Sleep Apnea Low Heart Rate

2015 Atrial Fibrillation Patient Conference Managing AF Risk Factors Panel

Wilber: Well thank you. This is really,I think, a topic that I look forward to talking to people about and I think more and moreit's assuming increasing importance in how we take care of patients. We're going to tryto do a broad overview. We're going to focus specifically on diabetes, sleep apnea andexercise as 00:00:30 potential risk factors and how they can be modified in our care ofpatients with atrial fibrillation, but we'll try to give your broad overview of some ofthe other topics as well. So although I'm going to mostly talk about obesity today andatrial fibrillation, we'll talk about a couple of other things as well.

There are a variety of risk factors for atrialfibrillation and this was initially, I think, mostly of interest to epidemiologists, peoplewho study how disease, what the prevalence of it is, and how it comes to pass. I thinknow we've really begun to understand that central role, not only in sort of understandingthe disease but really in treating it, and if we don't consider these as we treat patientsthen I think our outcomes are not nearly as good as they might be otherwise. This is the traditional list and I think thereare probably even a few more. I've starred a few of them where I think that the evidencenow is becoming very clear that these are

potentially modifiable and that's really whatI want you to take home today. These aren't static risk factors that cause something andthen there's nothing you can do about it but treat the consequences, but in fact by intervening,both early and late, you have a chance to modify the disease and improve outcomes. What that means for you as patients is thatyou have to participate in your care and that's really something I want to emphasize; andif you're not invited to do so, then you must insist on doing it. Because I think your outcomesfor atrial fibrillation really depend on how you address each of these risk factors asthey apply to you individually.

Just to briefly talk about hypertension; wewon't spend a lot of time. It's certainly important; it's one of the most common riskfactors associated with atrial fibrillation. Somewhere between 60% and 80% of patientswho have atrial fibrillation in large populations studies have at least hypertension as a riskfactor, and by itself may account for the 20% to 25% of the overall risk of new onsetatrial fibrillation. There's some evidence that systolic bloodpressure probably plays a more important role than diastolic blood pressure, but there'sno clear threshold value. When you look in large population studies, each increment insystolic blood pressure is associated with

the increasing risk of atrial fibrillation.There's no sort of magic number necessarily that if you get below, your risk of atrialfibrillation goes away. It's probably reasonable and what I like to use as a therapeutic targetis somewhere around below 13080. What that means is that that's even below the sort oftraditional guidelines for treatment of hypertension, but it's very clear that even mild elevationsof blood pressure within the range of what we would call normal can still confer afibrisk. There's no clear superiority of one drug overanother although the control of atrial fibrillation certainly can improve the symptoms and thefrequency with which you have atrial fibrillation.

It's not clear that any single drug is absolutelybetter. There's some evidence that ACE inhibitors and ARBs, which are drugs that many of youmay be on to treat your hypertension, may be particularly beneficial, particularly whenyou have relatively advanced hypertension with end organ involvement like thickeningof the heart muscle, the left ventricular hypertrophy, as we call it. But there's also evidence that uncontrolledhypertension as you start antiarrhythmic drug treatment and after catheter ablation, ifyou enter into that with poorly controlled blood pressure, in fact, you have much pooreroutcomes than if your blood pressure is controlled.

Podcast 185 Robert Lee Breathing for Performance Focus Freediving

Dave: I'm Dave Asprey with Bulletproof Radio.Today's Cool Fact of the Day is that reading is all about carbon dioxide and it has verylittle to do with oxygen. Air has about 21% oxygen and the body only needs about 5%.Today's guest spoke at the Bulletproof Conference and his name is Robert Lee. Robert's a researchfellow in Law, Science, Technology at Stanford and this is his first time coming on BulletproofRadio. I invited him to speak at the Bulletproof Conference on his topic that you probablyhaven't heard of. It's the art of respiratory hacking. It's about breathing for focus andperformance. You've heard me talking about breathing exercisesand doing things like pranayama or yogic breathing,

but what Robert has done is look at the very,very edges of respiration including things like deep diving. He's looked at the wholespectrum that you can do for breathing and built around that some practices that canhelp you focus and perform better. This is an area where there just isn't enough information,so you're going to learn quite a lot about that.Stress in your mind finds its way into your body and if you can discover how to relaxyour mind by just hacking your breathing, you can turn off that fight or flight response.That will clear the fog. You can focus on mental performance. This is not a typicalBulletproof Radio episode because we're just

diving deep on that. Robert is a true biohackerin that he's done a lot of this because he's just interested in it. You're going to learnsome cool stuff here. Dave: Robert, thank you so much for beinghere with us today. Can you tell us what you're speaking about at the 2014 Bulletproof BiohackingConferenceé Robert Lee: I'm speaking about how to be mindfuland aware of your breathing patterns. That's, for me, based upon my experience as a freediverand a freediving instructor. Dave: Tell us how much control do we haveover our breathingé Robert Lee: Breathing is very interestingin that it's the only physiological function

we have that's both autonomic and voluntary,meaning, digestion for instance is autonomic, so we don't have to think to digest our food.Whereas, let's say, doing a bicep curl is purely voluntary. We have to think activelyto do it. Breathing is at the intersection of both. Normally we don't have to think aboutit, but we can easily stop it whenever we want or speed it up, so in that sense, it'sa very interesting physiological function. Dave: You are a freediver or you were. Canyou tell us about that and how that actually made you aware of your breathingéRobert Lee: Free diving is simply the sport of diving on breathhold, so not using scubaequipment, just taking a deep breath and going

down. Some people do it competitively, tryingto set records for depth, for length of time they hold their breath in the pool. I do thisfor very much in the mode of somebody who's a scuba diver. In other words, I like to beunder water, I like to look at the coral reef and the marine life. Freediving is just anotherway of doing that. One great advantage of free diving, and obviouslyyou don't have as much equipment, but one really great side benefit is dolphins andother marine mammals actually recognize you almost as one of their own, in other words,another airbreathing creature in the water. You can imagine scuba divers they find tobe a little bit alien, but freedivers they

actually welcome almost as one of their communitynow. Under U.S. Law, you're not allowed to approach marine mammals within 100 yards butif they swim up to you, there's really nothing you can do.When we're training in Hawaii and teaching classes, often times we have pods of dolphinscome and swimming around with us and they're very playful with us. I've even had baby dolphins,which are incredibly cute because they're about four or five feet long, and they'reswimming and squeaking and what have you. It's so quiet that you can hear a shrimp cracklingon the reef, because freediving, you're holding your breath. It's utterly quiet. You can hearwhales singing in the background if they happen

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