Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.
From the OHSU Knight Cancer Institute
Babak Nazer, M.D.
Dr. Nazer specializes in cardiac arrhythmias, with advanced training in cardiac electrophysiology. He is assistant professor of medicine and biomedical engineering at OHSU and is board certified in cardiology, internal medicine, and clinical cardiac electrophysiology.
As a primary care provider, you likely have patients with ventricular arrhythmias. These disorders fall into three main categories: idiopathic arrhythmias in patients with structurally normal hearts, VAs with structural cardiac disease due to a previous myocardial infarction, non-ischemic cardiomyopathy or congenital condition; and genetic arrhythmia syndromes.
Considerations for patients with VAs
Most patients with structural VAs have implanted cardioverter defibrillators, or ICDs. These devices are a mixed blessing. When they work as intended, they can save lives, but experiencing a shock commonly leads to anxiety, depression, or both. Frequent ICD therapies are also associated with increased hospitalization rates.
Amiodarone – a familiar drug with toxic potential
Amiodarone was used to treat arrhythmias even before its 1985 approval by the U.S. Food and Drug Administration. This drug is widely used, yet clinicians must remain mindful of its short-term and long-term toxicity to the lungs, liver, thyroid, eyes, and skin. Nonetheless, many patients take it regularly, for many years and at increasing doses. This trajectory indicates poor rhythm control. Typically, patients who suffer ICD shocks despite amiodarone, or do not tolerate it, are candidates for catheter ablation.
Advances in treating VAs
Cardiac ablation has long been an option for a subset of patients with ventricular arrhythmias to reduce the frequency of ICD shocks and the side effects of antiarrhythmic drugs. Newer approaches include epicardial and hybrid surgical ablation. At OHSU, we also offer bipolar ablation on an investigational basis and are non-invasive radiation therapy for arrhythmias.
Patients admitted on an acute basis with ICD shocks may be treated with anti-sympathetic stellate ganglion blocks. We place a catheter in the neck near the stellate ganglion and infuse lidocaine-type agents to counteract adrenaline and rapidly decrease the burden of abnormal rhythm. Patients cannot return home with the catheter, so the ganglion block is often a bridge to ablation or surgical sympathectomy.
More lasting than ganglion block, sympathectomy is a new application of a treatment used for some time to treat long QT syndrome and hyperhidrosis. Typically, the surgeon removes the first two or three of the six ganglia (T-1 through T-2 or T-3) inside the ribcage with a thoracoscope or small thoracotomy.
Treating the mind as well as the heart — a first-of-its-kind clinic
There is a gap in traditional arrhythmia care. Most programs effectively treat the actual arrhythmia but lack the resources to lessen anxiety and depression from past shocks, risk of future shocks and associated conditions. To bridge this gap, we established the new OHSU Multidisciplinary Ventricular Arrhythmia Program — a combined inpatient-outpatient service that aims to provide truly comprehensive care, including for psychological needs.
Our program has one of the few psychologists in the country specializing exclusively in cardiac care. Adrienne Kovacs, Ph.D., has extensive experience caring for people with heart disease and ICDs. Initial referrals for psychological care resulted in remarkable improvements in mood, anxiety, treatment adherence and capacity to engage in care. Subsequently, Drs. Nazer and Kovacs co-founded the OHSU Multidisciplinary Ventricular Arrhythmia Program to provide psychological care to VA and ICD patients on a routine, longitudinal basis.
Each visit includes ICD interrogation, meeting with an electrophysiologist and counseling with Dr. Kovacs. Patients also meet as needed with specialists in heart failure, adult congenital heart disease or hypertrophic cardiomyopathy, as patients with VAs often have these underlying conditions. Finally, clinical decisions utilize a shared decision-making model with multidisciplinary provider input.
Who benefits from specialty care?
- Any patient who has a defibrillator and has received shocks.
- Any patient with an ICD who is having difficulty adjusting to the device or underlying heart condition.
- Patients exhibiting avoidance behavior – for example, a patient who survived a cardiac arrest or received ICD shocks who avoids the location, activity or circumstances from the time of the arrest or shock.
- Patients who have had ablation but need a more advanced procedure, whether epicardial, surgical, sympathetic or potentially investigational.
The OHSU Multidisciplinary Ventricular Arrhythmia Program provides comprehensive care, including for the psychological aspects of heart disease and treatment.
If you have questions or would like to refer a patient for evaluation, please call the OHSU Physician Advice and Referral Service at 503-494-4567.