Interview With John D. Day, MD, FHRS

DOI: 10.19102/icrm.2015.060906

ANGELINA WAGNER

Editor-in-Chief

Introduction

Major developments are on the horizon for the field of electrophysiology and patient care. While new developments and research are being conducted, we speak with Dr. John D. Day about patient education and new treatment results beyond device therapies.

Dr. John D. Day is a practicing electrophysiologist at Intermountain Heart Rhythm Specialists in Salt Lake City, Utah. He leads the integrated EP group which includes multiple hospitals through Intermountain Health Care. Also, he serves as President of the Heart Rhythm Society, an international non-profit organization with more than 6,000 physician members in more than 70 countries. Dr. John D. Day has also served as the Founding Editor for the Journal of Innovations in Cardiac Rhythm Management. He specializes in the treatment of atrial fibrillation, pacemakers, implantable defibrillators, and catheter ablation procedures.

As a pioneer in the field of electrophysiology, he holds a patent on technology that allows physicians the ability to map the source of atrial fibrillation three-dimensionally. His research and colleagues demonstrated in 2010, how catheter ablation can reverse the risk of developing Alzheimer’s. Dr. John D. Day has appeared on NBC, ABC, CBS and Fox affiliates as a health expert.

We speak with Dr. John D. Day, Director of Intermountain Hearth Rhythm Specialists in Salt Lake City, Utah, about the new research and developments being made to atrial fibrillation.

Wagner: What new developments and research are being conducted at Intermountain Medical Center Heart Institute?

Day: There are a number of things that we’ve been looking at. For example, we’ve long been fascinated with new mapping strategies for atrial fibrillation. The goal has been to see the source of atrial fibrillation or these atrial fibrillation drivers. Another area where people have come to follow our work is through our efforts on maintaining cognitive function with atrial fibrillation. Our goal here has been to prevent dementia and maximize the cognitive function despite having atrial fibrillation. Then the third area we have been interested in is looking at lifestyle interventions, including weight loss, as a way to prevent and reverse atrial fibrillation.

Wagner: What lifestyle interventions are being seen with this research?

Day: Thanks to the great work by Dr. Prash Sanders and colleagues, the EP field is now very much aware of the profound effects of lifestyle interventions in treating atrial fibrillation. Atrial fibrillation used to be viewed as something that was inevitable, that there wasn’t much you could do about it once you got it. Now we know that close to half of the cases can be reversed, without drugs or ablations, with dramatic lifestyle changes including weight loss. Even if these lifestyle changes don’t completely reverse atrial fibrillation, we know that these positive changes can dramatically increase the effectiveness of our medications and ablation procedures.

Wagner: A study at Intermountain Medical Center Heart Institute talked about how heart patients using antiplatelet meds could have greater risk of dementia. How have these risks been evaluated within that study?

Day: We have published a number of studies on this, and more studies will be coming soon. There are three aspects that we have found in our research; First, excessive anticoagulation appears to increase the dementia risk. This is likely through a process of cerebral microbleeds. Second, inadequate anticoagulation also seems to increase the dementia risk. Lastly, new research from our center suggests that the NOACs may be much more effective at preventing dementia than warfarin.

Wagner: How has cranial imaging and genetic markers furthering prospective studies, and finding safer anticoagulation drugs for patients?

Day: Genetic markers have been very important in predicting the response to warfarin. This is something that we have also seen from the genetic work at our center. We have also been fascinated by the use of cranial imaging as a way to identify dementia, microbleeds, etc. in our atrial fibrillation patients.

Wagner: What key strategies could you give on developing and maintaining a thriving AF practice?

Day: The most important thing in developing a great atrial fibrillation program is to commit to your center. You need a dedicated team to make this work. An atrial fibrillation program is not something you can do part time.

Once you have a fully committed program, the key to making it successful goes back to the “3 A’s.” These three A’s are “Able, Affable, and Available.”

For “Able” this means that you and your team have to stay up to date. You need to use the latest techniques. You need to know everything about atrial fibrillation. For “Affable” this means you need to get along well with your team, referring physicians, and patients. “Available” means that you or your program are always available to patients and referring physicians. At the end of the day these “3 A’s” are the key to building any successful medical practice or program.

Wagner: What key experiences have you encountered as president of the Heart Rhythm Society?

Day: When I first began my service as President, the months of May and June were incredibly busy as we were struggling with challenges from the American Board of Internal Medicine (ABIM) regarding their Maintenance of Certification (MOC) program. Fortunately, things have stabilized somewhat. Having said this, our goal is to continue to keep the pressure up, as high as possible, on the ABIM for ongoing changes as well as to evaluate possible alternatives to the ABIM.

The other major challenges, and these are good problems to have, is how do we find meaningful ways for the hundreds of members that we have who want to serve but have not yet had an opportunity to do so, and how to engage more deeply with our international colleagues. To meet these challenges, we have ramped up our Heart Rhythm Advisory Board and have created Communities of Practice where people can get involved and make meaningful contributions to the EP field. On the international front, we have dramatically increased joint symposia and international travel to meet the needs of our international members for more face-to-face interaction.

Wagner: You and your wife led a research team investigating the health and longevity of China’s Longevity Village. What experiences and lessons will be shared in your upcoming book in 2016?

Day: This has been something that really came quite unexpectedly. A few years ago I hit some health problems in my own life with an autoimmune disease, eosinophilic esophagitis, hypertension, high cholesterol and other challenges. For those that know me, I regularly travel to China and give EP presentations there in Chinese. Through my close interactions with our Chinese colleagues, they shared with us the existence of a small, mountainous village that was cut off from the rest of China and the world.

The amazing thing is that the people of this small village just did not seem to get cardiovascular disease, dementia, cancer or the other diseases of aging. Over our study of these people, including genetic analysis, we have concluded that the environmental and lifestyle factors of this village allowed this health miracle to occur.

When we first shared our findings with the cardiology community, many of our colleagues encouraged us to write a book to share our findings. One thing led to another and we ended up selling our book to Harper Collins with a planned publication date in late 2016. The exciting thing is that the same thing that we learned from our research is the same thing that can be very effective in treating atrial fibrillation.

Wagner: As a pioneer in the field of electrophysiology, what have been your main areas of patient education?

Day: Patient education is something that is near and dear to my heart, and it’s something that I’ve struggled with because of the time demands of a busy EP practice. To try and find the time to educate our patients on atrial fibrillation, as well as how to engineer a healthy lifestyle, we created a blog, weekly newsletter, local TV segments, and a social medial presence. In other words, we have used these methods as a way to educate patients. Our patients love the weekly newsletter and have made significant lifestyle changes through these ongoing teaching opportunities.

Wagner: Has your newsletter and blog been reaching a wider audience beyond just your patients?

Day: The surprising thing is while we started this for our patients, we now have tens of thousands of people, throughout the world, who are now following the blog, subscribing to the newsletter, or following through social media. The more we can help people to prevent or reverse cardiovascular disease the better. As you know, at least 80% of what we see everyday in our EP practices is totally preventable with healthy lifestyles.

Wagner: What treatment results have you seen from being able to map the source of atrial fibrillation three-dimensionally?

Day: We are still in the early stages of this technology. As mentioned, the goal is to see the source of atrial fibrillation or the atrial fibrillation drivers. To date, we have had to do this tediously “point by point” to differentiate near-field from far-field atrial fibrillation signals. As we know, just looking at the fastest or most complex electrograms doesn’t work. The key is to separate out near-field from far-field signals.

We are currently working on developing software that will help us with this process. The signal is there, we just have to separate it out from all of the “noise.”

Wagner: What has been the most interesting advancement in the field of electrophysiology?

Day: One of the reasons why I went into electrophysiology is because of all the really interesting technology we have in this field. If you think about it, it really is quite amazing. We can three-dimensionally map out the sources of arrhythmias and we will soon be able to do it reliably with atrial fibrillation. We now have left atrial appendage closure devices as well as wireless pacemakers and this will soon extend to ICDs and CRT devices. Perhaps we may even someday have biologic pacemakers.

However, despite all of this high tech stuff, we can’t forget the human element or the human touch. We can’t let all of this technology, or our electronic medical record systems, get in the way of truly connecting with our patients. High tech will only get us so far. We must have the human touch to truly help our patients and change their lives in a positive way.

Wagner: What major developments do you see on the horizon that will impact the field and patient care in EP?

Day: As mentioned, the key to atrial fibrillation is to see the source. We will get there as this field is advancing quickly. We cannot do the “shotgun” atrial fibrillation approach. We need to identify and treat the source without extensive collateral damage with our ablation procedures.

While the wireless pacemakers are great, but the real goal would be a biologic solution. Whether this is through the biologic pacemaker or genetic manipulation to change how the heart beats at the most fundamental level.

Lastly, we need a better approach to anticoagulation for atrial fibrillation. Once again, the “shotgun” approach carries too much risk. We have to focus our anticoagulation efforts. Whether this is through left atrial appendage approaches, “PRN” anticoagulation based on home detection systems of atrial fibrillation, or more localized pharmacological approaches, we must do something. It is too hazardous to our patients to anticoagulate the entire body when our focus is really just the left atrial appendage.