Living With AFib: A Conversation with Dr. Nino Isakadze

The most common heart rhythm disorder can be silent, frightening, or somewhere in between. A Johns Hopkins electrophysiologist explains what women should know about atrial fibrillation, and why no one should manage it alone.

High blood pressure is one of the most common risk factors for atrial fibrillation, or AFib. So when participants in IAWH Health's hypertension programs ask about irregular heartbeats, AFib is often the answer they are looking for.

IAWH Health Executive Director Cheryl J. Thompson, MSPH, sat down virtually with Dr. Nino Isakadze, a cardiac electrophysiologist at Johns Hopkins Medicine whose work focuses on improving the lives of people with AFib. Joining the conversation was Sabrina Chau, a public health major and American University Public Health Scholar completing her beyond the classroom practicum with IAWH Health this semester.

The interview has been edited for length and clarity.

Understanding AFib

Sabrina Chau: For someone who has never heard of atrial fibrillation, what is it, and why does it matter?

Dr. Isakadze: Atrial fibrillation is the most common heart rhythm disorder, or arrhythmia. If we live long enough, one in four or five of us will develop it. AFib is associated with a higher risk of stroke, a weakened heart muscle, and heart attack, so identifying and managing it is very important. It is an irregular heart rhythm. Some people have pronounced symptoms that significantly affect their quality of life and their ability to enjoy it. So AFib matters both for serious health outcomes and for how people feel day to day.

IAWH Health: How did atrial fibrillation become your area of focus?

Dr. Isakadze: It started when I was a medicine resident. I worked on a project developing an algorithm to detect AFib with a Samsung wristband. That was before Apple Watches and the other tools we now have for detecting AFib. I found that work fascinating. The more I learned, the more I saw how many things we can do to improve the lives of patients with AFib, and that became my mission.

IAWH Health: Did you always know you wanted to work in medicine?

Dr. Isakadze: I went to medical school in the country of Georgia, in Eastern Europe. It was a six-year program that you enter straight from high school, so I started at 17. I loved physiology in my pre-medical classes. And when I was young, my grandfather had a heart attack while we were at our summer village, two hours from the nearest ambulance. I watched him go through it, and I wanted to be on the other side, able to help. That was my first inspiration.

IAWH Health: For the sake of putting things in plain language, I once heard a cardiologist compare an AFib episode to shaking milk in a jar very fast. If you're not careful, it begins to clump and clot, and treatment is meant to prevent the clumping and clotting that can cause stroke. Is that accurate?

Dr. Isakadze: I love the creativity there. The heart has two top chambers and two bottom chambers. AFib happens in the top chambers, which beat very fast and irregularly. They quiver. Attached to the top left chamber is a small pouch shaped a bit like an earlobe, called the appendage. When the chamber quivers instead of contracting normally, a blood clot can form there. That clot can break loose and travel to the brain, causing a stroke, or to other organs, cutting off their blood flow.

That is why stroke prevention is one of the core pillars of AFib care. With each patient, we calculate stroke risk using a score called CHA₂DS₂-VASc. It accounts for factors such as high blood pressure, a weak heart muscle, age, diabetes, and previous stroke. We weigh that against the risk of bleeding. Most people will need a blood thinner. Those who can't tolerate one may have a procedure to prevent stroke instead. AFib care is highly individualized; there are no general rules.

So yes, you're right. With AFib, we don't want the milk, or the blood, to clump up and cause a stroke.

Women, Symptoms, and Detection

Sabrina Chau: Do women experience AFib differently than men? Are the symptoms, diagnosis, or treatment different?

Dr. Isakadze: Studies show that women tend to be more symptomatic from AFib. It's hard to say whether that is good or bad. It's good that you feel it, because that leads to diagnosis. AFib can be silent, and sometimes the first sign is a stroke, which we want to prevent in every patient.

On the other hand, strong symptoms create a lot of anxiety and uncertainty. AFib comes and goes. You may be planning a trip and not know when the next episode will arrive. AFib that comes and goes is called paroxysmal. When an episode lasts more than seven days, we call it persistent. It usually starts as paroxysmal and can progress to persistent, where it stays on until we intervene.

There are also significant disparities in treatment. Some of the most effective interventions, such as catheter ablation and cardioversion, are performed less often in women than in men.

Sabrina Chau: Some people with AFib have few or no symptoms. How is it discovered, and when should an irregular heartbeat or unusual symptom prompt a medical evaluation?

Dr. Isakadze: Symptoms range across a wide spectrum. Believe it or not, some people have a heart rate of 150 and feel nothing. At the other end, some people know the moment they go into AFib: their heart races, they get short of breath, they feel they might pass out.

The most frequent symptom is actually fatigue. "I feel tired. I can't do things I used to do." Walking from one room to another, or climbing stairs, now leaves them breathless. It doesn't have to feel like your heart is jumping out of your chest.

Detection varies, too. A primary care doctor may notice an irregular pulse at a routine checkup. People with symptoms usually get picked up through follow-up testing. Many of our patients are found to be in AFib during a pre-procedure evaluation, before a colonoscopy, for example.

And now we have wearables and smartwatches. They detect AFib in two ways. Some monitor nearly continuously and send an alert that you may have AFib. That alert is not a diagnosis; you still need a confirmatory test. Others let you record your own 30-second EKG, which can document AFib. If you feel palpitations, you can record a tracing and show it to your doctor.

It is very important not to self-manage. Seek care to confirm the diagnosis. The reading could also be a false positive.

IAWH Health: Is an EKG the only way to confirm AFib?

Dr. Isakadze: We need an actual electrocardiogram tracing. It can come from a wearable, from a 12-lead EKG in the office, or from an ambulatory patch monitor stuck to the chest. An AFib alert alone is not enough. And EKGs from wearables are sometimes unclear, so we may need to confirm with an in-office EKG.

IAWH Health: Our audience is primarily women, who juggle stress and many other demands. How should women think about AFib when they might assume their symptoms are just stress, anxiety, or hormonal changes from menopause?

Dr. Isakadze: As we age, our bodies change, and our risk of AFib goes up. So it's important not to attribute everything to hormones or anxiety. Listen to your body, talk with your primary care doctor, and get evaluated. In some cases a heart monitor will be important, because we don't want to miss a diagnosis.

We also have technology in everyday life. Check whether your pulse is regular or irregular. If you don't have a wearable, pay attention to your heart rate when you check your blood pressure. If it's unusually high, something may be going on.

At the same time, it's important not to fuel anxiety. An AFib episode feels very uncomfortable, but the episode itself is not going to kill you. Knowing what AFib is and how it's managed lowers anxiety and helps you take control of your condition.

Sabrina Chau: How useful are smartwatches and other wearables, and how reliable are they?

Dr. Isakadze: Every time you look, there are more tools that can detect irregularities and help diagnose AFib. We see many patients who were first flagged by their watch. But don't get consumed by it. Constant monitoring creates a lot of anxiety for some people. I often tell patients to check an EKG once a week rather than every day.

The key point is this: if your watch flags a possible arrhythmia, seek care, confirm or rule out the diagnosis, and set a monitoring plan with your physician. These are consumer devices. At least for now, they are not integrated into medical care.

IAWH Health: I have a friend who wears a ring, a watch, and more because she loves to run. It seems like too much data. What would you recommend?

Dr. Isakadze: We research many of these devices, and we're still working out how to integrate them into care. If you bring us data from three monitors, we often don't know what to do with it. Apart from AFib alerts, there are no clinical workflows for all those trends and heart rates. The data isn't integrated into our health records, and it isn't humanly possible for a doctor to review that volume for every patient.

That is where artificial intelligence will come in: triaging, putting deviations into context, and turning them into actionable insights as we learn what these signals mean. For now, choose whatever wearable empowers you to make lifestyle changes, like exercising and living healthier, and ideally one that lets you take an EKG when your heart is racing or monitors for AFib. We can now detect disease early and be proactive about our health. It's a positive direction, but there is still a lot of uncertainty about how to use this technology at its best.

Risk, Treatment, and Taking Control

Sabrina Chau: Who is most at risk for atrial fibrillation?

Dr. Isakadze: Age is the number one risk factor. Over time, normal cells in the heart's upper chambers are replaced by abnormal ones. Other risk factors include excess weight (we usually think of a body mass index above 27), lack of exercise, alcohol, smoking, and high blood pressure. Alcohol consumption is directly associated with increased AFib risk.

For people diagnosed with AFib, lifestyle changes can reduce how often it comes back. Risk factor modification alone is usually not enough; we combine it with other treatments. But it slows AFib's progression and reduces how much AFib people have. Specifically:

• Lose about 10% of body weight.
• Exercise 210 minutes per week, a target that comes from a study of exercise's effects on AFib.
• Control blood pressure.
• Quit smoking.
• Treat sleep apnea, if you have it.
• Cut alcohol to zero, or to no more than three drinks per week.

It's empowering. This is a case where we have strong evidence that lifestyle changes can change the trajectory of the disease.

IAWH Health: You said AFib can "come back." Is it not a permanent condition?

Dr. Isakadze: Some AFib comes and goes, and some stays on. But unfortunately, there is no cure. We have many great tools to manage it, but no single treatment cures it.

We do have strong evidence on treatment. One major study asked: if we restore normal rhythm soon after diagnosis, with medication or a procedure called catheter ablation, do outcomes improve? In catheter ablation, we go inside the heart and deliver energy to eliminate the spots that trigger AFib. The study measured deaths from heart causes, stroke, and hospitalizations for heart failure or heart attack. It was stopped early, after about five years of follow-up, because restoring normal rhythm was more effective at preventing those outcomes.

Another study compared ablation with medication for restoring rhythm. Patients who had ablation were much more likely to stay free of AFib. Together, those results mean we can now offer catheter ablation as a first-line treatment.

At one year, about 70% of people with paroxysmal AFib and 60% with persistent AFib remain free of AFib after ablation. Some people do great after a single ablation. Others need a combination of medication and ablation, or a repeat procedure.

Sabrina Chau: If AFib runs in your family, are you more likely to get it?

Dr. Isakadze: AFib is very common whether or not you have a family history. When we see it before age 45, we think about genetic predisposition and recommend genetic testing. Some genetic factors raise risk for both AFib and certain types of heart failure. But if someone is 75 with AFib, we're not chasing genetics; it's most likely related to aging and other health conditions.

IAWH Health: What is happening at Johns Hopkins around AFib?

Dr. Isakadze: A lot, more than I can cover. Our mission is to improve the lives of patients with AFib. On the clinical side, we just expanded our AFib clinics to five locations. Women and people from underrepresented groups are less likely to receive specialty care. Our goal is quick follow-up. If you're diagnosed in the hospital or the emergency room, we see you right away, explain what AFib is, walk you through treatment options, and start guideline-recommended therapy early, which we know saves lives.

We're also working with community members and partners to raise awareness, so clinicians know they can refer patients to a clinic without six- or twelve-month waits.

On the research side, eligible patients can join clinical trials of the newest treatment technologies. We study how digital health tools, combined with lifestyle and risk factor changes, can improve outcomes after heart procedures. And we're building a digital biobank of wearable data collected between visits, to learn which signals are actionable, which predict the course of disease, and how we can improve care.

What IAWH Health is doing, raising awareness and educating, is very important as well. After an AFib diagnosis, we often hear, "I'm confused." Patients face many treatment options, stroke prevention, and blood thinners all at once. Educational content helps people understand the disease and make informed decisions.

IAWH Health: Our readers range from their mid-20s to their 70s. What would you like to leave with them?

Dr. Isakadze: Don't be afraid to ask around. I heard this from a patient just yesterday. AFib management is a complex decision, and you'll usually be presented with several options.

Talk with others living with AFib. Patient forums such as StopAfib.org are full of shared experiences. People tell me it relieved their anxiety and stress, because clinics often don't cover the emotional side. You've been told you have a condition with no cure, and you never know when the next episode will come.

That emotional side matters. Whether it's a family member, a forum, or another resource, find support. Focusing on your mental health after this diagnosis is important.

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