YOU CAN LIVE WITH IT!
ARRHYTMIA
PALPITATIONS
SKIPPED BEATS
HEART FLUTTERING
A guide to living a better, more comfortable life
By
Robert DiBianco, M.D.
A practicing Cardiologist
and
Maggie Shand, R.N.
A registered nurse
Introduction
Most
people have had an irregularity of the heart’s rhythm at one time or
another. These changes are hardly ever
noticed and are seldom serious. An
irregular heart rhythm does not necessarily mean that heart disease is present
or that elaborate medical tests or treatments are required.
Doctors
call any irregularity of the heart rhythm an “arrhythmia” (pronounced
ah-rith’me-ah). Whenever a person is
aware of the heart’s beating, doctors speak of this feeling as “palpitations.”
You
can be sure that doctors know more about heart rhythms today than ever
before. In most cases simple tests
provide a diagnosis and often no treatment is necessary, especially when the
heart is otherwise healthy and free of damage. In other cases, when heart problems are truly present, newer
diagnostic tests, medications and devices are making these problems totally
manageable.
This
contains information for patients and their families and loved ones. It can help answer many of the common and
important questions about palpitations and arrhythmia that all too often
trouble patients or those caring for them.
The information can relieve much anxiety and fear that come from “not
knowing.” It can give patients a better
understanding of arrhythmia, their doctors’ approach to diagnosis and treatment
and guide them to a more active role in caring for their own health.
Please
understand that this contains a great deal of information. It is not supposed to be read quickly or all
at one sitting. It can be referred to
over and over again. So, take you
time. First, go to the sections you are
most interested in. Then, when time
permits and more questions occur to you, look into other chapters. The advantage of having this all “written
down” is that you can get to know and understand more at your own pace!
Table of Contents
Normal
heart function: The beat goes on and on
Palpitations:
Often normal
Step
by step: From symptoms to diagnosis
Abnormal
heart rhythms: How you might feel
Abnormal
heart rhythms: How many are there?
Causes
of abnormal heart rhythms
Tests
to help diagnose the type of arrhythmia
How much rest and exercise are good for me?
Caffeine,
alcohol and nicotine
Medications
for the TOP of the heart
Medications
for the BOTTOM of the heart
Other
medications
Prescription
medications
Hospital
treatments
Implant
devices: Technology takes yet another giant step!
Surgery
to treat arrhythmia
Glossary
A
personal message
About
the authors
Acknowledgements
Medication
card
Normal heart
function: The beat goes on and on
·
The heart is a pump
The
normal heart functions as a pump. It
has four chambers, or cavities: two on the right side and two on the left. The chambers on the right (called the right
atrium and right ventricle) receive blood from the body and pump it to the
lungs to get oxygen and get rid of carbon dioxide. Blood coming back from the lungs, laden with oxygen, comes first
to the left atrium and then to the left ventricle, which pumps the blood
throughout the body. The left
ventricle is the most powerful chamber in the heart.
Arteries
carry blood away from the heart; veins carry blood from the body back to the
heart. The four valves of the heart
separate the chambers from each other and separate the chambers from the blood
vessels they pump blood into. The
heart’s valves are delicate but strong “one-way doors” that prevent the backflow
of blood into the chamber it was just pumped from.
|
|
|
- The heart has a “spark
plug”
Without an electrical “jump start” for each beat, the heart muscle would not move. The essential “spark of life” is provided by a small group of cells called a “node” that acts like a “spark plug” or natural pacemaker. Located near the top of the right atrium, this structure is called the SA (for sinoatrial, pronounced “sigh”no-ay’tree-al”) node or “sinus node” for short.
Every
second or so, the SA node produces a tiny electrical impulse that starts the
heart beat. The electrical impulse
travels along pathways starting at the top of the heart muscle, then through
the middle of the heart (junction) and to the bottom. The junction between the top of the heart (atrium) and bottom of
the heart (ventricle) is called the AV (atrioventricular) junction. The impulse leaves the junction and travels
onto the pathways of the ventricle. As
the impulse travels along it spreads throughout the muscle, which responds with
a contraction (squeeze) that pushes the blood through the one-way valves. The entire sequence takes about three-tenths
of a second at usual heart rates. After
a brief recovery, the process starts all over again for the next beat.
|
1 |
Sinoatrial
(SA) node |
|
2 |
Aorta |
|
3 |
Atrioventricular
(AV) node |
|
4 |
Right
atrium |
|
5 |
Interventricular
septum |
|
6 |
Left
ventricle |
|
7 |
Left
atrium |
|
8 |
Pulmonary
artery |
|
9 |
Atrioventricular
bundle |
|
10 |
Right
ventricle |
Palpitations:
Often normal
·
A “fast heart”
Running up a flight of stairs, you feel your heart “pounding.” The awareness that your heart is beating is referred to as “having palpitations.” The hard, fast breathing has a regular rhythm because it is caused by the normal action of our natural pacemaker, the sinus node. The increased pace of the heart is simply a response to the increased needs of your body.
This
palpitation symptom is not abnormal; that is, it is not caused by an arrhythmia
(abnormal heart rhythm). It is called sinus
tachycardia (pronounced “tak”ee-kar’dee-ah”), which means a fast heart
rate, usually above 100 beats per minute.
The SA node has responded to the body’s need for more blood and oxygen
by increasing the number of impulses it generates per minute. The heart simply beats more quickly in
response to it and gets more oxygen circulating to the parts of the body in
need.
Common causes of a rapid
heart rate (sinus tachycardia)
o
Exercise
o
Emotional stress (anger,
anxiety, fear, excitement)
o
Pain
o
Fever
o
Anemia (low red blood cell
count and hemoglobin)
o
Overactive thyroid
o
Medications such as:
Caffeine (coffee, tea,
chocolate, cola drinks)
Stimulants (amphetamines,
cocaine)
Cold and asthma remedies
Diuretics (water pills)
High blood pressure
medications: Vasodilators
Angina (chest pain)
medications: Nitrates
·
A “slow heart”
Lying in bed, you notice your heart beat. It seems it is beating very slowly at 45 to 50 beats a minute. Is it normal to have such a slow heart rate? In fact, it’s quite normal when the body is at rest and the need for circulating blood and oxygen is at a minimum.
The
regular, slow rate you’re able to feel is called sinus bradycardia
(pronounced “brad”ee-kar’dee-ah”), which means a slow heart rate. The SA node has responded to the body’s
reduced needs by initiating fewer impulses per minute. The heart is simply beating less frequently
in response to the reduced rate of the natural pacemaker.
Common causes of a slow
heart rate (sinus bradycardia)
- Rest and relaxation
(“dozing,” sleeping, lying down)
- Good physical
conditioning (frequent, regular exercise)
- High blood pressure
medications such as calcium channel blockers, beta blockers or clonidine
Some
of these medications may be used to treat angina, (chest pain), which is caused
by poor blood flow to the heart muscle itself.
Certain
eye drops for glaucoma can rarely be absorbed and in some individuals, slow the
heart rate.
·
A “varying heart”
A normal
fluctuation of the heart rate occurs with changes in breathing and is generally
so slight as not to be noticed, except in some individuals. It is called sinus arrhythmia. As we breathe in, our heart rate quickens
just a little. When we breathe out,
our heart rate slows.
You
can observe this yourself by resting quietly with your finger on your
pulse. Note that your pulse rate
quickens when you take a sudden, deep breath.
This is a normal response that is mistakenly called arrhythmia because
in some patients, especially children, the changes are more than expected and
appear almost as a true irregularity.
You can be sure this is a “normal arrhythmia” and never requires concern
or treatment.
It’s easiest to “find the pulse” where arteries are closest to the skin surface - neck, wrist, groin and ankles.
Step-by-step: From
symptoms to diagnosis
·
Understanding the visit to the doctor
As a person troubled by a symptom and possibly anxious concerning what lies ahead, you may find it helpful to know the approach your doctor will take to arrive at an accurate diagnosis and treatment appropriate for you.
The doctor’s goal is to find out if any heart disease is truly present and to do so in the least difficult manner.
The
medical history is the first step, usually completed through a
discussion with the patient that gives the doctor an understanding of the major
problem. This is usually supplemented
by a written questionnaire that asks for background information about the
patient’s health, including details about previous health problems,
hospitalizations, operations, medications, allergies, and cardiac risk factors
such as high blood pressure and cholesterol levels, smoking, diabetes and
family history.
|
|
The
physical examination is performed next in an effort to find any abnormalities
that could indicate the existence of a heart problem. The examination may be limited to the heart and circulatory
system (cardiovascular system) if the problem is solely arrhythmia. However, since other health problems can
cause arrhythmias, a complete physical examination may be performed and general
medical problems may be reviewed. The
search for signs of heart disease includes an evaluation of blood pressure,
heart rate and rhythm. The condition of
the neck veins and arteries as well as the blood vessels in the back of the eye
are assessed; and the lungs, heart, abdomen and extremities are evaluated as
well.
By
listening to the chest for breath sounds, the physician can determine if there
is fluid in the lungs (a sign of heart weakness or failure). Listening to the heart can provide not only
information about the rate and rhythm of the heart, but also whether a
mechanical problem exists with the heart’s pumping action. If a heart valve problem is present, such as
a blocked or leaking valve, the flow of blood through the heart
may be disturbed, causing heart murmurs that can be heard.
The
sound of a murmur is much like the sound of water running through a kinked
garden hose. Often, even the normal
flow of blood will produce a sound loud enough to be called a murmur
(especially in thin people or children).
Therefore, detection of a heart murmur alone does not necessarily mean
there is a problem with the heart or any of its valves. More information will be needed before it
can be labeled a problem.
The
next step is to schedule one or more routine non-invasive tests designed to
identify heart problems with a minimum of risk, inconvenience and discomfort to
the patient. When the problem is
palpitations, the four most common and informative tests are likely to be the
EKG, or ECG (electrocardiogram), exercise stress test, 24-hour Holter
(ambulatory ECG) recording, and echocardiogram. These are described later in this manual.
After
the history, physical exam and initial testing are completed, the physician
will review the results and determine the proper follow-up or treatment. It may be that the diagnosis is definite and
no treatment at all is necessary. On
the other hand, the diagnosis may still be unknown and require additional
testing. If the evaluation is done by
your regular doctor (primary care doctor, family doctor or generalist), a
consultation with a cardiologist (heart specialist) may be considered. If the evaluation has been done by a
specialist at the request of your regular doctor, a report will be sent to your
doctor summarizing the findings and recommendations. A cardiologist and primary care physician will generally work
together if ongoing consultation is needed.
If
follow-up testing or treatment is recommended, you can help your doctor care
for you by “joining the team” and actively assisting in your own care. Here are a few simple ways to help:
o
Follow instructions
carefully.
o
Be sure to have questions
about treatment clarified (write the answers down, or, if you are still doubt,
ask for them in writing).
o
Know each medication you are
taking and its dosage.
o
Keep regular follow-up
appointments.
o
Report problems in getting
or taking your medications.
o
Be a careful observer,
reporting relief of symptoms with treatment as well as any new problems that
may appear.
o
Learn as much as you can
about your problem and its treatment, but don’t diagnose yourself-that’s the
doctor’s responsibility.
From symptoms to
diagnosis
PATIENT-PHYSICIAN DISCUSSION
(Medical history-taking)
¯
PHYSICAL EXAMINATION
(Looking for sings of heart or blood vessel disease)
¯
DIAGNOSTIC TESTS
|
INFORMATION REVIEW
|
DIAGNOSIS
¯
PATIENT REVIEW AND
RECOMMENDATIONS
*Education
*Treatment (if indicated)
*Follow-up (office visits and additional testing, if
indicated)
Abnormal heart
rhythms- How you might feel
·
Awareness of the heart’s beating
(palpitations)
Abnormal heart rhythms (arrhythmia) might be reported by different individuals as “palpitations,” “skipped beats,” “extra beats” or “heart fluttering.” Some have called it:
o “flip-flopping inside my chest”
o “a little tickle, that makes me want to cough”
o “a sudden strong and hard beat”
o “a throbbing in my neck”
o “a nervous (jittery) feeling inside”
o “like a car with a rough idle”
o “a feeling of anxiety”
o “like my heart is stopped”
It’s difficult to describe a sensation coming from inside the chest with ominous implications. The anxiety and stress can often reduce our ability to observe and think clearly.
During an arrhythmia, patients have reported watching their neck veins “quiver” or “jump up and down.” Others report seeing the front of their chest wall move, just under the left nipple. This is where the heart touches the inside of the chest wall. Try to detect your heart’s motion by lying quietly on your left side with your right hand under your left nipple. Can you feel it? It’s easy to understand how this might be worrisome if the heart beat is very fast, slow or irregular.
·
Effects of abnormal rate and rhythm on the circulation
Lightheadedness is a symptom that may result from a temporary drop in blood pressure and may be caused by an arrhythmia if the heart’s pumping capacity is sufficiently disturbed. Sometimes referred to as “fainting,” “giddiness” or “dizziness,” the symptom is similar to the sensation you feel when you “stand up too fast.” You think you’re going to faint, but you don’t.
Fainting (syncope, pronounced “sin’ko-pee) is a severe form of lightheadedness that is generally the result of inadequate circulation of blood to the brain. It can result from a severe drop in the heart’s pumping capacity, caused by an arrhythmia that is either too fast or too slow, that results in a significant fall in blood pressure. This symptom is very important to relate to your doctor.
Chest discomfort (pressure, tightness or pain) may be caused by an irregular heart rhythm. The discomfort may belt in the neck, jaw, back, shoulders or arms, or may spread to these places. It may result from the high workload placed on the heart by a very rapid heart rate or be caused by too little blood flow through a diseased artery that supplies the heart muscle with blood and oxygen. In either case, the pain results from too little oxygen to the heart muscle.
Shortness
of breath may
result from an arrhythmia that sufficiently reduces the heart’s ability to pump
blood. If the heart rate is too slow
there may be too few beats to circulate enough blood. On the other hand, a very fast heart rate may cause the heart
muscle to contract so rapidly that it cannot fill properly, or the walls become
weak, causing an ineffective squeeze.
Increased
sweating
may occur during abnormal rhythms, especially if they cause a sluggish
circulation, low blood pressure or chest pain (angina).
Increased
urination may
be produced by certain fast heart rhythms (tachycardias). It may be the result of a hormone released
by the heart muscle and acting on the kidneys, causing them to make extra
urine.
Abnormal heart
rhythms-
How
many are there?
Classifying an irregular heart rhythm provides information that may help the cause of the arrhythmia and the reason for its persistence (the so-called “mechanism”).
·
Classified by rate
“Fast” (Tachycardia) vs. “Slow” (Bradycardia)
Normal rate (60-100
beats per minute)
Tachycardia
Bradycardia
Probably
the two most common terms used in discussions of arrhythmia are tachycardia,
usually over 100 beats per minute, and bradycardia, usually less than 60 beats
per minute. These terms describe only
the rate of the heart rhythm, and although important, the rate by itself
doesn’t tell you much. Learning which
part of the heart is involved in causing arrhythmia is even more valuable.
·
Classified by location
Arrhythmias are easily classified according to their
location in the heart. Dividing the
heart into three major areas-the top (atria), middle (AV junction), and bottom
(ventricular)-makes most arrhythmias understandable.
From the “TOP”
Abnormal heart rhythms from the top of the heart are called “atrial arrhythmias.” They are caused by abnormal electrical impulses from different places on the top of the heart. Because they usually cause the heart muscle to squeeze early, they are referred to as premature atrial contractions (PACs) or beats. These abnormal beats may be single, double, or three or more in sequence. The latter, three or more abnormal beats in sequence may be called PAT (paroxysmal atrial tachycardia), “atrial flutter” or “atrial fib” (atrial fibrillation) depending on the type of problem.
From the “MIDDLE”
Normally, electrical impulses pass from the top of the heart to the bottom of the heart through the middle, or junction (also called AV junction), of the heart. There the impulses may be slowed or even blocked completely. This can be considered a protective mechanism that prevents the major pumping chambers on the bottom of the heart, the ventricles, from beating too fast when the top of the heart has a fast rhythm (tachycardia). Abnormally fast rhythms can result in the ventricles not filling or pumping properly. The overall result can be poor circulation of blood. At times, there is an abnormal slowing or block of the electrical impulses as they pass through the AV junction (called Heart Block or AV Block). These “conduction delays” or blocks almost always result in a slow heart rate. Excessively slow heart rates may cause fatigue, lightheadedness or even fainting that may require a permanent pacemaker.
From the “BOTTOM”
Abnormal heart rhythms from the bottom of the heart are called “ventricular arrhythmias.” These are caused by abnormal electrical impulses from different places in the bottom of the heart. Because they usually cause the heart muscle to contract early, they are referred to as PVCs, or premature ventricular contractions. These abnormal beats may be single, double or three or more in sequence. The latter, three or more abnormal beats in sequence, is usually called VT (ventricular tachycardia). When the rhythm is so chaotic that the muscle can no longer contract, the abnormality is called VF (ventricular fibrillation).
Still
interested?
For
those who want to know even more (characteristics of specific arrhythmias)
Fast heart rates that are abnormal (Tachycardias)