Does every PM patient need an EP (in addition to cardiologist?)

Maybe I'm lucky

by Daedalus - 2022-04-13 23:22:15

So sorry you're going through such annoying and stressful times with your cardiologist.  Mine is awesome and here I thought they all were.  Lucky me?  
My first AFib attack in January and she came on a Sunday night (I'd been in hospital all day) in her street clothes from home.   Introduced herself and prescribed meds and set me up with an appointment a week later.  At that appointment , she covered all my heart questions, unrushed and very thorough.  Set me up with a follow up 2 weeks later to see how meds were doing.  At the second meeting, she freaked at the Bradycardia the Metoprolol was causing and took me off it while keeping the Eliquis.  Three days later and another AFib attack.  Back in ER.  She came and sat bedside and went over the options.  We decided on a PM.  Had that put in a couple days later.  Went perfectly (except for the AFib attack while on operating table prior to surgery...electro cardioversion fixed it and they proceeded).  The following week a follow up with the her and briefly, the Biotronik tech.   She spent lots of time with me.   Then another follow up 2 weeks later to remove tape, etc.  When done, she always asks "Do you have any questions?"  I do and she answers them all.  
Taking Sotalol along with the Eliquis now and so far, so good.  
I'd never heard of an electrophysiologist until this board and thought the cardiologists did it all.  Again, maybe I'm lucky with this one who loves what she does and cares.  
By the way, all my docs are women.  Perhaps that explains my good care.  Over the years I've found they listen better, don't condescend, are patient and responsive.
 
I sure hope you can find a cardiologist who can treat you as you should be treated. 

It Depends

by Marybird - 2022-04-14 01:17:57

....On what the patient's needs are, heartwise.

As you mention, Terry, the EPs are the go to people for malfunctions of the heart's electrical systems, ie, arrhythmias, tachycardias, bradycardias, etc. They're the docs who do ablations to correct or mitigate tachyarrhythmias of all types, implant pacemakers and other cardiac devices, and are experts in reading and interpreting Ekgs, wearable monitor reports and data from implanted cardiac devices. They'd also be the experts in optimizing pacemaker settings for the individual. 

If your cardiac issues are primarily electrical, and you're still going through a lot of adjustments to your pacemaker, and perhaps to medication for arrthymias, you are probably better off with an EP to help you with those. Whether or not you need an interventional ( or general) cardiologist would depend on if you also had coronary artery disease or structural heart disease- these would be addressed by an interventional cardiologist. If you don't, or you have issues an EP will take care of ( such as hypertension) in addition to your pacemaker and electrical issues, you probably don't need another cardiologist.

That said, it doesn't seem to me that there are a lot of EPs around, and most of them are kept hopping with ablations and other procedures, and in some cases reading and interpreting all those zillions of cardiac device reports, so it may be hard to find one to be your go to heart guy.

Many people with pacemakers and electrical issues see interventional cardiologists on a routine basis, and may be referred to an EP if a problem arises best handled by an EP. 

I was referred to an EP in the same practice as the interventional cardiologist I was seeing for tachy-brady arrthymias, and the EP put in a pacemaker,,adjusted my medication and addressed my hypertension. It sounded as though this EP planned to keep following me ( instead of the other cardiologist who referred me to him). He explained everything very well, and made adjustments in my pacemaker settings that have not needed to be changed to this day. Then he left the practice, but he mentioned in my last visit with him that technically I didn't need to keep seeing an EP, that one of the other guys would do. 

The practice hired another EP, and I saw him once, then he left the practice about a year after they hired him. At that point, the interventional cardiologist I had seen before took over my care again- including the pacemaker. I learned this had happened when his office called me on several occasions when they had received alerts for afib from my remote pacemaker monitor. 

I think many interventional cardiologists who manage pacemaker patients depend on their being monitored by a third party monitoring company ( the practice the cardiologist I see belongs to uses CardioNet). These companies collect the remote reports sent to the manufacturer's site, read and interpret the data for each patient and send a completed report to the cardiologist. The cardiology office may have a pacemaker clinic that employs one or more cardiac device technicians, these technicians ( often working with the manufacturer's pacemaker technicians) make needed adjustments in patients' device settings during an in-office device check/interrogation. 

The cardiologist I see is part of a practice of 5 cardiologists ( interventional), with a couple of PAs and a Nurse Practitioner thrown in for good measure. They have some sort of a liason with another practice- three EPs, to whom they refer patients needing EP services. As I understand it, after one followup visit to the EP after a procedure ( say, an ablation or Watchman implant), the patient goes back to his regular cardiologist. 

I couldn't tell you whether it's preferable over the long haul to be managed by an EP or another type of cardiologist. It's worked out well for me with the interventional guy, but my pacemaker issues are pretty much stable, and he manages a lot of afib patients with hypertension medically. I feel confident he'd refer me to an EP, if he thought it was indicated.

But you're just new at this, with a lot of questions and unsettled issues, and it just seems to me that an EP who's willing to spend the time you need to answer those questions, and address your concerns, would be your best bet right now., Down the road, who knows, but in answer to your question, no, not all us pacemaker patients need to be under the continued care of both an EP and a regular cardiologist.

Best of luck to you, Mary

I'm the oppopsite of Mary, sorta

by AgentX86 - 2022-04-14 02:01:03

I have permanent flutter and had an AV ablation to disconnect the top of the heart from the bottom and pacemaker implanted four years ago. Obviously an electrical problem.  I also have coronary heart disease, and had a bypass seven years ago. I obviousy need a cariologist.  My cardiologist is an interventional cardiologist, so I had both. Last summer I had my annual (was down to once a year) appointment with my EP and he fired me. ;-)  He said to come back if I had a problem and that my cardiologist could take care of the normal stuff. Since he is an interventional cardiologist, the does pacemaker implants and other stuff you'd expect an EP to do.  He only sent me to an EP for the attempts at ablations (three) and then the A/V ablation.  If it were a simple pacemaker implant, he would have done it.

The bottom line is that unless something changes, I really don't need an EP. There isn't anything more an EP could do.  Since I  have an interventional cardiologist, who has a device clinic in his practice(s), he can do everything I need.

Remember, EPs are cardiologists first and then have a further residency in electro-physiology. EPs are electricians.  Cardiologists are plumbers.  Interventional cardiologists can work somewhere between the two. They are plumbers who know how to install wiring but not necessarily diagnose blinking lights.

Do you need both? If you have Afib or flutter, probably (maybe).  If you have ischemic heart disease, too, you need both. If the heart disease is causing the electrical problems, an interventional cardiologist is likely all you need. If you have a pacemaker you need someone more than an off-the-shelf cardiologist.

Clear as mud?

Cardiologist or EP? When you are stable, you may not need to see either

by Gemita - 2022-04-14 06:10:46

Terry, all electrophysiologists (EPs) are cardiologists, but not all cardiologists are EPs.

You have already received some good advice.   Many cardiologists in my experience here in the UK are also excellent EPs.  I attend a main London hospital and am seen by a Consultant Cardiologist and Electrophysiologist which makes good sense because 

1. my electrical problems - Atrial Fibrillation (AF) and other tachy arrhythmias - sometimes cause heart failure symptoms that need treating by a good cardiologist and 

2.  any heart problems I get in the future like for example, AF mediated cardiomyopathy, valve disease, ischaemic heart disease can frequently lead to worsening electrical disturbances in any event, so ideally I would want a doctor who is both a specialist cardiologist and an EP and who has considerable experience in both areas.

When my condition is stable, as it is at the moment, I do not need to see my consultant, although I continue to have annual in person pacemaker checks with my cardiologist/EP's technicians and can also transmit data from home at any time if I get troublesome symptoms.  

I hope you find a caring doctor who will listen and help you to understand what is happening.  It can make all the difference to your well being as I well know from my initial experience with an uncaring doctor.  

On our part, we need to understand that our consultants are having to deal with some desperately sick heart patients who need urgent intervention to keep them alive, so they can perhaps be forgiven sometimes for appearing unconcerned or even rude about our difficulties in comparison.  When I attended clinic initially for my arrhythmias prior to receiving a pacemaker for tachy/brady syndrome, the Consultant Cardiologist/EP I saw had just lost a patient during an episode of Ventricular Fibrillation.  He unkindly told me "I want to see something more substantial on your ECG than runs of an atrial tachy arrhythmia".   I came home feeling wounded but I have since come to understand what he meant.  Heart blocks, pauses, falling heart rates, sick sinus problems can all be treated successfully with a pacemaker, medication or other treatments, whereas some conditions like end stage heart failure clearly cannot.

who to see

by new to pace.... - 2022-04-14 08:18:21

it would help if you filled in your profile.

new to pace

who to see

by Tracey_E - 2022-04-14 10:10:53

All practices are different, all patients are different. If your problems are only electrical and you have a pacer, an ep might be a better choice and you may not need both. 

I'm congenital so have had a cardiologist before ep was even a thing. My cardiologist would send me to the ep when it was time for replacement and all monitoring  was through the cardiologist. I switched to an ep that specializes in adult congenital a few years ago. I haven't been back to the cardiologist since because the ep monitors the pacer and all of my heart problems are electrical. As agent said, all ep's are cardiologists first, and cardiologists are the plumbers while ep's are the electricians. As long as I don't have plumbing problems, I can get by with just my ep. 

Cardio/EP

by WazzA - 2022-04-14 11:57:01

My Cardio is also an EP. Generally you see a cardio first to see if you have anything physically wrong with the heart which they would deal with ie faulty valves etc etc. If the diagnosis relates to the electrical system of the heart you will be referred to an EP specialising in the electrical system . Once my Pacemaker was implanted my primary care was handed to the "Pacing Team" at my local hospital where annual checks are done on the PM & it's settings Their findings are recorded & forwarde/still seen by a cardiologist . 

Thank you so much for the replies!

by Mrs.Marcha - 2022-04-14 23:12:22

Thank you so much to each of you who replied. I appreciate the time and thoughtfulness put into each one. After reading your responses, I can tell now that giving more detail upfront would have been helpful. (I was trying to be relatively succinct for what I thought was a pretty general question). However, the responses that came as a result have enlightened me greatly and were just the information I was seeking. I know that things are done differently at various hospital systems, so it helps a lot to know why one might need an EP and/or a cardiologist. And it was a great help to learn that when cardiology offices deal directly with the PM interrogations (and no EP involved), they are likely using a service as Marybird pointed out. That is certainly a question I can ask going forward if I change hospital systems in addition to finding a new cardiologist.

My PM was placed by an EP due to third degree heart block that was found when I wore a 30 day monitor. It took less than 6 days however for the cardiologist’s office to call me about the long pauses and skipped beats they were alerted to by the monitor company (Zoll). Things deteriorated pretty quickly that same day, and that’s when I went to the ER and came home 3 days later with the PM (a shock).

An echocardiogram and nuclear stress test the week before showed a strong healthy heart thankfully (I’m 62). The cardiologist said he wanted to keep an eye on one of the valves (another echo in 6 months) but other than that my issue seems to be mainly electrical. The EP who placed the PM made an appt to see me in a year, so that’s why I was following up with the cardiologist (who I had only seen once, and he ordered all the testing).

I have an appt on Tuesday with a new cardiologist, so my fingers are crossed that he is a good fit. My GP refers a lot of her patients to him, and she thinks highly of him.

Thank you again to all who replied. I feel safer already just knowing that there is a community like this so willing to answer questions & help those of us who are new to all of this. I’m so glad I found the Pacemaker Club!

Terry

with and without

by dwelch - 2022-05-04 01:35:51

I started off with a cardiologist that did it all, did the interrogation, did the surgery, the whole deal, nurse, tech, surgeon, doctor.

Moved to another cardiologist plus surgeon but a nurse or tech did the interrogations (changed jobs, new town).   

Next doc same story.  was an insurance game had to change providers and thus docs.

Been mostly lucky with docs liked all but one.  went back to the second one with the third took a new job out of town and insurance allowed me to go back to the second one.

changed jobs/towns, another doc, did not like this one fired him pretty quick, onto the doc I have now.

35 years of pacing on device number 5 a number of docs.  Some practices, like my first one it is a one stop shop.  I am on the other end of the spectrum now with an EP that I interface with most of the time for day to day stuff.  There are cardiologists in the practice and my very first visit was with one of them but moved on to the EP after that.  The EP does not do the surgery, there is at least a couple in the office that do that, one being the guy you want to see if you are in this part of the country for lead removal.  

I have covered the range of no phone checks to phone checks to lots of phone checks when that office paid for them as the device got close to the new pacers with the new boxes, etc.  From this site it seems that some folks a pacer rep does the interrogations, I have always had a nurse or dedicated tech do them. one time I had an issue (in 34 years) and a tech came in to fix it, other than that just techs and nurses or that first doc that did it himself.

Do you need an EP?  Do you need a honda specialist to change a timing belt or can any trained mechanic do it?  Do you need the pacer rep to run the interrogation machine or can you train a nurse to do it?  It all comes down to your problem, and the skills of the professional despite the title on the door.   Generic cardioligists can have the skills, and there are no doubt EPs out there there dont have experience with some conditions.  Folks like tracey_e and I are unicorns to many practices. Im their only one.  Depends on your condition, etc.

Im happy to hear you are changing docs in that you need to find one you trust, (and then trust the one you find).  If they have the techical skills but not the people/communication skills, I still call that a fail.   Shop around if you can...