Palpitations To Atrial Fibrillation: How To Diagnose And Treat Naturally

Joel Kahn, MD, FACC

Thanks so much Doc Fuhrman and yeah, you’re right. There are so many people out there looking at this topic and for solutions that are not standard cardiology approach. So let’s talk about it.

Joel Fuhrman, MD

So we’re talking here about palpitations, irregular heartbeat, PVCs, atrial fibrillations, SVT, all these things that trump a lot of people. You know, and are very prevalent in our population. So help us understand what we’re gonna talking about just ’cause people aren’t gonna know these words right now. Just go through them, what are palpitations? You know SVT, PVCs, afib which will hopefully explain this more.

Joel Kahn, MD, FACC

For sure, and it’s really a miracle that we don’t concentrate on but 100,000 times a day the top the heart squeezes, that’s called your atria. The bottom of the heart soon after squeezes, that’s called your ventricles and then the heart resets and does it again. Perfectly synchronized, optimal function. Just a well-tuned engine to provide all the blood flow through your body at rest, and more challengingly, to provide all the blood flow to your body when you’re physically active. Whether it’s walking, swimming or competing as you did yourself with your long history of competition. Perfect, perfect efficiency but that electrical system, and you know I’ve had the heart in my hands in the operating room, and I’ve been inside the heart through other mechanisms called catheterization, there are electrical portions of the heart but you can’t see them. You’ve gotta do an autopsy to see them but we know from that background they’re there and the top of the heart can spark early. That’s a premature atrial contraction. May be felt, may not be felt. Maybe felt as a thud. The bottom of the heart can spark prematurely. A premature ventricular contraction. Maybe asymptomatic, maybe felt as a thud or a flip flop and of course, if it happens, two, three, four, 10, 20 times in a row, it may be sensed as a racing. All of that we call palpitations. P-A-L-P-I-T-A-T-I-O-N-S, man it’s a sensation and it’s a symptom that a patient will relay to a healthcare provider. Can be very much on the benign side, can be very much potentially serious and that is the art of sorting all that out. It may a clue to just a little poor sleep, a little dehydration, a little excess caffeine but it also may be a clue to something more serious going on. So the number of people that are concerned and ultimately present to the medical office for palpitations could also be dizziness, light headedness. Just a sense of a flip flop in the chest and the standard medical model is here’s a prescription but we try and are talking about natural approaches throughout this summit. So there’s so much that can be done and there’s a lot of technology that’s come into play. I want to show you some of that too.

Joel Fuhrman, MD

Great, terrific. So you think that atrial fibrillation or afib is most common and what do you do, what do you do for a person? How do you evaluate and deal with that?

Joel Kahn, MD, FACC

Yeah and thank you for that question because you know, maybe not the most serious but nearly the most serious alteration of this wonderful synchrony is a particular rhythm called atrial fibrillation. If you remember I said the atria are the top of the heart. So it’s a completely disorganized beating of the top of the heart. Fibrillation is also sometimes called quivering of the heart. What happened to that beautiful synchrony working together for efficiency? It’s gone and that’s one aspect. People that transition from a good rhythm, called sinus rhythm to atrial fibrillation, because the efficiency drops, they may notice. They’re tired, they’re short of breath. They are fatigued going up stairs and they certainly may feel a symptom of fluttering in their chest. But the real concern is that the top of the heart has a little outpouching. It’s called the appendage that will lead to form blood clots and if those blood clots form and break loose, strokes occur. So atrial fibrillation has taken on a mega position in cardiology care around the world because of the risk of stroke and we want to prevent atrial fibrillation. 

All of this is based on making good diagnoses and the diagnostic approach. This is really interesting for the listeners. You know, you would visit a primary care doc and cardiologist. You would maybe have an electrocardiogram, very appropriate. And of course a history and a physical. Usually you’d walk out of there wearing maybe a 24-hour or a 48-hour monitor and if you happened to have your event, your palpitations, your premature atrial contraction on the top or your fibrillation, a diagnosis could be made but very often, and sometimes we can joke, you can guarantee the day you’re wearing the monitor is the day you’re not gonna have a palpitation. So while you know, I’m not a technology freak but we have to bring in and advance a lot and we’ve really now focused on the patient. Very often helping us so much with the diagnosis. So I brought just a couple toys here. But these are medical devices. Anybody can go online, a company I’m not involved with, a company called K-A-R-D-I-A, and buy a device. They’ve just recently changed it from this little metal device to one that looks more like a credit card. If you’re having palpitations at two in the morning and you put your fingers on this device, whether it’s the original version or this new credit card-looking version, your smartphone will show your electrocardiogram. People can take an electrocardiogram in their own home and they can then share that with their medical team. Whether by emailing what they recorded or bringing their smart phone to the office and letting a doctor like me scroll through it and we’re diagnosing all the time, accurately, with home-based devices for under $100. Premature atrial contraction, ventricular contraction. Tachycardias and particularly, atrial fibrillation. For those events that aren’t so frequent because that 24-hour or 48-hour monitor may miss an infrequent rhythm. In fact it usually does. I’ll just show another one. 

This is even a little newer. It’s another company out of California called the Bioheart Strap. Just like the straps you used to wear at the gym to monitor your heart while you were on your elliptical or your treadmill. But this is actually an electrocardiogram strap. It’s also inexpensive, it’s under $200. So it’s available if somebody’s interested. You have an app on your smartphone, you wear this during the day, at night. Maybe at work, maybe during your activities and you can do it day after day after day. It records what’s going on in your heart and saves it and if you’re having symptoms you can then say at two o’clock in the afternoon, I can identify what’s going on. But even if you don’t have symptoms and you scroll through it. You will be able to identify if there were abnormalities. It’s basically a home heart monitoring unit. 

Widely available, transforming cardiology. Bringing the patient, the person with the concern you know, bringing them into involvement in the actual diagnosis and that also applies to treatment. If we are applying certain treatment, we can use these to monitor. I don’t have an example but I have to just say for a minute, the Apple Watch would be the third foundation of home diagnosis, home followup. There literally are research studies going on now. We took a population of people with atrial fibrillation, we gave them Apple Watches and we were able to remove some of the medication from the patients because they had a device that’s fairly accurate at identifying whether there’s symptoms or not that, particularly atrial fibrillation has recurred or has not recurred. So transforming healthcare through wearables like we call them, electric devices. This has really been exciting. Of course a wearable doesn’t make your rhythm go away but it has again, involved a patient in their care. They’ve gotten very interested, they’re much more motivated. But we still try and use natural approaches to identify and quiet the problem of course and its root cause.

Joel Fuhrman, MD

Right, ’cause sometimes, even when these irregular heartbeats, PBCs or afib, sometimes in a person it could be relatively harmless and other people that have them, it could be, be actually serious and that could, there’s a lot of factors that determine whether it’s harmless or serious and a lot of it’s the lifestyle and health of the person too right? So you probably impact that, do. How do you determine that and what do you do for a person? Do you, as supposed to just focus on the arrhythmia, you focus on the whole picture and then you also give some natural approaches to focus on the arrhythmia too?

Joel Kahn, MD, FACC

And you know, it’s always the whole person approach. So the standard cardiology approach is still important. You will have a history and a physical. You need labs, you need to know your potassium, your magnesium. A very thorough thyroid hormone panel because particularly overactive hyperthyroid can be a cause of all these problems, particularly atrial fibrillation. You’ll certainly be offered some kind of heart monitor, 24 hour or 48 hour. Maybe a two-week heart monitor and if you have the problem identified, that’ll make a diagnosis but these other devices can help in the followup. Certainly an echocardiogram, an ultrasound of the heart. Looking for valve problems, looking for cardiac enlargement. Looking for fluid around the heart and looking for the very strength of the heart. Particularly in atrial fibrillation and there is a more advanced echocardiogram that requires hospitalization so you can look down the throat. 

These will be amongst the techniques selected to make that firm diagnosis. I will say there was an old teaching in cardiology that atrial fibrillation affects some people and coronary artery disease affects other people but the two didn’t have much to do with each other. And that has fallen apart a bit with the advance of these heart artery calcium CT scans. I always am concerned if it’s a person age 40 and up and they particularly have atrial fibrillation. We have to ask the question if there’s silent coronary artery disease that’s altering the anatomy of the heart. That’s reflecting an aging and a deterioration and a senility of the heart. So usually do now include those inexpensive, widely-available coronary calcium CT scans. And it depends on the pathology found. There are low risk atrial fibrillation patients and they may not need any particular attention to anticoagulation blood thinning and then there are certainly those that do need standard cardiology care. Still, always still striving for removing the root cause. 

In some it’s caffeine, clearly alcohol can be a heart toxin, triggering all of these palpitations and heart rhythms we mentioned. In others, it doesn’t seem to affect them but in many they’re very sensitive to alcohol intake and really need to eliminate it from their program. I want to focus for just a minute on sleep. When you went to medical school, Dr. Fuhrman and I did, I can remember specifically about a 30-minute lecture on sleep medicine in a four-year medical program and then probably in internal medicine training and cardiology training, no further education on sleep. And it was a rare event that you would really refer somebody for a formal sleep study in an office building or the hospital. 

Many thousands of dollars. Now we know that altered sleep, and particularly sleep apnea and various pathologies, central sleep apnea and peripheral sleep apnea and the rest, that they’re much more common than we thought. And how do we know that? I just want to show this again. This has so altered our practice in my clinic. There are now very reliable home sleep studies that are a few hundred dollars and I know that’s a cost but when we’re talking the standard sleep study can be thousands of dollars. This is a very popular one, made in Israel. Used at all the major medical centers around the world and it’s, basically it’s a watch that you wear on your wrist one night in bed. You have a sensor on your finger that’s full of oxygen monitors, skin temperature monitors, blood vessel waveform monitors and one last electrocardiogram that you put under your pajamas by your heart and at nighttime you hit a button on your smartphone and that starts your home sleep study. And in the morning you hit a button and it ends your home sleep study.

Joel Fuhrman, MD

Wow.

Joel Kahn, MD, FACC

We have diagnosed so many cases of severe sleep apnea in that person coming to us for palpitations.

Joel Fuhrman, MD

And you don’t have to wear one of those horrible masks either.

Joel Kahn, MD, FACC

Well, if you don’t have sleep apnea you don’t. If you are identified with severe sleep apnea, we’ll discuss and usually refer to a sleep doctor but if you’re questioning why do I have fibrillation, why do I have PACs? Why do I have palpitations? You have to you know, talk about of course, all the obvious things. Blood pressure, weight, physical fitness but sleep has really risen to the top. We can make these diagnoses so simply and then we’re still gonna try and apply as many natural approaches as possible. That often will focus on nutritarian diets, healthy, sustained weight loss without yo-yo because so much of sleep pathology is excess weight. Not all, but so much of it is excess weight and then we’re gonna talk about supplements. And supplements that may quiet the heart and provide some benefit as much as or even more so than prescription drugs.

Joel Fuhrman, MD

Now have you seen like, the overuse of prescription medication? Like when people are let’s say, doing a diet but they’re left on blood pressure medications and they don’t need them anymore and their diastolic blood pressure is now too low and maybe they’re not getting adequate diastolic returns of the heart. Could precipitate arrhythmia, have you seen anything? Like the overuse of high blood pressure medications be a cause of atrial fibrillation or arrhythmias?

Joel Kahn, MD, FACC

Yes, and particularly probably diuretic use. Somebody gets on a water pill, very commonly used in the primary care world for somebody with high blood pressure and they come to a clinic like mine or a retreat like yours and they make progress and they lose weight and they are lowering their blood pressure in the proper way. With you know, good mineral support and vitamin support and food-based healthy sustained weight loss in the plant-based world and yet they’re still on their medicine and they actually may be somewhat volume-depleted by their daily diuretic. They may be hypokalemic, low potassium and hypomagnesemic, low of magnesium. So that is usually one of the first things I’ll do is reevaluate the medication, try and eliminate the diuretic and safely lower, because we certainly want people to have a home blood pressure cuff and use it correctly. I’ll lower the medication down but then a lot of people come to me and I’m sure they’ve come to you saying, “You know, doc I don’t want all those medicines. 

“Let’s take a more common, just the PACs, the PBCs.” The spectrum of people, maybe it’s stress, caffeine, poor sleep and the rest. They do not want that prescription drug. We’ll pull out our heart-friendly supplements and we know that many, many people will benefit by some magnesium supplementation which we get through food and our seeds and our nuts and our leafy greens and our crucifers. But sometimes a magnesium chelate like magnesium glycinate, magnesium taurate will be very helpful and these are low cost and generally well-tolerated if there’s healthy kidneys. Certainly co-enzyme Q10. When I have a patient with the more benign form of palpitations in my clinic and we add that combination of one a day co-enzyme Q10, wonderful vegan versions if that’s important to somebody and that’s what I have in my clinic and add.

Joel Fuhrman, MD

But 100, how much CoQ10 do you add? How much magnesium do you add?

Joel Kahn, MD, FACC

I’m pretty aggressive with CoQ10. I carry a vegan version that’s 400 milligrams.

Joel Fuhrman, MD

400, okay.

Joel Kahn, MD, FACC

And then I follow up with a blood level. There is a blood level that’s available. I’m looking for a blood level about two to three. Although there’s really no known toxicity to be higher, but.

Joel Fuhrman, MD

And these are people without, because I know people on statins need more CoQ10, they should be on CoQ10. But you’re saying even people who are not on statins benefit from this, especially if they have arrhythmia?

Joel Kahn, MD, FACC

They really do. And as you know, CoQ10 and magnesium have uses in migraines and uses in blood pressure support, natural support of healthy blood pressure but it’s very effective and if they’re on a beta blocker and they’re tired and a bit depressed, sometimes just that simple introduction to coenzyme Q10 and magnesium will allow them to reduce. See, always being cautious. Always work with your healthcare team, but reduce, sometimes eliminate their beta blocker and they get the same benefit without the side effects. I occasionally have to go a little bit beyond those two. There is a supplement amino acid taurine. T-A-U-R-I-N-E, that’s available. Around 1000 milligram capsule, many, many vegetarian, vegan versions of that capsule that worked very well. In addition to the CoQ10 and magnesium. 

You asked about magnesium, it’s typically around 400 milligrams a day. You can go double that. Magnesium glycinate. You just gotta watch bowel tolerance. Some people will get a bit of a loose bowel and won’t enjoy the experience. Of course it will resolve by reducing or giving them a bit of a break but there’s much that can be done with this kind of root cause. Food-based, alcohol-based, sleep-based, weight-based, blood pressure-based considerations and trying to address that root cause, even if it takes a little bit of time to get the actual trigger of what’s driving the heart to have palpitations and arrhythmia to be eliminated.

Joel Fuhrman, MD

I know if I drew an amino acid profile I would see that most likely in vegans, taurine would usually be most often, amino acid that’s low.

Joel Kahn, MD, FACC

Exactly.

Joel Fuhrman, MD

That they get to be low. So are you saying that a person on a vegan diet who has heart disease who develops arrhythmia, that’s something that should be considered, the taurine could be a factor there?

Joel Kahn, MD, FACC

Yeah, it has been used. The famous cardiologist, Stephen Sinatra introduced the idea of supporting the heart with CoQ10, magnesium. Ribos, but a little lower down the list was taurine and that wasn’t directed at a vegan population but you’re absolutely right in the data you.

Joel Fuhrman, MD

Aren’t you confusing, isn’t Stephen Sinatra the famous singer?

Joel Kahn, MD, FACC

Haha nah, I think we got Frank.

Joel Fuhrman, MD

Or maybe he’s the brother of Frank Sinatra.

Joel Kahn, MD, FACC

They were related, or they are related. Unfortunately.

Joel Fuhrman, MD

Oh, they were related?

Joel Kahn, MD, FACC

Yeah they were related. And.

Joel Fuhrman, MD

Oh wow, oh wow. I was just coming up with a joke but I guess it’s real.

Joel Kahn, MD, FACC

Oh yeah. Unfortunately Dr. Sinatra had an amazing career. We’re talking about him in one of our interviews at this summit so please listen to them all but he passed recently. He has taught so many physicians in this kind of nutritional support and supplemental support could get some people away from being locked into those lifelong prescriptions for palpitations. Now I want to address just one reason people see me so frequently. “Dr. Kahn, I’ve got atrial fibrillation “and my doctor says I need to take these blood thinners “for the rest of my life.”

Joel Fuhrman, MD

Right.

Joel Kahn, MD, FACC

And it used to be warfarin, also known as Coumadin. And as you saw in your practice, the weekly or the monthly blood tests. Advice about maybe avoiding green leafy vegetables. My God, how can you live by avoiding green leafy vegetables? You know, and fortunately now for more than a decade we have newer drugs like XARELTO, Pradaxa, Eliquis. There is, in the world of cardiology, a lot of data about assessing the risk of a person with atrial fibrillation for stroke and there are very high risk people and there are very low risk people and cardiologists are trained to do this even in conventional cardiology. I sometimes disappoint people that come and see me thinking I’m gonna pull some magic herb out of my rabbit hat that can replace their powerful blood thinner because there’s some people that should not do that. That really are at enough risk and the risk is partly, females are more at risk for stroke and atrial fibrillation than males, it’s science. The elderly are significantly more at risk than the younger population. 

Those who’ve already had a stroke, or a mini-stroke, a TIA are at more risk. Diabetes, high blood pressure, the usual risk factors there. So there’s a scoring system and some just can’t be safely advised to come off their medicine. What is evolving and very exciting is there are people that are in fibrillation, out of fibrillation. In and out, paroxysmal fibrillation. That technology of something like a smart Apple Watch is being used in research studies and I think we’ll see it more commonly. Mr. Jones, Mrs. Smith, okay. You’re a little lower risk. You’re not having fibrillation very often or at least at all since we’ve started your CoQ10, your magnesium, your taurine. With your Apple Watch alerting you if you should go back into fibrillation, not perfect but still able to do it. We can take you off your blood thinner and monitor you but those are very carefully selected patients and it is the area of ongoing research right now about can we introduce technology like this to get people off pills? Now I know that’s not very natural but it is still an exciting area of trying to address people. If you’ll.

Joel Fuhrman, MD

Right, there’s still a risk of hemorrhagic stroke from being on the pill too. So you have to weigh that. Do you ever use any kind of natural blood thinner like natto or anything like that? When will the.

Joel Kahn, MD, FACC

Right.

Joel Fuhrman, MD

Use of the in between you know?

Joel Kahn, MD, FACC

That same population that will consult with me and say, “Can I stop my XARELTO and use nattokinase?” Something from an earthworm called lumbrokinase. Sometimes they’ll ask about fish oil or turmeric or vitamin E. And other, mild agents that have blood thinning effect. Unfortunately the data there for that population that’s in fibrillation all the time are that, are significantly in and out of fibrillation but have the older age, the female gender, the previous heart failure, the diabetes. You can’t really, in good conscience, recommend these natural thinners. They do have a role in other situations and some of the coronary artery disease patients, peripheral vascular disease patients, cholesterol patients and all but I’m very cautious about advising somebody about their risk, can be. 

There are still some people that are on warfarin. If you have mitral stenosis, which is pretty rare in the United States, rheumatic fever disease and fibrillation, warfarin is still, unfortunately necessary based on science. So we’re making progress but the bottom line is, it’s just like you teach people. You know, would you be willing to make some changes to get off some of your medication for the more benign spectrum of palpitations? Would you be willing to eat a nutritarian diet and lose weight and increase your natural intake of magnesium and your natural intake of health-supportive amino acids that come from eating healthy foods? Would you be willing to improve your sleep quality by losing weight? So you don’t have to wear that mask at night and people had not heard that these are pathways to success with arrhythmias and palpitations and they are very powerful pathways.

Joel Fuhrman, MD

That sounds great. So it’s a whole portfolio of interventions that collectively put together, can have the person in many cases, resolve even irregular heartbeats.

Joel Kahn, MD, FACC

Absolutely, I’ll give you this is a strange one but a lot of people, and perhaps you.

Joel Fuhrman, MD

And they don’t, by the way. They don’t have to actually eat earthworms right?

Joel Kahn, MD, FACC

No, you have your lumbrokinase as a capsule and it is used a lot around the world.

Joel Fuhrman, MD

I’m sorry, I come up with these stupid jokes. I can’t stop myself.

Joel Kahn, MD, FACC

I know, well we had the prop but we decided not to bring it for talent. I just want to go back to sleep because sleep and arrhythmia, sleep and palpitation, sleep quality and atrial fibrillation are really huge. So it turns out the miracle molecule called nitric oxide is made in our nasal passages. We were taught in med school it’s made in our arteries and taught in med school that be chewing leafy greens.

Joel Fuhrman, MD

Chew better, yeah.

Joel Kahn, MD, FACC

It turns out, if you can train yourself at night to breathe through your nose, you will produce more nitric oxide, better vascular status. It has an impact on rhythm disorders. So if you have severe sleep apnea, diagnosed on a home sleep study or an office sleep study. You’re gonna need to pursue certain pathways. A lot of people are working on shutting their mouth at night and breathing through their nose and there actually is an application on something called mouth taping, very gentle, little tapes that are comfortable and not unsightly. And people all over the world are doing that and seeing benefit and it’s having an impact. Better sleep quality, less burden of palpitation. So it’s something we use here in my clinic, at a very low cost and very safe trial. Do it for a week, do it for two weeks.

Joel Fuhrman, MD

So mouth taping could help a person with something like atrial fibrillation even?

Joel Kahn, MD, FACC

Well, milder and infrequent cases. But certainly the PACs, the PVCs, absolutely.

Joel Fuhrman, MD

Nice.

Joel Kahn, MD, FACC

If we can support their sleep.

Joel Fuhrman, MD

Can you use duct tape?

Joel Kahn, MD, FACC

My.

Joel Fuhrman, MD

Special type of tape.

Joel Kahn, MD, FACC

Yeah, my dentist actually has pictures, you would think he was suggesting duct tape. It’s usually.

Joel Fuhrman, MD

Think a guy in America’s Got Talent could tape their mouth, you know who’s in Vegas now doing this show. He’s got his mouth taped over.

Joel Kahn, MD, FACC

That’s.

Joel Fuhrman, MD

But probably, his heart’s in good shape you know? With no atrial fibrillation.

Joel Kahn, MD, FACC

We’re not suggesting mouth taping your relatives that annoy you, there’s all kinds of potential uses. But actually, if you just go to an online seller and put in mouth tape you’ll see a few different versions.

Joel Fuhrman, MD

Great.

Joel Kahn, MD, FACC

Maybe 20 cents a night, you can actually get that mouth closed and give it a try but again a natural approach to improve your sleep and decrease your arrhythmia. So these are some of the fun and some of the technical, I like showing out some of these toys ’cause they’re transformative in patient care.

Joel Fuhrman, MD

It sounds fantastic. I’m now thinking of getting some of that mouth tape and taping some of my relatives while they’re sleeping.

Joel Kahn, MD, FACC

There you go, there’s no doubt that won’t be popular though.

Joel Fuhrman, MD

I learned a lot here, that’s.

Joel Kahn, MD, FACC

Something I wanted to share with people on this important topic with that caution about blood thinners. I mean.

Joel Fuhrman, MD

Very

Joel Kahn, MD, FACC

Strokes and.

Joel Fuhrman, MD

Very important information. Very good stuff, yeah.

Joel Kahn, MD, FACC

There are some people, just one more technical comment. That are people that should be on blood thinners but either don’t want to or they have a high risk of life. I have a patient who’s a motorcycle racer and he has to be on a blood thinner but if he were to crash on a blood thinner it’d be terrible. So of course he couldn’t retire. So there are now devices going inside the heart, little filter meshes that allow a person to have a screen so that if a blood clot forms it can’t go up to the brain, allowing them to get off of blood thinners. It’s a procedure, it’s expensive, there are complications. Something we didn’t really have 15 years ago. It’s not as simple as eating a beautiful cruciferous salad with a nut-based dressing and some seeds but I just want to let people know that. Because people that are trapped on blood thinners are really searching for alternatives.

Joel Fuhrman, MD

Yeah, yeah fortunately we’ve learned about eating healthily when we’re young so we have ourselves, our families, our loved ones and people we’ve shared this with can avoid the need for invasive medical care and surgeries and heart surgeries and all types of things that you know, we’d prefer to avoid and not to live with the fear of heart disease and you know, it’s so. The confidence it gives people, there’s so much of not having to go to doctors all the time and get all kinds of treatments and you know. I don’t even go to myself.

Joel Kahn, MD, FACC

The last thing I read is that by 2030, 50% of the United States population will be defined as obese by the BMI measurement and we’re just gonna see more arrhythmia and particularly more atrial fibrillation and more medication and more procedures and we have that opportunity that you’re teaching and have taught for decades and I’m trying my best to also teach and the summit is all about. So I think we’re gonna do some good for people.

Joel Fuhrman, MD

Terrific, so thanks again Dr. Kahn. What a pleasure to be working together on this, so.

Joel Kahn, MD, FACC

Thank you so much. I agree Dr. Fuhrman, thank you.