EP Online: New Resources for the Cardiac Professional

In this article, Dr. S. Venkatesan tells us about some of the online projects he is working on. Dr. Venkatesan is the Assistant Professor of Cardiology at Madras Medical College in Chennai, India. What were your reasons for starting the blog at “https://drsvenkatesan.wordpress.com/”? When and why was it launched? Even though my primary work involves patient care, I have always been fascinated by the scientific literature coming out of various sources. In India, especially working in a governmental institution, it has been difficult to publish in major journals. There is a huge gap in India between what is available as scientific information and what can be published. Even sending a case report to a journal can require major efforts. Sometimes even genuine works are rejected, citing various reasons. In addition, you will be surprised to know that there is hardly any dedicated staff meant for research and publication in most of the institutions here. So then, how does an individual experience become scientific evidence? It requires the act of publication! At this point I realized what is important in science is genuine propagation of individual experience and facts — not just ratings, peer reviews and impact factors. There are many individual experiences and observations in clinical medicine that are unused in this part of the world and never get published. Therefore, I wanted to put all of our thoughts into one forum, and let the readers be the peer reviewers. The only thing I make sure is that whatever I blog, my conscience should say it is worth discussing. What information have you written about on the blog? How often do you update the site? The blog is approximately one year old. Since I am a cardiologist, I plan to cover as many issues as possible on the subject, of course with some overlap with general medical topics. I try to update every week whenever possible. I must also tell you, though, that I do all the online work myself, so I realize there is a lot to improve upon in some of the presentations, especially with syntax and spelling, etc. In the future, if I get sponsors, I hope to improve the blog with a dedicated online staff. What are some of the most important or controversial topics in cardiac electrophysiology that are discussed on your blog? Many of my blog topics touch upon some controversial areas of cardiology. I often find that criticizing or questioning an established form of therapy is considered a negative approach. However, I wondered if a positive development in science could have a positive impact on the patient’s well-being. Many times I have realized that what is positive for the scientific community and industry can ultimately be negative (cost wise) for the patient. For example, at our institute, we have implanted about 5,000 VVI pacemakers over the last 15 years. Except for a few complications, none of our patients complained about the quality of life issue. Advocating dual chamber, I am strongly against the concept of dual-chamber pacing as a routine measure in patients with complete heart block (CHB) or sick sinus syndrome (SSS). This issue has been addressed in my blog. Similarly, the long-term viability of cardiac resynchronization therapy is being debated. I also realized there is no place in standard journals to present our view in a forthright manner. Hard language is often used in mainstream media regarding politics, sports, or any other field to effectively convey a point. So why are these opinions not allowed in scientific forums? This is one of the reasons I feel the growth of science is very difficult to regulate compared to other fields. For example, look at how difficult it can be for the FDA to reject a concept drug or device in spite of volumes of evidence against it. I find many peers and experts in the field of medicine feel undignified and consider it indecent to differ from the mainstream concepts. I wondered if any of the delegates in a major scientific forum would stand up and say that a particular concept they are discussing is bound to fail for a specific reason. Consider this scenario: if someone were to point out a flaw before launching a space shuttle that could prevent a major catastrophe, then that person would be considered a hero. However, in the field of medicine, if someone were to specify a wronged concept, he would be considered a zero! I agree that unrestricted freedom and innovation are required for science to grow. But in today’s world, with science as a speculative commodity, this freedom is being misused. I feel there needs to be strong monitoring for scientific freedom. I have also written about the ambiguity in selecting patients for pacemakers, stents, etc. When we say that all symptomatic bradycardias require pacing, what symptoms are we talking about? Dizziness, syncope, or palpitations? In my opinion, dizziness in an elderly individual with bradycardia is not an indication for pacing. At the time when plain old balloon angioplasty (POBA) was used, it was a great innovation. However, the moment stents were put in use, plain balloons became a dangerous entity. How is that possible? There will still be thousands of candidates for POBA. I wanted to stress this point, because when one technology overtakes the other, it doesn’t necessarily mean the old one should become obsolete. We have to constantly scrutinize the old concepts as well. The other major issue I would like to address is the concept of evidence-based medicine (EBM) guidelines by the ACC, AHA and others. For example, what does it mean to have a class 1a recommendation based on level of evidence C? Is it evidence-based or experience-based cardiology? We need to clarify with our younger colleagues and physicians about what is a class 2b and class 3 recommendation. Why is there hesitation in calling a class 3 recommendation an absolute contraindication for the said form of treatment? I know many of our junior physicians still think class 2b and 3 recommendations can still be used as an indication. In fact, there is a strong case for removing class 2b and 3 advisories from the ACC/AHA bulletins. What sorts of responses or feedback have you received about your blog? Who do you find most often visits your website? I am getting positive feedback as well as some occasional comments saying that my blog is biased. Overall, I am finding a good scientific audience. Many younger medical and paramedical students visit my blog. I was also thrilled to find from the YouTube insight data that I have web visitors from all across the globe, from Brazil to Japan to Australia. What impact has having a blog made on your life? It gives me the satisfaction of conveying some useful ideas to like-minded people. It makes me realize this world is a wonderfully small place, and that everyone can make a positive impact in this world! In addition, tell us about the YouTube site at “https://www.youtube.com/user/venkatesanreddi”. What is included on this site, and how does it differ from the blog? The YouTube site was created earlier than my WordPress blog. I use the YouTube site to share important clinical images. Since we do a lot of echocardiograms, my site will be carrying more of that. I want to share further clinical rarities through this site. One of the most viewed videos on your YouTube site is titled “How to become a good cardiologist in 7 minutes.” Why was it important to address the mental aspect of cardiology, not just the clinical images? This was a random thought I had when I was reading “A father’s instructions for life” in the famous book Life's Little Instruction Book by H. Jackson Brown, Jr. Why not put together some advice for our future cardiologists? That resulted in this video. Surprisingly, it got a huge response, and in the process I also realized it is always easier to give advice than practice it! But we must try at least. I am now 45, and I often come across many younger generation doctors. They are all intelligent, hardworking and highly skilled, but I also find in them a harsh truth — that their passion is not primarily in academics or patient care, but something else. Where are those great physicians and medical professionals this world produced decades ago? Where are those inspirational giants? Where are those empathetic physicians? We all tend to be hijacked by the science and modernity, but common sense and compassion are the rarest commodities. Thus came the concept of the video. Finally, tell us about your website at “https://www.onlineheartcare.co.in/home”. This website is a collection of all my resources in one place. It aims to cater to the needs of patient, the medical student, and the physician. I hope to form this website into an ultimate source for all useful links in cardiology. How have cardiac arrhythmias impacted India? Are cardiac arrhythmias on the rise there? What treatments are available to patients? What are the more common heart rhythm conditions you most come across? There has been increasing awareness about cardiac arrhythmias in our country. The referral rate to tertiary hospitals for specific arrhythmias has increased. As rheumatic heart disease is still rampant here, the primary arrhythmias we encounter often are atrial flutter and atrial fibrillation. In the coronary artery disease (CAD) population, more ventricular tachycardias (VT) are being diagnosed and treated. However, the usage of ICDs has been very less. Idiopathic VTs and RVOT/LVOT VTs are also increasingly diagnosed. Regarding bradyarrhythmias, there is a huge burden of both CHB as well as SSS. However, only a fraction of patients get permanent pacemaker therapy due to lack of funds. The one good thing here is that every general cardiologist is trained to implant a pacemaker in any cath lab. There are only about a dozen institutions that do dedicated EP studies in our country. So the future is wide open, and there is a lot of potential for growth in this field. What research advancements in cardiac electrophysiology would you like to see made in the next decade? Cardiac electrophysiology has revolutionized our understanding and treatment of cardiac arrhythmias. My thoughts are always with the incidence and impact of primary ventricular fibrillation (refer to the video at “https://www.youtube.com/watch?v=J9DH6Vr04es&feature=channel_page”). There is only one specific treatment for this deadly arrhythmia. Fortunately, AEDs are having some impact on this issue. But is it not a paradox? There is electricity everywhere in this world — in our mobile phones, laptops, etc. — and yet a life can be lost for want of a meager 100 joules of electric energy at the right place at the right time. I visualize a fantasy here, whereas a mobile phone, laptop or iPod could act as mini defibrillator and extinguish the cardiac short circuiting as and when it is happening. The other area of potential research is in ultrasonic cardioversion and ablation. When we are able to destroy hard renal calculus with ultrasound, why not use electrical focus from soft tissues? In addition, biological pacemakers should also help liberate our patients from wires and metals. Is there anything else you’d like to add? Thank you for asking me to share my thoughts in your forum. I must also thank the networking sites YouTube and WordPress for providing us with a platform to serve the public and patients. Finally, I would like to reemphasize that in this era of economic uncertainty, there will always be many forces (advertent and inadvertent) that will create and maintain a gap between genuine medical science and the welfare of humanity. At least let us be aware of it, and whenever possible, let us try to eliminate or narrow this gap! For more information, please visit: https://drsvenkatesan.wordpress.com https://www.youtube.com/user/venkatesanreddi https://www.onlineheartcare.co.in/home