In a quaint cabin atop Flagstaff Mountain near Boulder lives 70-year-old Sue Femmer has a clear view of the sprawling Denver metropolis and the Rocky Mountains.

She has an effervescent smile, a warm and friendly energy, a jolly approach to life. She loves to knit, usually for the delight of gifting her creations to others. Femmer greets her guests with coffee and freshly baked bread.

Before she retired, Femmer worked in Boulder Valley School District as a special education professional and, before that, a juvenile probation officer. Her firewood is cut and stacked, porch and walks shoveled and her property has been mitigated for wildfire. Femmer is not at all intimidated by the challenges of mountain living.

Her heart, though, has a much different story, one that would require the expertise of medical professionals she saw through a partnership with UCHealth cardiology and the Boulder Medical Center.

Where it all began

“I was passing out in weird places for no reason, like in the police chief’s office,” Femmer said. “Another time I was walking the Boulder Creek path, and then a few times at the school. … Each one brought me to the hospital.”

Femmer’s primary care doctor looked for common themes among the incidents, and Femmer recalled each time she’d experienced breathing issues. Living at 8,000 feet and working at an elevation even higher during her school years, she figured her “symptoms” were products of her Rocky Mountain lifestyle.

But it was actually heart arrhythmia, a change in the normal sequence of electrical impulses, causing the heart to beat too fast, too slowly or erratically.

“We don’t see that people have worse symptoms (of arrhythmia) at higher altitude, but what we do see is that they feel worse — there is less oxygen, so they tend to be winded,” said Dr. Eric Riles, a clinical cardiac electrophysiologist at UCHealth Heart and Vascular Center – Medical Center of the Rockies.

Needing an alternative to blood thinners

In 2015, about the time she retired from teaching, Femmer was prescribed warfarin, a common blood thinner medication.

With heart arrhythmias, the blood doesn’t pass efficiently through the heart because the top chambers are beating irregularly. Slowing of the blood means clots can form, and those clots account for 25-30% of all strokes, according to Riles.

“We put patients on blood thinners to prevent that,” he said.

Medications are usually the first line of treatment for such heart conditions because they are fairly straightforward and people respond well to them, Riles said.

But on Sept. 28, 2015, Femmer was once again in the hospital, and this time for a cerebral hemorrhage (bleeding inside the brain). She spent more than 10 days in the hospital but recovered without needing surgery. It was clear that they needed to consider an alternative to blood thinners.

Dealing with arrhythmia

On June 18, 2018, shortly after UCHealth partnered with Boulder Medical Center, Femmer’s primary care physician referred her to Dr. Riles.

“Sue had lots of symptoms, palpitations, shortness of breath, and was not feeling well,” Riles said. “She had a history of abnormal heart rhythm and had undergone ablations in 2017 for atrial tachycardia.”

Atrial tachycardia is one type of arrhythmia. Ablation is a treatment in which doctors identify a tiny area of abnormal heart tissue where the arrhythmia originates and cauterize that region to stop the arrhythmia. It’s usually the next line of defense when medication is no longer an option.

Identifying arrhythmias to better treat the condition

Femmer’s previous two sessions of ablation treatment had provided only temporary relief, so when she met Riles, her condition had worsened.

“At that point it was unclear what was causing it — she had arrhythmia, but what type?” Riles said. “We weren’t sure if it was a recurrence of the arrhythmia she had before or something new.”

Cardiologists are able to correlate palpitations and shortness of breath with specific heart conditions. But in order to do this, they must be able to see and hear those often-sporadic symptoms when they examine the patient, which can be difficult.

To capture cardiac symptoms over a longer period of time, patients are often sent home with heart monitors. There are several different monitoring options, both short- and long-term.

“Recording is everything,” Riles said. “Catching it is like fishing. You need to be there at the right time.”

Femmer was hooked up to a long-term monitor that was placed under her skin and records rhythms for up to three years. Doctors download that information and use it in their diagnosis.

Dealing with several heart arrhythmias

There are about a half-dozen arrhythmias, which originate in and affect different locations of the heart, according to Riles. The type and location direct the treatment plan.

Femmer was found to have both AFib and tachycardia.

Doctors started again with medications, but Femmer had various side effects that made her and her care team consider other options.

“We have to talk about the risks and benefits (with the options),” Riles said. “We knew we needed to protect her against stroke with blood thinners, but the cost of bleeding was too high.”

That’s when Riles reached out to his colleague, Dr. Justin Strote.

Team-based approach to cardiology

Riles is part of a specialized cardiology team of almost a dozen UCHealth providers who visit with patients weekly at Boulder Medical Center.

“We have selected a group of people for our team that can provide the spectrum of care for different cardiac conditions,” Riles said. “And through that partnership with (Boulder Medical Center), we can then coordinate care among the other doctors so patients can get advanced care in a small community setting.”

Dr. Justin Strote, an interventional cardiologist, performs transcatheter heart procedures, such as TAVR and the Watchman.

The Watchman option

“When we hear of patients who have been on blood thinners and have some sort of bleeding problem, that raises a red flag for us and makes us concerned for using blood thinners,” Strote said.

For patients on blood thinners, problems with bleeding aren’t just internal. Wounds can bleed profusely, so blood thinners make already risky activities such as rock climbing more dangerous. Patients can bleed from the GI track or have a drop in their blood count that is otherwise unexplained. This causes them to be more prone to dizziness and therefore, falls. Falls can be very serious for someone on blood thinners, especially if they’re like Femmer and don’t have quick access to emergency medical help because of where they live.

However, patients who are at risk for arrythmia-related strokes but need an alternative to blood thinners because of the risk, can often be treated with the Watchman. The procedure is offered at Medical Center of the Rockies, Memorial Hospital Central and University of Colorado Hospital.

“The Watchman gives protection against stroke without the need for blood thinners by reducing that risk of clots,” Strote said, adding that it’s just as effective as warfarin. “Sue is exactly the patient the Watchman was developed for.”

The Watchman procedure

On Nov. 18, 2018, Strote implanted the Watchman device into Femmer’s heart via a minimally invasive technique that uses a catheter, by way of a small puncture into a vein, to deliver the device to the correct location. The Watchman opens, sealing the left atrial appendage.

After surgery, she was put on baby aspirin and spent fewer than 48 hours in the hospital. For the next six weeks, she had to be on blood thinners again while the tissue closes around the Watchman so it can effectively do its job.

“Usually people can tolerate blood thinners short-term,” Strote said of putting Femmer back on the risky medication.

The Watchman doesn’t address arrhythmia, however. It only reduces the risk of stroke caused by arrhythmia. Since the implant, Femmer has had two more ablation therapies, both successful in addressing her different arrhythmias.

And the Watchman has also done its job — likely saving her life on several occasions.

Don’t worry, I have the Watchman

A little over six months out from the Watchman surgery, Femmer had another bleeding problem: an ulcer.

“It was quite fortunate that she wasn’t on blood thinners when that occurred,” Strote said. “If she was, the bleeding from the ulcer would have been significantly worse.”

Femmer said she just wished such advances in heart care would have come sooner.

In early 2016, UCHealth was the first to implant the Watchman in Colorado after its FDA approval. But Femmer can only wonder how such a device — or the other procedures and options offered up by her team of cardiologists — may have been able to benefit her late father and several uncles, who had suffered from similar heart conditions.

“We have so many more options now,” Femmer said. “And UCHealth has got the right people here. It’s so nice to have them at Boulder Medical Center.”