Recap and review the top pearls from recent episodes #320 Palpitations and #317 Erectile Dysfunction with Watto and Paul. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for shows #317, #320!
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Featuring Joshua Cooper with production and graphics by Eddie Jyang and Paul Williams. Get full show notes for #320 here
Consider asking the patient to tap out their palpitations on the back of their hand (e.g., is it strong, slow, and steady, or fast and intermittent). PVCs are sometimes described as a sensation of “flip-flopping,” or heart pounding, then briefly stopping (Weinstock 2021). Dr. Cooper thinks of tachyarrhythmias like SVT having an abrupt onset versus anxiety, which builds over time. Red flags include chest pain and syncope.
Wearable devices: Dr. Cooper welcomes patients to bring rhythm strips from their wearable devices (analogous to a family member who brings cellphone video of a potential seizure to an epileptologist).
An EKG in the office is likely to be normal, but this is still helpful info! Check a CBC, metabolic panel, and TSH. Ask about alcohol and other substance use. Let the severity of symptoms dictate the pace/intensity of the workup. With implantable devices, monitoring duration ranges from days (if frequent symptoms) to weeks (event monitors) to months or even 3 to 4 years. Note: two weeks seems to be optimal (Weinstock 2021). All patients do not require an echo but get one if red flag symptoms, multifocal PVCs, or high suspicion of structural heart disease by history and exam.
Dr. Cooper outlines three different possible management approaches for AVNRT or AVRT. The first, my favorite, is to counsel that SVTs are usually benign and to teach them vagal maneuvers to terminate them. These include bearing down and applying an ice pack to the face. Second, medications are an option and include beta blockers and calcium-channel blockers. Dr. Cooper favors the non-dihydropyridines, which have a more favorable side effect profile. A third option, and perhaps the most definitive, is catheter ablation, which can be both diagnostic and therapeutic, being curative 95% of the time.
These are not always benign. In young patients with minimal symptoms, infrequent PVCs, and without structural heart disease, reassurance is usually enough. However, frequent PVCs (>10% of the patient’s heartbeats) or PVCs in the setting of structural heart disease or prior ischemic disease require management. Management includes beta blockers and catheter ablation. A reminder that PVCs can cause cardiomyopathy, and vice versa.
Dr. Cooper has a YouTube channel where he explains cardiac arrhythmias using animations.
Featuring Ashley Winter and production and graphics by Hannah Abrams. Get full show notes for #317 here
The first tip is to normalize the conversation. If you aren’t comfortable discussing, then the patient will not be comfortable. Does ED occur with partnered or unpartnered sexual activity?
Dr. Winter points out that the penis does not need to be erect for the patient to experience an orgasm. Thus, ask the patient why ED matters to them (e.g., are they worried about the general health implications, or is it impairing their ability to practice penetrative intercourse?).
Do they have CV risk factors (obesity, OSA, diabetes, smoking)? 2018 American Urological Association (AUA) Erectile Dysfunction Guidelines: “Symptoms of ED may precede a cardiovascular event by up to five years. Further, when ED is present in younger men, it predicts a marked increase (up to 50 fold) in the risk of future risk cardiac events, suggesting that young men with ED, in particular, may benefit from CVD risk factor screening and interventions. (Hodges 2007, Montorsi 2003, Inman 2009)
The degree of erectile dysfunction correlates with the degree of underlying cardiovascular disease. Happily, the management of risk factors is in our wheelhouse. It provides a chance to counsel about tobacco cessation, work on lipid control, screen for diabetes and pre-diabetes, and encourage exercise and weight loss. Adipose tissue contains aromatase, which converts testosterone to estrogen. So weight loss can mitigate erectile dysfunction. In addition, treatment of OSA can improve testosterone levels and increase energy levels to allow for greater participation in sexual activity.
PDE5 inhibitors will not cause an erection without a source of arousal! They do not cause priapism, which is mostly seen with injectables! Daily tadalafil can treat both BPH and generate a steady-state concentration to treat erectile dysfunction.
It’s worth noting that our Urology colleagues have other non-medication options for patients with erectile dysfunction. Injectable medications like papaverine can be offered. These don’t have the systemic effects of the PDE5 agents, but do have the risk of priapism. There are also vacuum devices, although Dr. Winter is not wowed by their efficacy. Surgical implants are an option. These can be either malleable or inflatable. Psychotherapy is also an option in patients who have a psychogenic component to their erectile dysfunction.
We should also mention it is worth testing for and treating hypogonadism in the right patient population (middle-aged men with other symptoms).
Honorable mentions: Dr. Winter recommends avoiding most supplements, though she suggests L-arginine if a patient strongly prefers a nutraceutical as it is a nitric oxide donor and has vasodilatory effects (Leisegang 2021, Xu 2021).
Mirabegron may have pro-erection effects (Karakus 2021), and might be selected in patients with overactive bladder symptoms.
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Williams PN, Watto MF. “#336 Palpitations, Erectile Dysfunction: Rapid Review (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date May 27, 2022.
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