Eric N Prystowsky (director of the Cardiac Arrhythmia Service at St Vincent Hospital, Indianapolis, and a consulting professor of medicine at Duke University Medical Center, Durham, USA) talks to Cardiac Rhythm News about his distinguished career. He considers the challenges facing electrophysiology, his most important accomplishments, and the perils of social media, as well as future developments and their likely impact on practice.
Why did you decide to become a doctor and why, in particular, did you decide to specialise in electrophysiology?
My mother was a child psychiatrist and my father a paediatric cardiologist. Their discussions about medicine were never about money, but about helping patients in need and how rewarding that was. I am sure this influenced my decision to consider medicine as a profession. Electrocardiograms (ECGs) in those days were long strips of paper and I would help my father make a composite 12 lead ECG by punching out segments to be mounted on one sheet. I was fascinated by the squiggles representing the heart beat. As I advanced in my training and learned more about arrhythmias, I knew I wanted to become an electrophysiologist, and that was why I did cardiology training at Duke.
Who have been your career mentors?
Mentors are key for a successful career, and I was fortunate to have several. My parents set an example for how medicine is to be practised; Ephraim Donoso during my internal medicine residency increased my knowledge of arrhythmias, and was my first academic mentor. At Duke, Harold Strauss taught me the concepts of research, and John Gallagher mentored me in clinical electrophysiology and solidified my desire to pursue academic medicine.
What has been the most important development in the field of electrophysiology during your career?
I began in the operating room mapping arrhythmia pathways for the surgeon to destroy. The three major advances in clinical electrophysiology have been development of the implantable cardioverter defibrillator (ICD), radiofrequency catheter ablation of arrhythmias, and biventricular pacing for heart failure.
What is the biggest challenge facing electrophysiology?
There are two big challenges. The first is in the science of electrophysiology; we need to understand why arrhythmias occur, not just how to treat them, and this will undoubtedly inform us about their mechanisms. The second challenge is more of a more practical nature—I worry about a shortage of electrophysiologists in the future. The number of applicants to programmes seems to be declining at a time when many more are needed.
What has been the biggest disappointment?
There has not been a new and effective antiarrhythmic drug developed for many years, and that is a disappointment. Although ablation is a wonderful method to cure certain arrhythmias, many are not suited to this therapy, and there are not enough electrophysiologists available to care for the multitudes of arrhythmia patients worldwide.
Of the research you have been involved in, which do you think will have the greatest impact on clinical practice?
I was involved in early trials in catheter ablation, the findings of which are a key part of patient care. I also cofounded the MUSTT study, which changed our approach to ventricular tachycardia. Following that, serial drug testing in the electrophysiology lab is no longer performed.
What did the COMPANION trial add to the understanding of cardiac resynchronisation therapy (CRT) pacing and CRT defibrillation?
COMPANION demonstrated the role of CRT to improve survival, and the benefit of ICD therapy for this aim.
What are your current research interests?
My current research interests focus on the autonomic nervous system and arrhythmias, AF tachycardia-induced cardiomyopathy, and risk stratification for sudden death in patients with mitral valve prolapse.
What are the key priorities for future research in this area?
We need a better understanding of how to risk profile for MVP, and this will require a large registry, as only a small segment of patients are at risk for sudden cardiac death. This is similar to other “boutique” diseases, for example long QT syndrome.
What is the potential for future developments in the prevention of heart failure?
Minimising disease states that cause both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), are areas for potential development. In the atrial fibrillation (AF) population, some progress can be made through education on tachycardia-induced cardiomyopathy.
What role does e-medicine have in monitoring chronic heart disease?
E-medicine will have an increasing role in monitoring and detecting cardiac problems. Wearable or implantable monitors can relay timely information that hopefully will minimise stroke or worsening heart failure and allow patients to be involved in their therapy. This may facilitate pill-in-the-pocket treatments for certain disease states, once safety and efficacy data have been verified.
Social media is increasingly used for medical communication. What are the pros and cons of these platforms?
I do not use social media but understand why others like it. Its advantage is the instant exchange of information that may help diagnose and manage patients. But, I have seen much misinformation. I cannot understand why a physician would listen to the advice of someone unknown to them who may not have worked in the area.
What is your most memorable case?
Of many memorable cases over 40 years, one sticks out. A teenage girl was referred for palpitations due to premature ventricular contractions. During the workup she was noted to have a nonischaemic dilated cardiomyopathy, but no heart failure symptoms. This was years before ICD trials had been performed in such patients, but her situation worried me, and I sought permission to implant an ICD. It was placed under her breast to minimise psychological impact. Her father felt I had done her harm; however, years later, when he was driving her home from college, she lost consciousness and woke with a start. The ICD printout showed an episode of ventricular fibrillation and the ICD had resuscitated her. Her father changed his attitude, but more importantly she married and had children, and years later underwent a successful heart transplant.
What is your advice to someone starting out in cardiovascular medicine?
My advice to anyone entering the field is to ignore all the noise about what is wrong with the practise of medicine, and concentrate on the wonderful field you have entered—one that will allow you to cure patients if you go into electrophysiology, or reduce suffering and improve survival if you become a general cardiologist, heart failure specialist, or interventional cardiologist.
Outside of medicine, what are your hobbies and interests?
I enjoy wildlife photography and have been to Africa to do so, and also to Churchill, Canada to photograph polar bears. I am an avid sports fan, particularly Penn State football and Duke basketball and I also enjoy the symphony. But, my major source of joy is visiting my grandchildren.
What would you have been if you had not been a medical doctor?
Vocational tests I took in school indicated my aptitude was for medicine or law. I have always enjoyed debating, so maybe I would have been a lawyer. However, I am very happy that I chose medicine.
What do you think have been your most important accomplishments?
One is the scores of fellows I have trained, many of whom have added to research in our field. Secondly, I discovered that a nurse was killing patients and was part of the team that convicted him. Thirdly, the privilege and pleasure of caring for thousands of patients with cardiac arrhythmias.
FACT FILE
Current appointments (selected)
- Director, Cardiac Arrhythmia Service, St Vincent Hospital and Health Care Center, Indianapolis, USA
- Medical director, Office of Research and Clinical Trials, St Vincent Hospital and Health Care Center
- Consulting professor of medicine, Duke University Medical Center, Durham, USA
Honours and awards (selected)
1992–present: Best Doctors in America
2002: Distinguished Teacher Award, Heart Rhythm Society
2002: Master Teacher Award, University of Miami School of Medicine
2002: Lifetime Achievement Award, University of California
2007: Distinguished Alumnus, Penn State University
2009: The President’s Award, Heart Rhythm Society
2014: Distinguished Physician Award, St Vincent Hospital
2018: Cardiac Pacing and Electrophysiology Pioneer Award, Heart Rhythm Society
Prior appointments (selected)
2004–2018: Editor-in-chief Journal of Cardiovascular Electrophysiology
2004–2008: Chairman, ABIM Electrophysiology Test Writing Committee
1992–1994: AHA Council on Clinical Cardiology Executive Committee
2001–2002: President, Heart Rhythm Society
1986–1988: Professor of Medicine, Duke University Medical Center
Memberships and committees (selected)
1979–present: Cardiac Electrophysiological Society
1980–present: American Heart Association
1988–present: American College of Physicians
2005–present: Heart Rhythm Society
Key papers
- Inhibition of the human heart, Circulation 1983
- Preexcitation index, Circulation 1986
- Vagus effects on SAN and AVN function in humans, Circ Res 1991
- MUSTT study, N Engl J Med 1999
