when we started decades ago, and Nassir remembers this, there was this question about whether AF ablation really worked. That was the big question. There was a lot of skepticism. Did we need a placebo control trial? It was all a placebo effect. Over the last couple of years, we've had this seismic shift where finally the message is that AF ablation works. I think the CIRCA-DOSE study did a lot to get us there and how the AF burden drops by 99% with implantable monitors, and so forth. But I think the world now believes AF ablation works. I was struck by the impact of the EAST AFNET trial. When this study came out, it really pushed us over where all of a sudden, the least my referring physicians now get it. AF is bad, sinus rhythm is good. All of a sudden, the floodgates have opened with loads and loads of AF ablation patients. But I think the real question is one which I think Mel brought up. You have a patient with 2-3 episodes of paroxysmal AF in a 55-year-old man. We all see patients like that. Do you put that patient on a drug and see how they're responding? If they respond well, do you leave them on the drug until they have breakthroughs? Or is there some urgency to get into the lab and do an AF ablation? I'm interested in data from the Cleveland Clinic that I personally don't see in my own practice. Maybe you can comment on that a little later. I've heard some data that the critical number is the time since first onset of AF from when you had your first episode of AF. The sooner you do the ablation, the better, irregardless of whether you're having AF burden or how much AF in between. You have to get there soon. My own experience is like Mel's, that if you're in sinus rhythm on a drug, you basically preserve your candidacy for AF ablation. You remain a good candidate for an AF ablation 5-10 years ago, years later, when you have better tools. With that introduction, let me ask Mike about that 55- or 56-year-old patient, let's say it’s maybe one of your colleagues or a faculty member in your practice. They show up with AF. What do you tell him? What do you think? How do you phrase the discussion with that person? How do most of your patients end up deciding what to do?

Michael Riley, MD: I would say, it’s an individualized approach. You know, as other panel members have said, is very important. I guess my perspective is somewhat unique. You know, I come from a large community-based practice. We have about 100 general cardiologists in our group and 7 EPs. So, the majority of our consults that we see are for AF management, and the majority of those are persistent AF. I think just having a detailed discussion with the patients is important because patients oftentimes will tell you what they prefer. You know, when you go through the risks and benefits of using drug therapy versus ablation therapy, some would rather try 10 different drugs than go for ablation, and other people don't want to, as they say, waste any time with drugs. Oftentimes what we'll do is we will cardiovert and use a drug in the short term to see if there's an improvement in symptoms and how patients feel. If you can use a drug safely like flecainide or a class 3 antiarrhythmic drug for a short amount of time, then then we tend to do that. If it's a choice between ablation and amiodarone, particularly in a younger patient, we steer clear of amiodarone and tend to recommend ablation early. The ablation approach that we tend to take for most of our persistent patients is the convergent hybrid approach, so we have a panel of about 400 patients that have been treated that way and the results have been excellent. 

Thomas Deneke, MD: Well, as already said, it really depends on the patient. For this young patient with paroxysmal AF, it really depends on the symptoms. If he has disabling symptoms, I think we're very close to saying, “let's ablate,” because as we all know, that is the most effective way of treating symptoms related to AF. That's a fair choice. Those patients were, by the way, excluded in EAST AFNET. The highly symptomatic patients were not in there. So, I think it's just a matter of what we do if this patient says that every once in a while there is some disturbance in their heart rhythm, but they don't really care. I would discuss openly with the patient that this may lead to further symptoms in the future or that this may lead to persistent AF. But there is not an urge to do anything apart from if he is in need of anticoagulation. So, I would really individualize and break it down to the specific patient. 

Christine Albert, MD: I echo pretty much what everybody has said. I think one of the things that's important is for us to talk about the risks of the drugs, too, because sometimes patients think the ablation has more risks than the drug. If you look at early AF, the recent report that came out after 3 years, there actually was a fair amount of complications over 3 years in people who had drugs pushed to the level of max. So, a lot of times what I'll do is I will discuss both options with the goal of getting somebody into sinus rhythm. If they pick drugs, I would say that I don't really max them out to the point where I would worry about those kinds of complications, and at that point, I might counsel somebody to move over to ablation. But in general, I would offer both as a first-line therapy, because I think we have enough data now that it’s a reasonable thing to do. 

John Mandrola, MD: I agree with all that. But I want to push back on what you said, Hugh. I don't agree. You started your comments by saying that we're convinced that PVI works, and you cited CIRCA-DOSE. But the thing with CIRCA-DOSE, RF versus cryo, there was a 99% reduction in AF burden, but it's extremely low AF burden. So, the absolute reduction was minimal. I think CIRCA-DOSE and all our trials should have a column that has no treatment, because Soren Diederichsen from Copenhagen has shown beautifully, and, Eric, you showed this as one of the most important studies, that a lot of low burden, subclinical, or short duration AF goes away. Dominic presented it. So, I don't think we use enough of Voltaire's approach, right? Voltaire famously said that the art of medicine is humoring the patient until nature cures the patient. So, we don't wait enough. I don't want to restart the whole placebo control / sham control thing, but I do think we need a little more scientific approach to what actually PVI is doing. Furthermore, on EAST AFNET, at 2 years, if you look in the supplement of EAST AFNET, 80% of the rhythm control alarm was in sinus and 60% of the rate control were in sinus. So, you're telling me that 20% delta is going to reduce cardiovascular outcomes. I totally believe it's real, but I don't think it's from maintenance of sinus rhythm. I think it's from all the extra care and interactions from the health care system for the patients in the rhythm control arm, which is an argument for what we do in our AF clinics. 

Hugh Calkins, MD: John, let me ask you a question. What is your view of the safety and efficacy of catheter ablation today? Do you believe it works, and should we be doing it?

John Mandrola, MD: In the clinic, I am far more fearful of flecainide and propafenone than I am of AF ablation. I think one of the greatest advances of AF ablation has been in safety. We've learned so much, we're much better at it, and just like all the panelists, I go to AF ablation much earlier than I used to, especially in symptomatic patients, once I'm sure that they're educated, once I'm sure that they're not fearful and being coerced, and once I'm convinced that we've given risk factor management a good chance. I'm an early ablator.

Hugh Calkins, MD: What about obese patients? Are you one of these EPs that say you have to be 200 pounds or get 10% weight off before I'll let you in the lab, or do you ablate those who have some indiscretions and are unable to lose weight?

John Mandrola, MD: I work in Kentucky, so if I didn’t ablate patients who were overweight or obese, that may be an issue. I work hard on it, and of course, we have table limits and we cannot do those patients, but I don't have any hard and fast rules.

Hugh Calkins, MD: The next thing I wanted to ask the panelists is everyone says is that it works and we have to do it sooner, but the problem I'm seeing is all our EP labs are full and there are wait lists. I hear in England it's like a year to get an AF ablation. I don't know what it is in Europe, but in Baltimore, it's 2-4 months or something like that before you can get access to the EP lab. I'd love to go down the panel and have our panelists comment on, how long is your waiting list? How do we address this problem?

Michael Riley, MD: I'd say that the wait is a problem. Typically, when I see a patient and schedule them for ablation, they may have to wait for 8-10 weeks or so. I'm not sure if that is long or short compared to some of the other panelists. But when we do a hybrid convergent ablation, we typically do a staged procedure, so once the decision is made to pursue convergent, then the patient is referred to the surgeon. Typically, we can get the patient in for part one, the epicardial portion of convergent, pretty quickly, followed in several weeks by the endocardial portion.

Hugh Calkins, MD: How about Europe? 

Thomas Deneke, MD: I think our waiting list is close to 9 months, but I think that's quite fair. So, if a patient is scheduled for AF ablation in the summer and he's still coming there, there is the urge to do it as well. So, we have a waiting time of 3 or 4 months, during which time we can work with the patient on risk factor management or try other options like antiarrhythmic drugs. But out of those patients scheduled, I rarely see patients who do not show up. 

Hugh Calkins, MD: One other question, Tom. In terms of having the benefit of PFA available in your center, how has this changed throughput in terms of how long your procedures take and how many ablations you can do per day? Is that sort of the game changer we're all waiting for? Tell us about the impact.

Thomas Deneke, MD: I have to admit that it's a fantastic tool. We have 2 different options. We have Farapulse and Galvanize Therapeutics, so we have a focal catheter and a multipolar catheter. The Farapulse procedures are shorter, so we can schedule an additional PVI in the day. This has been very helpful in that regard. I think in regard to safety, it has been fantastic as well. So far there have not been any increase in complications. I would still be cautious, but I think it's a good hint into the direction that we are increasing safety, and this is our main point when discussing this with patients. So, if the procedures get safer and safer, I think the choice in regard to PVI will become easier.

Hugh Calkins, MD: Christine, how about on the West Coast?

Christine Albert, MD: I live in LA, and it's interesting, I used to use that time for risk factor management. But I don't see a lot of obese patients. It's really incredible. People are quite motivated to lose weight and to change their lifestyle. So, a lot of times that happens even before I schedule a procedure. Right now, our wait times are not as bad as others. I think it's around 6 weeks, and we are able to do 3 a day, and sometimes 4 if we can. So, I think that we have the throughput right now, but I do think it's a different population than other places in the country.

Hugh Calkins, MD: John, how about you? 

John Mandrola, MD: We don't have a long waiting list, I would say 3 to 5 weeks. I actually think waiting time is okay, because there's time to work on other things like education and risk factor management. 

Hugh Calkins, MD: We have a question: how do you follow AF patients after early diagnosis to ensure they're responding to treatment? Does anyone want to comment on that? Once you diagnose someone with AF, what is your management strategy? How often you see them and follow up? Do you tell them to get an Apple Watch or an AliveCor? What's your follow-up plan now that they've had a first episode of AF? What follow-up do you recommend, or what tools?

Thomas Deneke, MD: It's a tough question for Germany, because we have 2 sectors of the clinics and the patients who are in ambulatory care. First, I would definitely consider and put the patient on anticoagulation if that's needed. More and more patients actually get wearables to detect their AF and this has been working quite well, I have to admit. We're not putting them on any event monitoring implantable loops anymore. We don't do that. In the end, it's more about symptom control and to see what the patient is up for. AF is always the tipoff to start a cardiology diagnostic pathway, and I think that's crucial, so if you can identify any cardiological abnormalities, that's important to know and treat. 

Mark Link, MD: My question is for Thomas. At the time EAST AFNET was going on, there were multiple randomized trials showing that RF or cryoablation decreased the time to first episodes compared to drugs. In the US, we were somewhat astonished that there was such a low use of ablation, both initially and even at 2 years, at 20%. So that's my first question: why was there such a low rate of ablation? My second question is if EAST AFNET was going to be repeated now, what do you think the percentages of ablation at both 0 and 2 years would be?

Thomas Deneke, MD: It’s a very good question, and I don't have a good answer. I would think, first of all, the very symptomatic patients were excluded in EAST AFNET. So those are the patients who actually would go straight for an ablation. That may be the reason why there's only 10%-20% of EAST AFNET patients undergoing AF ablation. That that would be my take on that. When looking into the scenarios in Germany, we're doing about 100,000 AF ablations per year in Germany, so I would not consider this to be a low number, I would think, in regard to the total population. This is this is more than in many other European countries. So that may not reflect the scenario in Germany. When you look into EAST AFNET 5 years ago, I think today we would have a decent percentage of AF ablations in the early rhythm control group at least 20%-25%, most probably even 30 or 35.

Christine Albert, MD: How do you think the age, though, impacted the use of ablation, because the mean age was like 72 or 74? How do you in Europe use older age when you're thinking about whether to go with ablation or drugs? 

Thomas Deneke, MD: Very good question. I mean, I love the younger patients. But the old 70 is the new 80. I really have to admit that we see patients who are 80 or 85 who are very fit and definitely good candidates for AF ablation, most probably even better than the younger population, because their management with antiarrhythmic drugs is very hard since you only have amiodarone. So, I would think even the older patients are those who benefit most from an ablation approach.

Tom Deering, MD: The title of this session is drugs or ablation in AF. But there are 2 other considerations, although they're along those lines. Thomas, you alluded to cardioversion. There is also the pill-in-the-pocket approach, which is admittedly a drug. But those are topics that we oftentimes want to utilize. So how I'd like to ask the panel across the board: do you utilize those approaches, especially in a patient who is compliant and maybe aware of their AF, that's not always the case, or is willing to utilize an app or something to find out. I find we’re using that a lot and many times go far down the road, or sometimes they only go a short period. I use that very frequently if there are no other factors. What do you all think?

Michael Riley, MD: I certainly use pill-in-the-pocket flecainide quite a bit with paroxysmal patients. You know, I think it has to be the right patient. Someone you can depend on, someone who can reliably monitor their rhythm to be able to tell when they're in AF, and someone that you can trust is going to follow up closely. But I use it quite a bit for young, otherwise healthy patients with relatively infrequent episodes of AF.

John Mandrola, MD: It's one of the most common approaches that I use. Actually, if you have someone who has a monthly episode of AF. I don't even use many 1c drugs. I actually want to invent a pill that is blue and has nothing in it, where you can just give it to the patient who has AF, because the time will convert them. We often give a little bit of metoprolol because it just takes the edge off and the AF goes away. So, if patients can be managed in that way, you give them time to address risk factors and it takes away the fear. It's a beautiful strategy. 

Thomas Deneke, MD: Can I answer that? The one thing I would not perform a pill-in-the-pocket approach for a patient who has a one per month episode. I would go more for a rhythm control strategy in the beginning there. But maybe once a year you have these patients, and I think they're ideal candidates for a pill-in-the-pocket. But apart from that, we don't use it that often, because as you said, for the patient, the most fear is related to the next AF episode. They’re fearful of getting into AF again during whatever scenario that may be, at work, during the holidays, etc. So, I think a rhythm control strategy is good. I actually only use beta blockers as pill-in-the-pockets. I don't use any antiarrhythmic drugs. I use cardioversion very frequently. Cardioversion is the ideal tool to identify the symptoms related to AF, and that's where I always use it. 

Mel Scheinman, MD: I think we're all impressed with the results of AF ablation. But after ablation, invariably, if you monitor them, there is some AF. So, my question to the panelists is, when do you intervene with drugs or reablation? What kind of burden do you use? Do you use symptoms? I'd like to get the feel of the panel on that question. 

John Mandrola, MD: It's a very difficult question, because it depends on the patients. I don't have an answer for you, Dr Scheinman. I have to say in recent years, we do a lot less reablation, because I think ablation is working better or doing better. We do a lot. We see a lot less flutters, flutters have forced us into doing more ablations. So, I think it has to be individualized. 

Christine Albert, MD: Where I live, most people will have an Apple Watch, but I also agree that it's very individualized and related to symptoms. It's hard to take somebody back because of one episode or something that was detected on an Apple Watch. But I think we still will routinely, in people who are asymptomatic, do a 2-week monitor, and really look for AF because the reason you did it was because you were trying to get rid of AF. But in general, I think it's individualized, similar to what John said.

Thomas Deneke, MD: But you all agree that if you've done an ablation once, usually these patients would, if they have recurrences, go for a second ablation as well? Having set them on that road, I think you need to go for the second ablation. 

John Mandrola, MD: But it depends, right? 

Sana Al-Khatib, MD: This has been a great discussion. I have 2 questions. The first question is thinking of that asymptomatic patient like we talked about, and I actually believe there are some patients with AF who are asymptomatic. One of the previous panelists raised that question. There are definitely patients who are asymptomatic. You cardiovert them, you restore sinus rhythm, they are now in sinus rhythm and don't feel any different. But is there a role to monitor these people once you keep them in AF with like serial echoes, or any other imaging study, to see if they are having significant remodeling, at which point you may think that intervening would help that patient? Because, as Eric alluded to, a lot of these people are not asymptomatic early on, but once they have all that remodeling, they become symptomatic, and it might be too late at that point if you wait that long. So that's my first question. The second question is, are there any thresholds related to the AF chronicity or the left atrial size beyond which you think that referring the patient for an ablation, if you do ablations, is futile?

Thomas Deneke, MD: Maybe I can start and then hand it over to the others. I would see no clear border for not performing an ablation, at least once. So, if it's a patient with a huge left atrium, all scar, I would say to this patient, “I've done this once, if this does not work, this is not an option really anymore.” The second thing is in regard to the asymptomatic patients, and I'm just sharing the German guidelines on AF management, and I have the role of being part of the rate control arm. I think those are good candidates for rate control. As EAST AFNET indicated, there is not a high chance of these patients to become symptomatic, but if they become symptomatic, then it may be different. But I think rate control in these asymptomatic patients is a good strategy if the patient is really asymptomatic. I've not seen so many patients who are asymptomatic, I have to admit. But they clearly exist.

Hugh Calkins, MD: I think one of the questions is, if you leave them in AF if they are in continuous AF, do you recommend a follow-up echo in a year or 2 years? 

Christine Albert, MD: Yes. It's to be emphasized that the complications sometimes occur years later. If you look at where you started to see the benefit in EAST AFNET—this makes me nervous—it's like 5 years. So, somebody is fine, they have a structurally normal heart, and have asymptomatic AF, and then I see them eventually develop MR and TR, and really remodel. So, I think your question is great. I do yearly echoes, but do we find that, and before we can intervene? So, it is something that I discuss with my patients.

John Mandrola, MD: This is one of the hardest questions in EP, I think. I walk out of the patient room, and the decision to leave an asymptomatic young patient in AF is something I struggle with mightily. Because, on the one hand, you know sinus rhythm is better. Like Eric says, it's for sure better. But, on the other hand, the patient tells you they're fine. They’re playing sports or whatever, they're fine. And then, you're going to put this person who feels fine and tells you they're fine under the potential for esophageal fistulas. So, I don't know what to do. I have done rhythm control in these asymptomatic young patients very reluctantly, and I'm scared. But I don't know the right answer.

Michael Riley, MD: I would reiterate, too, that it's very important to have that discussion with your “asymptomatic” patient, because even if they're asymptomatic now, AF progresses and then when do you have that discussion? Does a patient really want to become permanent at some point in their life? Maybe they will have symptoms later on, and the treatment success rate is much less at that point.

Helmut Pürerfellner, MD: I want to put into the discussion 2 issues that we did not talk about. The first is, if we're talking about early rhythm control, we are talking about the Western world: the United States and Western Europe. We have a very different situation in other parts of the world. In Eastern Europe, for example, there is a shortage of staff, catheters, and EP labs. They are waiting forever. So, I think if we think about what we think is good, it relates at the moment heavily on the economic situation and on where people live. The second thing is, and this is a question to the board, I want to go to the end of the other spectrum, the ones who have had 3 ablations, 78 years of age, and heart failure. I see in my lab that there is an increasing portion of patients where I've put in pacemakers and do AV node ablations, CRT, or conduction system pacing. Is that so in your experience?

John Mandrola, MD: I am. I couldn't agree more, Helmet. Thank you for bringing this up. I know this is an AF conference, and people don't like to talk about pacemakers, but I've been sort of a religious early adopter of conductance system pacing. It's the most beautiful thing I've seen in EP in years. So, when you put in a left bundle branch area pacer in an older patient and you have ablate them, it's like Lazarus—they just rise up. I couldn't agree more. I use that strategy quite often, and there's even a trial, right? 

Hugh Calkins, MD: Helmet, you're right. There are these patients. You get them through one ablation and it comes back, and you do a second one on them. I described it to one patient as the final chapter. One patient recently said, “Don't use the term the final chapter. It's too soon.” But you've tried everything else. They're having a lot of AF, fast rate, AV node ablation and pacemaker, you know, either His or left bundle or BiV. What is the right option? It's not the last chapter, but the next chapter, and it usually gets them out of our AF clinics over to the device clinics. But many patients do well, so we cannot forget that. One last question someone asked online was, when do you graduate a patient from your AF clinic? You've done an ablation and they’re doing well a year later. When do you give them their “diploma” and graduate them from your program? What is your graduation strategy, Mike, or do you never graduate them?

Michael Riley, MD: I think we, as an EP group, continue to follow our patients long term. Usually, our patients are followed both by general cardiologists and EPs. So, if they're doing well, let's say they're a year or 2 out from ablation with no evidence of recurrence, then we usually will see them once a year or so in follow-up. 

Thomas Deneke, MD: Strategically, we do it for 12 months, and that means that we do at least 2 follow-up visits. But if the patient is then good, we lead him out, and if he comes back, we're there. 

Christine Albert, MD: I think it's similar that for that first year where we have a couple of follow-up visits to asymptomatically screen for AF and then it is individualized. Some patients just keep following up with you. Others have cardiologists in the community and follow up with those. As you said, they'll come back and we take care of it.

John Mandrola, MD: I’m the same. If they're complicated patients, we will see them long term. But a lot of times, if they've done well and they're not having AF, we can have them follow up with their primary care or general cardiologist. 

Hugh Calkins, MD: With that, we're out of time and I want to thank our panel for the discussion. It was a very lively discussion. Thank you all.

The transcripts have been edited for clarity and length.