Electrophysiology (EP) is a subspecialty of cardiology that focuses on the evaluation, diagnosis, management and potential cure of abnormal heart rhythms. While EP focuses on the electrical issues of the heart, the specialty also has close interaction with other fields within cardiology and medicine in general. As I tell my patients, I am essentially an “electrician of the heart,” with the heart being a mechanical pump that requires the electrical function to work appropriately.
Beginning decades ago as an area of interest for a group of cardiologists, EP is now a board-certified specialty that requires additional training after completion of a cardiology fellowship. Over the past 40 years, EP has evolved to include therapies that involve the implantation and management of cardiac devices, such as pacemakers, defibrillators and long-term monitors called loop recorders, as well as catheter-based procedures known as ablations, to diagnose and treat certain arrhythmias. Each patient has a unique situation, with a unique history and comorbid conditions, so the treatment approach for two patients with the same diagnosis may differ, underscoring the wide range of options we often have in treating a single type of arrhythmia.
Cardiac arrhythmia issues are fairly common, and chances are that you may know many people with rhythm disorders. The most common type in the adult population is atrial fibrillation (AF), which tends to be more prevalent with age. Indeed, as our population in general ages, the prevalence of AF is rising rapidly, with up to 20 percent of people over 80 affected by the condition.
Other common rhythm disorders include atrial flutter and supraventricular tachycardia, each of which has its own risks and treatment options. Certain rhythm disorders tend to be treated with implanted devices due to the risk of cardiac arrest, including bradycardia (slow heart rate), which may require a pacemaker, and certain types of heart failure, which may require implantation of a defibrillator.
Does an Arrhythmia Require Treatment?
If cardiac arrhythmias are left untreated, consequences can vary greatly. In benign cases, the patient will simply experience symptoms such as palpitations or fatigue. In more significant cases, however, symptoms can impact quality of life and/or functional ability. In severe cases, some potentially devastating outcomes—including heart failure and stroke—can occur if treatment is delayed or avoided. Some of these issues can be addressed with medication therapy initiated and followed by a primary care physician or general cardiologist, without need for EP input, in hopes that a more conservative approach may improve symptoms and prevent complications. If medical therapy proves ineffective, however, proceeding to intervention is often warranted.
In some cases, other factors may lead to an intervention more directly: perhaps no acceptable medical option is available, or the issue is so severe that medical therapy is not expected to improve the condition, or the success rate of intervention is very high.
Typically, more invasive EP procedures (pacemakers, defibrillators, ablations) are indicated only after extensive discussion between the electrophysiologist and patient, having considered both the risks and benefits of such a procedure. Ultimately, as with all important medical decisions, the final treatment decision lies with the patient, once he or she has been fully educated on the available options.
What to Know About EP Procedures
Thankfully, EP procedures generally carry relatively low levels of risk. Depending on the type and expected duration of a procedure, general anesthesia may be used; in other cases, moderate (conscious, or twilight) sedation may be employed. Most procedures require just a single night in the hospital, and patients usually can return to regular activity in about a week for ablations, or two weeks for pacemakers and defibrillators.
At Sentara Martha Jefferson Hospital, a wide range of EP services are offered, including complex catheter ablation procedures, as well as device-based procedures to implant or upgrade pacemakers and defibrillators, or to implant loop recorders. Newer EP technology—also available at Sentara Martha Jefferson—includes highly accurate three-dimensional mapping of arrhythmias for more accurate ablation, offering lower risk to the patient and shorter procedure times, as well as catheters that give constant feedback on the amount of force on the tip, helping to minimize the risk of cardiac injury and other procedural complications.
What Should You Do if You Suspect an Abnormal Heart Rhythm?
First, if you are experiencing symptoms such as palpitations, shortness of breath with exertion or excessive fatigue that is new, or a feeling that you may pass out, you should consult with your primary care physician. If the symptoms are so severe that you feel your safety is at risk, seek emergency care. Arrhythmias often come and go, and if not present on an initial echocardiogram evaluation, it may not be possible to confirm the arrhythmia until it is recorded on longer-term cardiac monitoring. I often tell my patients that arrhythmias are like ninjas: “If you can’t see them, you can’t be sure they were ever there.”
Once an arrhythmia has been documented, discussion of treatment options can begin, and therapy can be initiated. If appropriate, referral to a cardiologist or electrophysiologist can be made to initiate higher-level therapy.