Cardiology and Electrophysiology

Featuring: Evan Diamantakos
In the United States, heart disease is the leading cause of death for most racial and ethnic groups, contributing to about a fourth of US deaths every year. Every 40 seconds, someone in the US has a heart attack.

While a cardiologist is equipped to deal with most cardiovascular disease, sometimes the input of a cardiovascular subspecialist is required. Electrophysiology is one such subspecialty.

An electrophysiologist, also known as a cardiac electrophysiologist or cardiac EP, is a cardiologist who focuses on testing for and treating problems involving irregular heart rhythms, also known as arrhythmias. They examine your heart's electrical system, which sends an electrical signal through your cells in order to regulate heart rate and rhythm.


Evangelos "Evan" Diamantakos, DO, is Board Certified in Internal Medicine and Cardiology, and Board Eligible in Cardiac Electrophysiology at Eisenhower Desert Cardiology Center in Rancho Mirage, California.

After medical school, Dr. Diamantakos completed a residency program in Internal Medicine, as well as a fellowship program in General Cardiology at McLaren Macomb Hospital in Mount Clemens, Michigan. He then completed a fellowship in Clinical Cardiac Electrophysiology at Ronald Reagan UCLA Medical Center in Los Angeles. Most recently, he was a clinical cardiac electrophysiologist at Loma Linda University Medical Center.

Dr. Diamantakos decided to pursue a career in medicine after his grandfather passed when he was in 8th grade. "My grandfather came back to the States (from Greece) after being diagnosed with cancer for his care. My parents worked full-time and I became his primary caregiver at a young age. He was my inspiration and motivation in becoming a physician," states Dr. Diamantakos. During medical school, Dr. Diamantakos had many interests, but he pursued Cardiology due to its complexity, and the willingness of patients to be proactive in their care.

"When it comes to patient care, establishing a good rapport with my patients is essential for a trusting patient-physician relationship," states Dr. Diamantakos. "Cardiac patients come to discuss vulnerable and overwhelming aspects of their care and need to depend on and have confidence in their physician. Mutual respect is very important, and I encourage my patients to be active participants in their care. In turn, my role is to provide them comfort, reassurance and quality up-to-date information on treatments that would benefit them so they can understand their options and make sound medical decisions with which they are comfortable."


Prakash Chandran (Host): We often associate a fluttering heartbeat with feelings of being in love. Other times, our heart beats rapidly because we're frightened or watching a crazy movie. And while everyone experiences skipping a beat on occasion, if you endure these episodes where your hearts a flutter for no apparent reason, it might be time for electrophysiology. We're going to learn more about it today with Dr. Evan Diamantakos, Cardiologist and Specialist in Electrophysiology at Eisenhower Health. This is Living Well with Eisenhower Health. My name is Prakash Chandran . So first of all, Dr. Diamantakos, it's really great to have you here today. I'd love to get started by understanding the basics. What exactly is electrophysiology?

Evan Diamantakos, DO (Guest): Sure, thanks for having me on on this podcast. Electrophysiology in it's basic definition is the study of the electrical system of the heart. And as you alluded, deals with many different heart arrhythmias, primarily fast rhythms that we deal with as well as even slow rhythms and the intricacies of our field focus in on those conduction system issues. And we try and help our patients as best as we can when they come to us complaining of either low or fast heart rate.

Host: Okay. Understood. So, am I correct in saying that an electrophysiologist is different than a cardiologist?

Dr. Diamantakos: Electrophysiology itself is the subspecialty within cardiology. So, all electrophysiologists have to undergo a Cardiology Fellowship, which is three years of training. And for electrophysiology, particularly the year that I started training in 2017, it became a two-year subspecialty fellowship. And that allowed us to learn more in depth, the intricacies of the electrical system and how to better manage our patients. So, our foundation lies in cardiology and the extra training that we do specifically hones in on the electrical system.

Host: Okay, just to clarify. So, you are a cardiologist first and then you undergo two years of specialty training to become an electrophysiologist. Is that right?

Dr. Diamantakos: That's correct? That's correct.

Host: Okay. So we're talking specifically about electrophysiology and I know that there is something called an electrophysiological study. So talk a little bit about what it is and what it measures.

Dr. Diamantakos: Sure. For patients who need an electrophysiology study, we bring them to our ology lab and with different types of sedation that can be deep sedation or conscious sedation, also known as Twilight. We place catheters through the veins of the leg, into the heart and primarily into the right side of the heart where our electrical system resides. Now it obviously has different branches from the right to the left side.

But primarily most of the work is done in the top chamber of the heart on the right at - also known as the right atrium and the bottom chamber of the heart known as the right ventricle. I kind of fasten it to being a puppeteer, so to speak where we can electrically stimulate the heart through these catheters and make the rhythms go fast.

And if we create a rhythm that is clinical for the patient or the reason that brought them to see us, then we can learn more about it by altering it's conduction mechanism and understanding how it's affecting the patient. And if necessary, proceed with what's called an ablation, which is a cauterizing procedure to eliminate the circuit that's allowing the arrhythmia to occur and hopefully free the patient from their arrhythmia.

Host: Okay. So, before we get into that specific procedure, I want to understand some of the conditions that cause a patient to actually come in and get an EP study to begin with. So, maybe talk about that broadly.

Dr. Diamantakos: Sure. So, the arrhythmias oftentimes are grouped into what we call supraventricular. So, those would be rhythms that come from the top chambers of the heart or the atrial chambers. And then there's another group of arrhythmias that we deal with called ventricular arrhythmias. And those tend to be arrhythmias that originate from the bottom chambers of the heart.

And so oftentimes those rhythms can be in patients who have structurally normal hearts, which means their heart function is squeezing normal. And other times it can be in patients who have weakened heart muscle, and the electrical study that we do, depending on what the presenting rhythm is or what the patients come to us in the clinic for, then allows us and guides us in our electrical study to focus in on those particular chambers, more thoroughly to try and elicit those heart rhythms. So, oftentimes they'll come to us complaining of palpitations, fluttering, skipped heartbeats, even very rapid heartbeats that may potentially cause them to feel lightheaded, dizzy, or even pass out. And those clinical symptoms will help clue us into the rhythms that we may encounter during the electrical study.

Host: Okay. So just for, as a lay person, when we're talking about a heart arrhythmia, that's kind of like the fluttering or the skipping of the beat sensation, is that correct?

Dr. Diamantakos: Yeah, that's a great question. Yeah. So, oftentimes patients can come to us complaining of fluttering or skipped heartbeats, and that can be an arrhythmia. They may come to us let us know that they're feeling rapid heartbeats, and that can also be termed an arrhythmia as well. I think, as electrophysiologists, what we try and tease out is, really identify with even heart monitors as an outpatient, what the true definition for that particular patient is for their fluttering. And that can just be an extra skipped beat here or there, or it can be a true ra - heart rate that's causing them problems. So, I think the term arrhythmia kind of encompasses a lot of different things and it really is tailored to the patient on what their symptoms are and what we may find on further investigative studies we do in the clinic.

Host: Okay, understood. So, I've heard of atrial fibrillation before. I know that my Apple watch can measure for it. Is that a subset of a heart arrhythmia or is that something else entirely?

Dr. Diamantakos: No, that's a great question. It is a subset of the super ventricular arrhythmias, as I mentioned. So, it's an upper chamber heart arrhythmia, primarily confined to the left atrium, which is the top left chamber of the heart. And it's basically tissue that is irritable. Tissue, actually that we are all born with. We call them pulmonary sleeves. And they're an extension of our heart, as it grows from an embryo to adulthood that can trigger the rhythm to happen. And atrial fibrillation is one of the most common arrhythmias that we deal with. And it actually is an arrhythmia of patients who are elderly and we tend to see it more in our 70 to even 80 year old population.

And so it is one of the major rhythms that we treat both as cardiologists and as electrophysiologists. When patients come to us and say, we have palpitations that tends to oftentimes be their description for atrial fibrillation.

Host: Okay, understood. So, I want to dive a little bit deeper into maybe the specific tests and the type of treatments that you do as an electrophysiologist. You know, you talked about I think it was the ablation, which is the cauterization of a circuit. What is maybe like the first line set of tests and treatments that you do before it gets to that.

Dr. Diamantakos: Yeah. So, as patients come to us as far as being referred to electrophysiology, our general cardiologists have, may have already done all the work. And if they haven't, usually what that work would entail for us to do is get a baseline EKG. See what their current heart rhythm is doing. And if there's any abnormalities that might point us towards patient's having arrhythmia and following that will do what you use actually, it called an event monitor, sometimes also known as a Holter monitor, and those can range from 24-hour monitors all the way up to 30 days, and in between, be 48-hour monitors, seven day or 14 days. And that allows us to get an idea of what patients may be experiencing on a day to day basis.

It also gives autonomy to the patient to be able to record the palpitation or fluttering that they're feeling, which would give us insight and follow up to try and correlate their symptom with potentially a heart arrhythmia on the monitor. Basic lab work is usually done to rule out some reversible causes like that for example, thyroid conditions, or even low blood counts, like anemia can cause fluttering palpitations, or even fast heart rates. And then depending on what we find. That would then trigger us to do an electrical study for patients who have circuit heart arrhythmias, where if it's safe to ablate or cauterize the tissue, we would do so obviously without causing harm to the patient. Our more complex heart rhythms like atrial fibrillation or our ventricular arrhythmias tend to be a little bit more detailed and lengthy in procedure time, roughly running around three hours worth of identifying circuits, what we call triggers or areas of the heart that can make the rhythm happen and trying to get the best result for the patient, obviously without causing harm.

Host: Okay. That's all good to know. One of the things that I wanted to ask you about is I definitely have some friends, one of them, I play pickup basketball with and you know, occasionally he'll have heart palpitations and he just kind of ignores it. He's like yeah, I just get that every so often. What is the risk of not addressing one of these heart arrhythmias and just letting it persist for years and years like what, what can happen to someone if they do that?

Dr. Diamantakos: Yeah, that's a great question. So, you know, you always worry or at least hear about in the news, you know, an athlete who suddenly collapsed while playing sports. And you always worry about what congenital and structural issues the heart may have either from birth that now has manifested either that as a teen, college or even professional sports.

And so whenever I hear of a athlete or somebody who's playing recreational sports, complaining of palpitations when they're active, it for me, raises a red flag. And I think for the electrophysiology community, as physicians, raises flags for us, I spend it should be at least addressed. Whether that's a initial appointment to make sure that the EKG is normal. An ultrasound of the heart to make sure that the structure is of the heart is normal. And oftentimes we like to recreate what that rhythm might be or what palpitation they might be feeling with activity. So, we'll actually have in a closed condition run on a treadmill for us and on a treadmill, we can monitor EKGs in real time.

And if there's an extra beat in the heart that occurs while running or many multiple beats that occur while somebody is running on a treadmill, that connects with what they were feeling when they were playing their recreational sport, then that can give us insight into stratifying the risk of what that arrhythmia or what that extra beat means for each patient.

Host: Understood. And, you know, as I hear you talk, I can't help but wonder if there are ways that we can all be proactive about our heart health, especially when it comes to these electrical systems and just be really proactive about things, so we don't suffer some of the conditions that you're talking about later in life, or even sooner.

Dr. Diamantakos: Yeah. So I think one of the best ways is, and I always preach this to even, you know, residents and fellows, that you should always trust what a patient has to say, because they know their body the best. And I think when patients don't feel well, they should be free to notify us. And sometimes they aren't, you know, and I tell them that if you don't feel comfortable coming to me or expressing each and every, you know, beat that you might be feeling well, I'll oftentimes inform them that it may be reasonable to get a smart watch or something that helps keep track of what you're feeling. I oftentimes don't deter them from performing exercise.

Now again, that also depends on what arrhythmias we might be dealing with. There are certain heart rhythms where I have to tell patients that activities such as power lifting, treadmill, marathon running, or even just recreational running can worsen the heart rhythm. So, it's almost counterintuitive, we say a healthy heart is somebody who exercises and eats well, but at the same time, exercising, especially strenuous exercise can actually progress heart arrhythmias and make them fatal.

So, I guess in a roundabout way, it's basically patient dependent and we have to really, again, tease out the rhythm when we see each other in clinic and then follow up, really know what they have, push for healthy heart by exercising and eating well, obviously, if that's not going to bring them any harm.

Host: Yeah, it really sounds like that if you are concerned about it or you're experiencing you know, something that just feels a little abnormal, you should feel free to kind of get it checked out because you never know what it is. And it's only in getting in there and testing those electrical currents that you're going to find out what you have. If it's something you should be concerned about, or if it's something that you can leave for now, isn't that correct?

Dr. Diamantakos: Yeah, I completely agree. I think the one thing that I'm oftentimes sad or upset about hearing is that, you know, patients from their teenage years, twenties, and thirties, who now come to me in their forties and fifties. You know, maybe somebody along the way has told them that it's anxiety, that's making you feel this way, when in actuality, it's a true heart arrhythmia that I've diagnosed and it's how the rhythm makes the patient feel and makes them anxious. It makes them almost seem and mimic anxiety. And so I've come to learn that, allowing the patient to understand that they really have a heart arrhythmia that's causing them to feel this way and it hasn't been binned to being just anxiety or some mental illness per se that's causing them to feel this way; I think is super reassuring for patients. It gives them control of, of what they're feeling and actually restore some faith and knowing their body and what they're actually feeling.

Host: Yeah absolutely. So, just before we close here, is there anything else that you want to share with the audience, whether it be new treatments or just general information about electrophysiology?

Dr. Diamantakos: Yeah. The sky's the limit with our field and at the forefront of our society, which is known as the Heart Rhythm Society, we have many individuals who are progressing our fields. And that includes learning the mechanisms and even more so some of our complex diseases, that is actually leading to more progressive tools that will give better success for some of the arrhythmias that we're dealing with.

And not only from an electrical standpoint of heart rhythms, but even basic pacemakers and even our defibrillators. The technology is growing significantly that there will be a time when pacemakers no longer have leads in the heart and we call those lead-less pacemakers. And I believe, fairly in the near future, we're going to have complete lead-less pacemaker systems for our patients. So, so many new things coming out. I think our field is excelling greatly and at the benefit of the patients that we have.

Host: Sounds absolutely amazing. Thank you so much for your time, Dr. Diamantakos.

Dr. Diamantakos: No problem. Thank you.

Host: That's Dr. Evan Diamantakos, Cardiologist and Specialist in Electrophysiology at Eisenhower Health. Thanks for listening to this episode of Eisenhower's Living Well podcast. For more information, you can visit Eisenhowerhealth. Org/heart. If you found this episode to be helpful, or if you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

My name is Prakash Chandran . Thanks so much for listening and we'll talk next time.