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Arrhythmias

What is an arrhythmia?

An arrhythmia (also referred to as dysrhythmia) is an abnormal rhythm of the heart, which can cause the heart to pump less effectively.

Arrhythmias can cause problems with contractions of the heart chambers by:

  • not allowing the ventricles (lower chambers) to fill with an adequate amount of blood because the electrical signal is causing the heart to pump too fast.
  • not allowing a sufficient amount of blood to be pumped out to the body because the electrical signal is causing the heart to pump too slowly or too irregularly.

In any of these situations, the body may not receive enough blood because the heart cannot pump out an adequate amount with each beat as a result of the arrhythmia's effects on the heart rate.

What are the symptoms of arrhythmias?

The effects on the body are often the same, however, whether the heartbeat is too fast, too slow, or too irregular. Some symptoms of arrhythmias include, but are not limited to:

  • weakness
  • fatigue
  • palpitations
  • low blood pressure
  • dizziness
  • fainting

The symptoms of arrhythmias may resemble other conditions. Consult your physician for a diagnosis.

To better understand arrhythmias, is it helpful to understand the heart's electrical conduction system.

Anatomy of the heart, view of the electrical system
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The heart's electrical system:

The heart is, in the simplest terms, a pump made up of muscle tissue. Like all pumps, the heart requires a source of energy in order to function. The heart's pumping action comes from an intrinsic electrical conduction system.

How does the heart beat?

An electrical stimulus is generated by the sinus node (also called the sinoatrial node, or SA node), which is a small mass of specialized tissue located in the right atrium (right upper chamber) of the heart. The sinus node generates an electrical stimulus periodically (60-100 times per minute under normal conditions). This electrical stimulus travels down through the conduction pathways (similar to the way electricity flows through power lines from the power plant to your house) and causes the heart's lower chambers to contract and pump out blood. The right and left atria (the two upper chambers of the heart) are stimulated first and contract a short period of time before the right and left ventricles (the two lower chambers of the heart). The electrical impulse travels from the sinus node to the atrioventricular (AV) node, where impulses are slowed down for a very short period, then continues down the conduction pathway via the bundle of His into the ventricles. The bundle of His divides into right and left pathways to provide electrical stimulation to both ventricles.

Normally, as the electrical impulse moves through the heart, the heart contracts about 60 to 100 times a minute. Each contraction of the ventricles represents one heartbeat. The atria contract a fraction of a second before the ventricles so their blood empties into the ventricles before the ventricles contract.

Any dysfunction in the heart's electrical conduction system can make the heartbeat too fast, too slow, or at an uneven rate, thus, causing an arrhythmia.

What is an electrocardiogram (ECG)?

The electrical activity of the heart is measured by an electrocardiogram (ECG or EKG). By placing electrodes at specific locations on the body (chest, arms, and legs), a graphic representation, or tracing, of the electrical activity can be obtained. Changes in an ECG from the normal tracing can indicate arrhythmias, as well as other heart-related conditions.

Illustration of a basic EKG tracing
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How does the physician know what an ECG means?

Almost everyone knows what a basic ECG tracing looks like. But what does it mean?

  • The first little upward notch of the ECG tracing is called the "P wave." The P wave indicates that the atria (the two upper chambers of the heart) are electrically stimulated to pump blood to the ventricles.
  • The next part of the tracing is a short downward section connected to a tall upward section. This next part is called the "QRS complex." This part indicates that the ventricles (the two lower chambers of the heart) are electrically stimulated to pump out blood.
  • The next short flat segment is called the "ST segment." The ST segment indicates the amount of time from the end of the contraction of the ventricles to the beginning of the "T wave".
  • The next upward curve is the T wave. The T wave indicates the recovery period of the ventricles.

When your physician studies your ECG, he/she looks at the size and length of each part of the ECG. Variations in size and length of the different parts of the tracing may be significant. The tracing for each lead of a 12-lead ECG will look different, but will have the same basic components as described above. Each lead of the 12-lead is "looking" at a specific part of the heart, so variations in a lead may indicate a problem with the part of the heart associated with the lead.

What are the different types of arrhythmias?

An atrial arrhythmia is an arrhythmia caused by a dysfunction of the sinus node or the development of another atrial pacemaker within the heart tissue that takes over the function of the sinus node. A ventricular arrhythmia is an arrhythmia caused by a dysfunction of the sinus node, an interruption in the conduction pathways, or the development of another pacemaker within the heart tissue that takes over the function of the sinus node. Arrhythmias can also be classified as slow (bradyarrhythmia) or fast (tachyarrhythmia). "Brady-" means slow, while "tachy-" means fast.

Listed below are some of the more common arrhythmias:

ATRIAL ARRHYTHMIAS

VENTRICULAR ARRHYTHMIAS
Sinus arrhythmia: A condition in which the heart rate varies with breathing. Sinus arrhythmia is commonly found in children; adults may often have it as well. This is usually a benign condition - there may be no symptoms or problems associated sinus arrhythmias. Premature ventricular contractions (PVC's): A condition in which an electrical signal originates in the ventricles and causes the ventricles to contract before receiving the electrical signal from the atria. PVC's fairly common and often do not cause symptoms or problems. However, if the frequency of the PVC's increases to several per minute, symptoms such as weakness, fatigue, dizziness, fainting, or palpitations may be experienced.
Sinus tachycardia: A condition in which the heart rate is faster than 100 beats per minute because the sinus node is sending out electrical impulses at a rate faster than usual. This condition may cause symptoms such as weakness, fatigue, dizziness, or palpitations if the heart rate becomes too fast to pump an adequate supply of blood to the body. Sinus tachycardia is often transient, occurring when the body is under stress from exercise, strong emotions, fever, or dehydration, to name a few causes. Once the stress is removed, the heart rate will usually return to its usual rate. Ventricular tachycardia (VT): A condition in which an electrical signal is sent from the ventricles at a very fast but often regular rate. If the heart rate is sustained at a high rate, symptoms such as weakness, fatigue, dizziness, fainting, or palpitations may be experienced. A person in VT may require an electric shock to "convert" the rhythm to a regular one.
Sick sinus syndrome: A condition in which the sinus node sends out electrical signals either too slowly or too fast. There may be alternation between too-fast and too-slow rates. This condition may cause symptoms if the rate becomes too slow or too fast for the body to tolerate. Ventricular fibrillation (VF): A condition in which many electrical signals are sent from the ventricles at a very fast and erratic rate. As a result, the ventricles are unable to fill with blood and pump. This rhythm is life-threatening because there is no pulse and complete loss of consciousness. A person in VF requires prompt defibrillation to restore the normal rhythm and function of the heart. It may cause sudden cardiac death.
Premature supraventricular contractions or premature atrial contractions (PAC): A condition in which an atrial pacemaker site above the ventricles sends out an electrical signal early. The ventricles are usually able to respond to this signal, but the result is an irregular heart rhythm. PACs are common and may occur as the result of stimulants such as coffee, tea, alcohol, cigarettes, or medications.
Supraventricular tachycardia (SVT), paroxysmal atrial tachycardia (PAT): A condition in which the heart rate speeds up due to a series of early beats from an atrial or junctional pacemaker site above the ventricles. PAT usually begins and ends rapidly, occurring in repeated periods. This condition can cause symptoms such as weakness, fatigue, dizziness, fainting, or palpitations if the heart rate becomes too fast.
Atrial flutter: A condition in which the electrical signals come from the atria at a fast but even rate, often causing the ventricles to contract faster and increase the heart rate. When the signals from the atria are coming at a faster rate than the ventricles can respond to, the ECG pattern develops a signature "sawtooth" pattern, showing two or more flutter waves between each QRS complex. The number of waves between each QRS complex is expressed as a ratio, i.e., a two-to-one atrial flutter means that two Waves are occurring between each QRS.
Atrial fibrillation: A condition in which the electrical signals come from the atria at a very fast and erratic rate. The ventricles contract in an irregular manner because of the erratic signals coming from the atria.

The symptoms of various arrhythmias may resemble other medical conditions. Consult your physician for a diagnosis.

How are arrhythmias diagnosed?

There are several different types of procedures that may be used to diagnose arrhythmias. Some of these procedures include the following:

  • electrocardiogram (ECG or EKG)
    An electrocardiogram is a measurement of the electrical activity of the heart. By placing electrodes at specific locations on the body (chest, arms, and legs), a graphic representation, or tracing, of the electrical activity can be obtained as the electrical activity is received and interpreted by an ECG machine. An ECG can indicate the presence of arrhythmias, damage to the heart caused by ischemia (lack of oxygen to the heart muscle) or myocardial infarction (MI, or heart attack), a problem with one or more of the heart valves, or other types of heart conditions. There are several variations of the ECG test:
  • resting ECG
    For this procedure, the clothing on the upper body is removed and small sticky patches called electrodes are attached to the chest, arms, and legs. These electrodes are connected to the ECG machine by wires. The ECG machine is then started and records the heart's electrical activity for a minute or so. The patient is lying down during this ECG.
  • exercise ECG, or stress test
    The patient is attached to the ECG machine as described above. However, rather than lying down, the patient exercises by walking on a treadmill or pedaling a stationary bicycle while the ECG is recorded. This test is done to assess changes in the ECG during stress such as exercise.
  • signal-average ECG
    This procedure is done in the same manner as a resting ECG, except that the heart's electrical activity is recorded over a longer period of time, usually 15-20 minutes. Signal-average ECG is done when arrhythmia is suspected but not seen on a resting ECG, since arrhythmias may be transient in nature and not seen during the short recording time of the resting ECG.
  • electrophysiologic studies (EPS)
    This is an invasive test in which a small catheter (hollow tube) is inserted through the groin or neck into the heart. This gives the physician the capability of finding the site of the arrhythmia's origin within the heart tissue, thus, determining how to best treat it.
  • Holter monitor
    A Holter monitor is an ECG recording done over a period of 24 or more hours. Three electrodes are attached to the patient's chest and connected to a small portable ECG recorder by lead wires. The patient goes about his/her usual daily activities (except for activities such as taking a shower, swimming, or any activity causing an excessive amount of sweating which would cause the electrodes to become loose or fall off) during this procedure. There are 2 types of Holter monitoring:
    • continuous recording - the ECG is recorded continuously during the entire testing period.
    • event monitor, or loop recording - the ECG is recorded only when the patient starts the recording when symptoms are felt.

    Holter monitoring may be done when an arrhythmia is suspected but not seen on a resting or signal-average ECG, since arrhythmias may be transient in nature and not seen during the shorter recording times of the resting or signal-average ECG.

Illustration of a man wearing a Holter monitor
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How are arrhythmias treated?

Arrhythmias may be present but cause few, if any, problems. In this case, the physician may elect not to treat the arrhythmia. However, when the arrhythmia causes symptoms, there are several different options for treatment. The physician will choose an arrhythmia treatment based on the type of arrhythmia, the severity of symptoms being experienced, and the presence of other conditions (diabetes, kidney failure, heart failure, etc.) which can affect the course of the treatment.

Some treatments for arrhythmias include:

  • lifestyle modification
    Factors such as stress, caffeine, or alcohol can cause arrhythmias. The physician may order the elimination of caffeine, alcohol, or any other substances believed to be causing the problem. If stress is suspected as a cause, the physician may recommend stress-reduction measures such as meditation, stress-management classes, an exercise program, or psychotherapy.
  • medication
    There are various types of medications which may be used to treat arrhythmias. If the physician chooses to use medication, the decision of which medication to use will be determined by the type of arrhythmia, other conditions which may be present, and other medications already being taken by the patient.
  • cardioversion
    In this procedure, an electrical shock is delivered to the heart through the chest to stop certain very fast arrhythmias such as atrial fibrillation, supraventricular tachycardia, or sinus tachycardia. The patient is connected to an ECG monitor which is also connected to the defibrillator. The electrical shock is delivered at a precise point during the ECG cycle to convert the rhythm to a normal one.
  • ablation
    This is an invasive procedure done in the electrophysiology laboratory, which means that a catheter (hollow tube) is inserted into the heart through a vessel in the groin or arm. The procedure is done in a manner similar to the electrophysiology studies (EPS) described above. Once the site of the arrhythmia has been determined by EPS, the catheter is moved to the site. By use of a technique such as radiofrequency ablation (very high frequency radio waves are applied to the site, heating the tissue until the site is destroyed) or cryoablation (an ultra-cold substance is applied to the site, freezing the tissue and destroying the site), the site of the arrhythmia may be destroyed.
  • pacemaker
    A permanent pacemaker is a small device that is implanted under the skin (most often in the shoulder area just under the collar bone), and sends electrical signals to start or regulate a slow heart beat. A permanent pacemaker may be used to make the heart beat if the heart's natural pacemaker (the SA node) is not functioning properly and has developed an abnormal heart rate or rhythm or if the electrical pathways are blocked. Pacemakers are typically used for slow arrhythmias such as sinus bradycardia, sick sinus syndrome, or heart block.
  • implantable cardioverter defibrillator
    An implantable converter defibrillator (ICD) is a small device, similar to a pacemaker, that is implanted under the skin, most often in the shoulder area just under the collarbone. An ICD senses the rate of the heartbeat. When the heart rate exceeds a rate programmed into the device, it delivers a small electrical shock to the heart to slow the heart rate. Many newer ICDs can also function as a pacemaker by delivering an electrical signal to regulate a heart rate that is too slow. ICDs are typically used for fast arrhythmias such as ventricular tachycardia.
  • surgery
    Surgical treatment for arrhythmias is usually done only when all other appropriate options have failed. Surgical ablation is a major surgical procedure requiring general anesthesia. The chest is opened, exposing the heart. At the site where the arrhythmia is located, the tissue is destroyed or removed in order to eliminate the source of the arrhythmia.

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