Addressing Major Knowledge Gaps in Atrial Fibrillation: The Top Five Priorities

Interview With Eric Prystowsky, MD

© 2025 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates.

Interview by Jodie Elrod

Watch as Eric Prystowsky, MD, discusses his presentation at the Western Atrial Fibrillation (AFib) Symposium 2025.

Tell us about your presentation at the Western AFib Symposium 2025. What are the take-home messages you would like viewers to leave with?

Hi, I am Eric Prystowsky, and I am here at Western AFib 2025. I had the pleasure to give the leadoff lecture this morning, and I was asked to give a talk on the topic of where the gaps in knowledge are in AFib. I titled my talk “Three Whys and Two Whats,” and the purpose was to remind the field of some major deficiencies we still have in understanding this disease. 

To begin with, we really do not know why any patient gets AFib. There could be 100 people with the same risk factors, including obesity, hypertension, or diabetes, but only a small percent will actually get AFib. Why does that small percent get AFib? We must delve into that before we can really start to conquer this disease. 

There are also the patients who have AFib who can go months without an episode, and then one night or one day, they suddenly have 2 hours of AFib. They will ask their physician why it happened, and the physician will go through all the questions. Did you drink a lot? Did you do anything unusual? They will say they did nothing different than they had been doing for the last 5 months. So, what that comes down to is a lack of knowledge about the triggers of AFib. 

The third thing that is really important is stroke. We have all these risk factors. The CHA₂DS₂-VASc scoring system is a little better than flipping a coin. Having said that, realizing how important anticoagulation is to prevent strokes, you must also understand that a lot of people taking anticoagulants are having bleeding problems. Now, these are not major gastrointestinal bleeds, but patients will experience bleeds on their arm or leg, see the blotches, and hate it. So, we must prevent strokes, but we also must target people who are really high risk for strokes. 

My other “why” is why a clot forms. It is not just CHA₂DS₂-VASc, it is far more complicated. We need more research. 

Last of all, I talked about the two whats. I asked about what to do for a patient who comes to the EP lab and we find out their veins are closed. That has been studied for years and no one knows. Why does no one know? Because we don’t know anything about non-pulmonary vein triggers. We really don't. We think we might in some papers, but we don't. So, until we understand what non-pulmonary vein etiology of AFib is, we are never going to get to that point. That is going to require research. Finally, what do we do about persistent AFib? Is it really just doing the veins? We know that does not work as well. Again, we need to understand the mechanisms of AFib, and if we can start working in those areas, I think we might be much better off as a field. 

The transcripts have been edited for clarity and length.