Instructions for Patients

Preparing for Your Initial Consultation

We would like to extend a warm welcome to you and your family for choosing to come to Heart Rhythm Specialists of Southern California.  This section discusses issues that can help your with you first visit to our center and we recommend that you go through this section carefully.

For many patients, seeing a new physician can be somewhat of a anxiety-provoking experience, but it really does not have to be.  We at the Arrhythmia Center are here to help you understand your medical condition and to help you choose the most appropriate treatment option.  Your visit is really an interactive session for us to get to know you and for you to get to know us.  The more you can tell us about your medical history, the better our physicians can understand your exact condition and provide the best recommendation for it.  Therefore, the following are some housekeeping items, or "homework," that you can prepare prior to your first visit

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 Medical records. The importance of having your old records available from other physicians can not be over-emphasized. A medical history is a health care provider's way to summarize a patient's medical condition in a succinct and concise way.  Even though a patient's own perspective on the disease is unequivocally important in the interaction with his or her physician, the physician can find medical records very helpful because in one minute of reading a medical history, the physician can gather more pertinent medical information than what a patient can explain in his or her own words in an hour.

Furthermore, records such as an Electrocardiogram (EKG), an Event Monitor, or a Holter Monitor are especially important.  Many different arrhythmias can feel exactly the same to patients.  For example, palpitation is the primary symptom for essentially all arrhythmias and yet treatments and prognoses may differ tremendously from one arrhythmia to another.  Therefore, making the correct diagnosis is of the utmost importance and an EKG can be very critical in that regard.

An EKG, an Event Monitor, or a Holter Monitor is a graphical recording of your heartbeat.  Such a recording that was done while you were having an actual attack of your arrhythmia is especially critical.  For, many arrhythmias are intermittent, meaning that they come and go.  Therefore, a definitive diagnosis of an arrhythmia can be made only when such an EKG recording is made during an actual episode of the arrhythmia.  Many of these EKGs were done at the emergency room where you visited during the last attack of your arrhythmia.  Obtaining these records would be tremendously helpful prior to your first visit.

 List of medications you take.  It is important for your physician to know exactly what medications, including dosage and frequency, you are taking.  This knowledge is extremely crucial to help determine your diagnosis and to decide on the next level of intervention.  In addition, knowing your current medications is critical in helping to prevent potentially dangerous drug-to-drug interactions, especially if a new drug is to be prescribed. If you do not have a complete list of all medications you take, may we suggest that youbring all your medicine bottles with you on your first and subsequent visits.

Having the names of previous medications which you have been on but which were ineffective is also very important, as it can help your physician avoid repeating what has already been tried and failed previously.  More importantly, knowing the side effects of your previous medications is critical in order to prevent making the same mistake.

 Drug allergy.  If you have any allergy to medications, it is critical that you report it to your physician.  This knowledge is crucial in helping to prevent mistakes, especially when and if you are admitted to a hospital for procedures.

 Fill out forms.  Please fill out both the administrative and medical forms and bring them with your on your first visit. These forms serve as a foundation from which your physician can get to know your medical condition. Be as concise and complete as you can, as every bit of medical history can be potentially important in the management of your condition.

Downloadable PDF Files (Questionnaire, Face sheet, Financial Responsibility)

 Insurance information.  Please bring your insurance card with you on your first visit.  If you have more than one insurance, you must bring all the cards.  The type of insurance or insurances you have determines how we bill and it can affect the amount of your co-payment.  It is also very important for you to know ahead of time what your annual deductible is because you may be responsible for a substantial portion of your bill if the deductible is not yet met.  Please read to section on Patient Financial Responsibility carefully.  For patients with HMO insurance, authorization is required for any visit to specialists.  For those with HMO who choose to use their POS (point of service) option, you must make this clear on your first visit.

 Direction to our office.  Please obtain driving direction prior to your visit, not 10 minutes before the appointment.  You may clickhere for our office locations.  Do give yourself ample time because of the unpredictable traffic and parking situation.

 Parking. Parking is typically very tight in Tarzana so please plan to arrive 10 to 15 minutes early for your appointments. Paid parking is available on the premise but we do not validate parking.  Parking is plentiful and free at our Thousand Oaks office.


Preparing for Your Office Tests

If you have been instructed to return to the office for tests, please note the following instructions:

 Holter, Event Monitor, Echocardiogram: You do not need to fast to make any special preparation.  You will need to disrobe for part of these procedures and therefore you should wear comfortable loose clothes.

 Treadmill Stress Test: Please wear comfortable clothes and shoes.  The outfit that you may wear for jogging would be perfect.  You must fast overnight, i.e., come in on an empty stomach without food on the morning of the procedure.  If you take medications that slow the heart rate (typically, beta blocker, calcium blocker, or digoxin), do not take it for 1 day before the procedure.  If you have any question, please ask the office staff way in advance.

 Tilt Table Test.  Please come in fasting overnight with comfortable loose clothes.  


Preparing for Your Surgeries

The following are general guidelines common to most procedures done in the hospital setting, including Cardioversion, Electrophysiology Study, Radiofrequency Ablation, Pacemaker implantation, and Defibrillator (AICD) implantation.

Disclaimer: These general guidelines apply to patients having procedures done by physicians at Heart Rhythm Specialists of Southern California only. They are not meant for patients who undergo the same or similar procedures by other physicians. This is because every physician practices somewhat different styles of medicine. What is applicable in one practice may not be for another.

 Labs. The hospital generally requires that routine laboratory studies (usually blood count, chemistry, and coagulation studies) be done within 7 days of the procedures. These studies must be performed at least 1 to 2 days before surgery and may be done at the hospital or at your internist's office.  If you choose to have your primary physician do your pre-operative laboratory studies, please have the results faxed to the hospital well in advance, or, better yet, have a copy with you on your arrival at the hospital. One may also choose to come to the hospital lab and have the blood drawn 1 to 2 days before the surgery. This way, the lab results will be in the hospital system already by the time of surgery. 

The last options is to have laboratory studies done at the hospital on the morning of surgery, but that means you must arrive at least 2 hours ahead to have the blood drawn and have results finished by the time of surgery. Waiting for blood test results is a common reason for delaying or canceling a surgery. 

Whatever method of blood test you choose, it must be done in a timely fashion or the hospital may cancel the procedure. Our receptionist can assist you regarding any of the above options for blood test.

  History and Physical. A complete dictated history and physical must be performed no more than 7 days before the planned surgery. This is a requirement by the hospital accreditation agency. This can be done in your primary physician's office. If more than 7 days have elapsed since your most recent physical, than you must obtain another one. This unfortunately is the rules that all hospitals have to abide by. You can download this form to be forwarded to your primary care physician (downloadable form for internist for H&P and labs).

 Fast overnight. Almost without exceptions, one must fast from midnight and on the night before surgery. If you are a diabetic and worry about running hypoglycemia (low blood sugar), you must consult your internist or endocrinologist for advises on how you should manage your diabetic medications (see below). One must allow at least 8 hours of time between the time of surgery and the last time you ate anything by mouth.

 Hold medications. Hold all your medications on the morning of surgery unless they are absolutely necessary. If it is necessary to take your medications on the morning of surgery, take them with only sips of water. Please be sure to discuss whether to withhold to take your medications with your primary care physicians well in advance of the surgery.

 Coumadin. One usually has to stop coumadin at least 4 to 5 days before most surgeries, with some notable exceptions (i.e. atrial flutter ablation). Your physician almost always would have discussed this with your on your pre-operative visit. If not, please call well in advance of surgery for specific directions. Do not wait until the last day to call us, as it takes several days for coumadin to get out of your system. Other medications such as aspirin and Plavix are generally OK for surgeries done by our physicians. These medications are not to be stopped without first consulting with your cardiologist.

 Conflicts of instructions. Very often, you may receive conflicting instructions from our office and from the hospital "pre-op" nurse who may call you the day before surgery. Please remember that the hospital nurse gives instructions to patients who will undergo all types of surgeries by different physicians and surgeons. Therefore, their instructions are often unnecessarily broad. In case there is a difference between the two sets of instructions (from our office and from the hospital), please go by the ones from our office. After all, you are having a surgery by our physicians, not from the pre-op nurse. This situation unfortunately has occurred too frequently and has caused a great deal of unnecessary anxiety and stresses for all parties involved.


What to Expect during Your Surgeries

 Get there early.  Be prepared to arrive at the hospital at least 2 hours before your scheduled surgery.  Having a surgery at a hospital is very similar to going to an airport: you have to "hurry up and wait."  There are many steps that one has to go through to get ready for surgery and these take time.  Surgery has been cancelled because of patient's late arrival in the hospital.

 What to bring.  Please bring comfortable clothes with you, which you will change to the hospital gown once you arrive at the hospital.  Make sure you have all your medicine bottles with you, especially if you do not know all the names of your medication and their exact dosage.  Leave valuables at home as there is no secure area to keeping valuable personal belongs.

 Prep and Hold.  A special area called "prep and hold" or similar names is designed to prepare patient for surgery.  You will meet one of several nurses who will be coordinating your care before and after surgery.  They are responsible for making sure all your paper work and labs are ready for the surgery and they also help start IV lines before procedures.  This is where many of your "last minute" questions can be answered before the procedure.

 Surgery.  Different procedures at different hospitals are done at different places.  For some  hospitals, pacemakers and defibrillators are implanted in the "cardiac cath lab," while for others, in the "OR" or "operating room."  Electrophysiology study and Radiofrequency ablation are always done in the "cath lab" or "EP Lab."  These are specialized rooms with high-definition XR equipment and multi-channel computer recording systems specifically for the studies of arrhythmias.  You will meet a different team of technicians and nurses in this room who will be with your during your entire procedure.  These personnel will help you on to the table where the procedure is performed.  There are several monitors in the room for fluoroscope (XRay) and computerized recording.  The procedure is done in a sterile manner, so the areas where catheters are inserted (usually in the neck or the groin) or where the pacemaker and defibrillators are implanted (usually on the chest) will be cleaned and sterilized with betadine or equivalent antiseptic solution.  You will be covered from head to toe by sterile drapes.  Multiple wires will be connected to your chest and to the catheters for recording the electrical activities of your heart.

 

 Recovery.  Recovery will be in the "prep and hold" area for the cath lab, or the main OR recovery room for the OR.  You will meet the same team of nurses who helped you prepare for your procedure early that day.  In the OR recovery room, you will meet yet another team of nurses to help you recover.  You will be able to see your family in the "prep and hold" area, but not in the OR recovery room.

 Driving.  If you choose to, you may drive to the hospital, but someone must drive you home because you may still be recovering from anesthesia on discharge. This is the case if you are discharged on the same day or the next day. 

 Home.  For most Electrophysiology procedures, one can expect to go home on the same day.  For those with pacemaker or defibrillator implantations, patients will stay overnight.  Room assignment will take place during the recovery time.


Care Following Surgeries or Procedures

The following are general guidelines for all inpatient surgeries, including Electrophysiology study (EPS), Radiofrequency Ablation (RFA), Pacemaker (PM) and Defibrillator (AICD) implantation.

Disclaimer: These general guidelines apply to patients undergoing surgery by physicians at Heart Rhythm Specialists of Southern California only. They are not meant for patients undergoing other surgeries or even similar surgeries by other physicians. This is because every physician practices somewhat different styles of medicine. What applies in one practice may not apply in another

 Medications. Almost all medications can be restarted right after surgery. Even coumadin often can be started right away because it takes several days for coumadin to "kick in." Instructions on medications will be given at the time of discharge from the hospital. But unless the physician has given you specific instruction to stop certain medications, you should continue all your medications.

 Activities. Almost without exceptions, strenuous activities should be avoided for at least 48 hours. Driving should be avoided for 24 hours until the effects of anesthetics wear off. Return to work is usually permitted within 24 to 48 hours unless your work requires strenuous activities. In the case of pacemaker and defibrillator surgery, one should avoid lifting anything heavier than a gallon of milk and raising the arm above the shoulder level on the side of surgery. There is no restriction on the other arm away from the pacemaker. Walking is a perfect exercise and should be continued. Almost always, one can shower right away unless specifically instructed otherwise.  For Ep study and Ablation where you have punctures on the groin, avoid bending over or lifting anything heavier than a gallon of milk and for 2 days.  Strenuous exercise is discouraged until you have been evaluated on your first follow-up at one week.  For other postoperative instruction, please see frequently asked questions section.

 What to expect after Electrophysiology study (EPS) and radiofrequency ablation (RFA)? The sites of catheter insertion (often in the neck and the groins) often may have very slight amount of oozing (no more than a few drops of blood). A slight swelling (no more than a quarter) may be seen. Within 2-3 days, one may see a large amount of black and blue in the groin area, which is completely normal, as long as there is no expansion of swelling at the groin. This black and blue can also extend down to the knee area. Anything other than those described above may be due to abnormal bleeding and must be evaluated by your physician.  A mild dull chest pain can be expected for a few days after ablation.  Severe chest pain or shortness of breath should prompt you to call your physician.

 What to expect after Pacemaker and defibrillator implantation? A slight swelling can be expected after surgery and should resolve within a week. If the swelling increases over the next few days, there may be a collection of blood clot (hematoma) and you must be evaluated soon. Tenderness is normal for the first 24 hours, but significant amount of pain after 24 hours should raise concern and should be evaluated right away. Within 2 to 3 days, some amount of black and blue can be seen on the skin extending from the pacemaker to the shoulder and down to the arm. This is normal as long as there is not a significant amount of swelling at the site of surgery. Redness, swelling, and pain above and beyond what is described above may indicate infection and should be promptly evaluated by your physician. For other postoperative instruction, please see frequently asked questions section.

 Conflict of Instructions. As with pre-operative instructions (see above), there is often inconsistencies between the discharge instructions given by your nurses in the hospital and those by your physicians. In these cases, the obvious thing to do is to go with those from your physicians. Nurses in the hospital work with many patients with different surgeries done by different physicians, each of whom has his or her specific preferences. Most of the time the differences are minor and immaterial, but they often can be a source of great anxiety for our patients. In any such cases, instructions from your physician should always prevail.

 Wound care.  Although it is safe to shower right away, do keep the area dry and avoid soaking or swimming for five days.  Very slight oozing may be present at the wound site and you may place a Band-Aid.  If it should get wet, replace with a dry one.  Excessive bleeding should be reported to your physician right away.

 Follow up visit. Almost without any exceptions, post-surgical patients should be seen by our physicians within one week of surgery for wound check, unless otherwise instructed. This appointment often can be conveniently made at the time of scheduling the surgery itself.

 Follow up for pacemaker or defibrillator check. Pacemaker will be checked at 1 week, 1 month, and 3 months after surgery, and thereafter every 6 months. Defibrillators will be checked at 1 week, 1 month, and 3 months after surgery, and thereafter every 3 months. For other postoperative instruction, please see frequently asked questions section.


Care Following Atrial Fibrillation Ablation

Ablation for atrial fibrillation differs in many ways from those for other arrhythmias.  Therefore, there are special sets of post-procedure instructions for patients who have undergone atrial fibrillation ablation.

 Activities.  Activity restriction is very similar to those for EP studies and other Ablation procedures listed above.  These restrictions must be absolutely adhered to because most patient would be back on blood thinners like coumadin or lovenox and their risks for bleeding from the puncture sites is significantly higher.  Activities should be curtailed to minimize risks of bleeding. 

 What to expect after ablation.  Slight swelling at the groin puncture site is normal, but large amount of swelling and pain is not normal and should be evaluated.  while bruising on the thigh is normal which can extend all the way to the knees, excessive swelling and hardening of the thigh may indicate internal bleeding.  Risk of bleeding after atrial fibrillation ablation is higher than that for other types of ablation because most patients resume blood thinner immediately after surgery.  

 Symptoms after ablation.  Like other ablation procedures, a mild and dull chest pain may linger on for several days, but should get better by the day.  Worsening chest pain beyond 2-3 days should be evaluated immediately.  Palpitation is extremely common after ablation for atrial fibrillation because there is usually very extensive amount of ablation done in the atrium, causing irritability to the heart.  Even full blown atrial fibrillation can recur in the first 2-3 months.  Recurrences during the first few months do not indicate procedural failure.  Results of the ablation can best be appreciated after complete healing and scarring have occurred inside the atrium, usually after after 3 months.

 Anticoagulation (blood thinner).  Use of blood thinners in the case of atrial fibrillation ablation is extremely important and strict adherence to the guideline will help reduce complications after the procedure.  Because atrial fibrillation ablation is performed in the left atrium, any blood clot that form in there can potentially dislodge and go into systemic circulation, resulting in a stroke.  Therefore, patients are usually on coumadin (an oral blood thinner) for 3 weeks before performing ablation.  This will help ensure that there are no blood clots in the atrium where the catheters are to be placed during ablation.  Five days before ablation, patients would stop coumadin and transition with Lovenox, an injectable blood thinner.  Coumadin is a drug that is slow to come off and slow to go on.  Five days are required for it to get out of the body system and for the blood to become thick enough for the procedure.  However, during this time without coumadin, the blood is becoming thicker by the day and one is not protected from blood clot as a results.  This is why one needs to start Lovenox once coumadin comes off.  After the procedure, coumadin will be restarted right away.  However, because it may take 5 to 7 days for coumadin to get fully into your body system, you will need to continue transitional lovenox until INR is above 1.8.  This transitional time before and after the procedure is critically important in order to minimize the risk of stroke associated with the procedure.  Also refer to coumadin clinic section for a discussion on INR.

 Follow-up visits.  Your first visit should be within 1 week from the ablation.  On this visit, you will receive an EKG and an INR evaluation to assess whether the blood thinner is working.  You will receive an explanation on the ablation itself.  A 24-hour Holtermonitor may be used to evaluate for atrial fibrillation, especially if the symptoms suggests its recurrences.  A 30-day Event monitor may also be required.  

 Long term Coumadin.  Coumadin should be used for 3-6 months after the procedure in order to minimize the risk of stroke.  The duration depends on the risk of blood clot in the left atrium and the frequency of atrial fibrillation.  If there is no recurrence of atrial fibrillation documented 6 months after ablation, one can safety stop comadin.


What to do if… Common Emergencies and Semi-Emergencies in Electrophysiology

 Defibrillator shocks. Defibrillators' function is to defibrillate, or to shock, the heart. This can be a very uncomfortable and terrifying experience. However, one must keep in mind that the defibrillator is simply doing its job and possibly saving your life. If the defibrillator shocks only once and you feel fine otherwise, without symptoms of fainting, then you should call within 24 hours and be evaluated in our office. If more than one shock occurs in a series, or if you pass out, you need to call 911 or drive to the nearest emergency room.

 Palpitation. This is the sensation of a rapid or hard beating heart. It can be due to a true arrhythmia (irregular heartbeat) or simply due to anxiety, caffeine, or alcohol intake. If you have a history of an arrhythmia, and you are experiencing an episode of palpitation, the following general guideline can apply. If you are feeling fine, without any chest pain, shortness of breath, dizziness, lightheadedness, or fainting, then you can usually wait until the next day to be seen. Arrhythmias frequently resolve on their own without any intervention. But if any of the above associated symptoms should occur, you may want to be seen right away. During office hour, you need to call the office for an urgent evaluation. During after hours, the only option is to go to the emergency room.

 Fainting. Fainting can be a very frightening experience. Anyone with the first fainting spell should be evaluated right away. If you have a history of fainting and your physician has determined that it is a "benign" type of fainting (such as vasovagal syncope), then nothing usually needs to be done. If you have any significant injury, then you need to be seen right away, in the office or in the emergency room, depending on the hour of the day.

 Bruising.  Following Electrophysiology study or Radiofrequency ablation, the catheter site at the groin will become bruised over the next 2-3 days.  The bruising may be alarming in appearance, but is completely normal and expected.  A large bruise, which can extend to the knee, can be completely normal.  Bruising around the pacemaker or defibrillator site is also completely normal, and can track all the way down the side of the chest and onto the elbow area.  What is not normal is excessive pain or large amount of swelling (bulging) at the groin or at the pacemaker/defibrillator site.  If this should happen, contact your physician immediately.

 Defibrillator beeping.  A defibrillator does a self-diagnostic every night.  If it sees something out of range, it will emit a beeping sound to alert the patient that something may be wrong and may require your physician's attention.  This beep presents a warning, some of which may be false alarm.  When this occurs, you should be seen by your Electrophysioloigist within 24 hours.