Heart disease and abnormal heart rhythm

Heart disease and abnormal heart rhythm (arrhythmia)

An irregular heartbeat is an arrhythmia (also called dysrhythmia). Heart rates can also be irregular. A normal heart rate is 50 to 100 beats per minute. Arrhythmias and abnormal heart rates don't necessarily occur together. Arrhythmias can occur with a normal heart rate, or with heart rates that are slow (called bradyarrhythmias - less than 50 beats per minute). Arrhythmias can also occur with rapid heart rates (called tachyarrhythmias - faster than 100 beats per minute).

What causes an arrhythmia?

Arrhythmias may be caused by many different factors, including:

Coronary artery disease.

Electrolyte (such as sodium or potassium) imbalances in your blood.

Changes in your heart muscle.

Injury from a heart attack.

Healing process after heart surgery.

Irregular heart rhythms can also occur in ‘normal, healthy’ hearts.

What are the types of arrhythmias?

The types of arrhythmias include:

Premature atrial contractions. These are early extra beats that originate in the atria (upper chambers of the heart). They are harmless and do not require treatment.

Premature ventricular contractions (PVCs). These are among the most common arrhythmias and occur in people with and without heart disease. This is the skipped heartbeat we all occasionally experience. In some people, it can be related to stress, too much caffeine or nicotine, or too much exercise. But sometimes, PVCs can be caused by heart disease or electrolyte imbalance. People who have a lot of PVCs, and symptoms associated with them, should be evaluated by a heart specialist. However, in most people, PVCs are usually harmless and rarely need treatment.

 Atrial fibrillation. Atrial fibrillation is a very common irregular heart rhythm that causes the atria, the upper chambers of the heart, to contract abnormally.

Atrial flutter. This is an arrhythmia caused by one or more rapid circuits in the atrium. Atrial flutter is usually more organised and regular than atrial fibrillation. This arrhythmia occurs most often in people with heart disease and in the first week after heart surgery. It often converts to atrial fibrillation.

Paroxysmal supraventricular tachycardia (PSVT). This is a rapid heart rate, usually with a regular rhythm, originating from above the ventricles. PSVT begins and ends suddenly. There are two main types: accessory path tachycardias and AV nodal re-entrant tachycardias.

Accessory pathway tachycardias. This is a rapid heart rate due to an extra abnormal pathway or connection between the atria and the ventricles. The impulses travel through the extra pathways as well as through the usual route. This allows the impulses to travel around the heart very quickly, causing the heart to beat unusually fast.

AV nodal re-entrant tachycardia. A rapid heart rate due to more than one pathway through the AV node. It can cause heart palpitations, fainting, or heart failure. In many cases, it can be terminated using simple manoeuvres, such as breathing in and bearing down, and others performed by a trained medical professional. Some drugs can also stop this heart rhythm.

Ventricular tachycardia (V-tach). This is a rapid heart rhythm originating from the lower chambers (or ventricles) of the heart. The rapid rate prevents the heart from filling adequately with blood; therefore, less blood is able to pump through the body. This can be a serious arrhythmia, especially in people with heart disease, and may be associated with more symptoms. A heart specialist should evaluate this arrhythmia.

Ventricular fibrillation.  This is an erratic, disorganised firing of impulses from the ventricles. The ventricles quiver and are unable to contract or pump blood to the body. This is a medical emergency that must be treated with cardiopulmonary resuscitation (CPR) and defibrillation as soon as possible.

Long QT syndrome. The QT interval is the area on the electrocardiogram that represents the time it takes for the heart muscle to contract and then recover, or for the electrical impulse to fire impulses and then recharge. When the QT interval is longer than normal, it increases the risk for ‘torsade de pointes’, a life-threatening form of ventricular tachycardia. Long QT syndrome is an inherited condition that can cause sudden death in young people. It can be treated with anti-arrhythmic drugs, pacemakers, electrical cardioversion, defibrillation, implanted cardioverter/defibrillator, or ablation therapy.

Bradyarrhythmias. These are slow heart rhythms, which may arise from disease in the heart's electrical conduction system. Examples include sinus node dysfunction and heart block.

Sinus node dysfunction. This is a slow heart rhythm due to an abnormal SA (sinus) node. Significant sinus node dysfunction that causes symptoms is treated with a pacemaker.

Heart block. This is a delay or complete block of the electrical impulse as it travels from the sinus node to the ventricles. The level of the block or delay may occur in the AV node or HIS-Purkinje system. The heart may beat irregularly and, often, more slowly. If serious, heart block is treated with a pacemaker

What are the symptoms of arrhythmias?

An arrhythmia can be silent and not cause any symptoms. A doctor can detect an irregular heartbeat during a physical examination by taking your pulse or through an electrocardiogram (ECG).

When symptoms of an arrhythmia occur, they may include:

Palpitations (a feeling of skipped heart beats, fluttering or ‘flip-flops’, or feeling that your heart is ‘running away’).

Pounding in your chest.

 Dizziness or feeling light-headed.

Fainting.

Shortness of breath.

Chest discomfort.

Weakness or fatigue.

How are arrhythmias diagnosed?

Tests used to diagnose an arrhythmia or determine its cause include:

Electrocardiogram

Holter monitor

Event monitor

Stress test

Echocardiogram

Cardiac catheterisation

Electrophysiology study (EPS)

Head-up tilt table test

 How are arrhythmias treated?

Treatment depends on the type and seriousness of your arrhythmia. Some people with arrhythmias require no treatment. For others, treatments can include medication, making lifestyle changes, and undergoing surgical procedures.

What drugs are used to treat arrhythmias?

A variety of drugs are available to treat arrhythmias. These include:

Anti-arrhythmic drugs. These drugs control heart rate and include beta-blockers.

Anticoagulant or antiplatelet therapy. These drugs reduce the risk of blood clots and stroke. These include warfarin (a ‘blood thinner’) or aspirin.

Because everyone is different, it may take trials of several medications and doses to find the one that works best for you.

Lifestyle changes can help arrhythmias

If you notice that your arrhythmia occurs more often with certain activities, you should avoid them.

If you smoke, stop.

Limit your intake of alcohol.

Limit or stop using caffeine. Some people are sensitive to caffeine and may notice more symptoms when using caffeine products (such as tea, coffee, juice drinks, and some over-the-counter medications).

Stay away from stimulants used in cough and cold medications. Some such medications contain ingredients that promote irregular heart rhythms. Read the label and ask your doctor or pharmacist what medication would be best for you.

What is electrical cardioversion?

If drugs are not able to control a persistent irregular heart rhythm (such as atrial fibrillation), cardioversion may be required. After administration of a short-acting anaesthesia, an electrical shock is delivered to your chest wall that synchronises the heart and allows the normal rhythm to restart.

What is a pacemaker?

A pacemaker is a device that sends small electrical impulses to the heart muscle to maintain a suitable heart rate. Pacemakers primarily prevent the heart from beating too slowly. The pacemaker has a pulse generator (which houses the battery and a tiny computer) and leads (wires) that send impulses from the pulse generator to the heart muscle. Newer pacemakers have many sophisticated features that are designed to help manage arrhythmias and optimise heart rate related function as much as possible.

What is an implantable cardioverter defibrillator (ICD)?

An ICD is a sophisticated device used primarily to treat ventricular tachycardia and ventricular fibrillation, two life-threatening heart rhythms. The ICD constantly monitors the heart rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle to cause the heart to beat in a normal rhythm again. There are several ways the ICD can be used to restore normal heart rhythm. They include:

Anti-tachycardia pacing (ATP). When the heart beats too fast, a series of small electrical impulses may be delivered to the heart muscle to restore a normal heart rate and rhythm.

Cardioversion. A low energy shock may be delivered at the same time as the heart beats to restore normal heart rhythm.

Defibrillation. When the heart is beating dangerously fast or irregularly, a higher energy shock may be delivered to the heart muscle to restore a normal rhythm.

Anti-bradycardia pacing. Many ICDs provide back-up pacing to maintain heart rhythm if it slows too much

Heart disease and abnormal heart rhythm (arrhythmia)

What is catheter ablation?

During an ablation, high-frequency electrical energy is delivered through a catheter to a small area of tissue inside the heart that causes the abnormal heart rhythm. This energy ‘disconnects’ the pathway of the abnormal rhythm. Ablation is used to treat most PSVTs, atrial flutter, atrial fibrillation, and some atrial and ventricular tachycardias. Ablation may be combined with other procedures to achieve optimal treatment.

What is heart surgery?

Heart surgery may be needed to correct heart disease that may be causing the arrhythmia. The Maze procedure is a type of procedure used to correct atrial fibrillation. During this procedure, a series (or ‘maze’) of incisions is made in the right and left atria to confine the electrical impulses to defined pathways. Some people may require a pacemaker after this procedure

Dizziness: Symptoms, diagnosis and treatment

What is dizziness?

Almost everyone has had a feeling of unsteadiness or a whirling sensation in their heads at some point in their lives. Usually it's put down to dizziness, but dizziness is a broad term that can mean different things to different people. It's a common complaint, but it can be serious. It has no specific medical meaning, but there are four common conditions that can be considered types of dizziness:

 Vertigo. The feeling of motion when there is no motion such as you spinning or your environment spinning. Spinning yourself round and round, then suddenly stopping can produce temporary vertigo. However, when it happens in the normal course of living, it signals a problem with the vestibular system of the inner ear - the body's balance system that tells you which way is down and senses the position of your head. About half of all dizziness complaints are vertigo.

Light-headedness. Also called near syncope, light-headedness is the feeling that you are about to faint. It is commonly felt by standing up too quickly or by breathing deeply enough times to produce the sensation.

Disequilibrium. A problem with walking. People with disequilibrium feel unsteady on their feet or feel like they are going to fall.

Anxiety. People who are scared, worried, depressed or afraid of open spaces may use "dizzy" to mean frightened, depressed or anxious.

Frequent dizziness sufferers may complain of more than one type of dizziness. For instance, having vertigo may also make them anxious.

Dizziness can be a one-off event, or it can be a chronic, long-lasting problem. Nearly everyone who is dizzy will get better. This is because a person's sense of balance is a complex interaction between the brain, each ear's separate vestibular system, and the sense of vision. When one component breaks down, the others usually learn to compensate.

What causes dizziness?

Vertigo can be caused by many things:

Infection such as the ones that cause the common cold or diarrhoea can cause temporary vertigo via an ear infection. This inner ear infection is generally viral, harmless and goes away usually in one to six weeks, but medicines are available if it is severe.

Benign paroxysmal positional vertigo (positional vertigo or BPPV) is caused by movement of the otolith - a tiny calcium particle the size of a grain of sand - from the part of the ear that senses gravity to the part that senses head position. The person feels as if their head is turning when it isn't. A two-minute therapy can move the otolith back where it belongs and fix the problem. This therapy, called the Epley manoeuvre, cures vertigo 80% of the time.

Meniere's disease is a disorder characterised by long-lasting episodes of severe vertigo. Other symptoms of Meniere's disease are tinnitus (ringing in the ear), hearing loss and pressure or fullness in the ear.

Bilateral vestibular loss is a feeling of everything bouncing up and down. It can happen to people who take an antibiotic that is toxic to the ear. It usually improves over time.

Less commonly, deadly diseases such as stroke can also cause vertigo

Dizziness: Symptoms, diagnosis and treatment

What causes dizziness?

Light-headedness is usually caused by some surrounding circumstance impairing blood flow to the brain when a person is standing up. Blame this problem on our ancestors who learned to walk upright - putting our brain above our heart. It's a challenge for the heart to keep the brain supplied with blood - and it's easy for this system to break down. When blood vessels in the brain become dilated, or expand, due to high temperature, excitement or hyperventilation, alcohol consumption, or certain medications, a person can become light-headed. There can also be more serious causes such as a stroke and heart disease.

Disequlibrium can be caused by:

A kind of arthritis in the neck called cervical spondylosis, which puts pressure on the spinal cord.

Parkinson's disease or related disorders that cause a person to stoop forwards.

Disorders involving a part of the brain called the cerebellum. The cerebellum is the part of the brain responsible for balance and coordination.

Diseases such as diabetes that can lead to loss of sensation in the legs.

Dizziness in the form of anxiety is often, but not always, caused by depression. It can also be due to an anxiety disorder or phobia.

Various medications can also cause dizziness as a side effect.

What are the symptoms of dizziness?

Feeling of motion when your body is still.

Feeling light-headed or that you are about to faint.

Balance problems such as being unsteady on your feet or feeling as if you might fall.

Feelings of anxiety or panic.

Seek medical advice if:

You also have tinnitus (ringing in the ears), hearing loss, or pressure or fullness in the ear - you may have Meniere's disease.

The whole world seems to bounce as you walk - you may have bilateral vestibular loss.

You also have double vision or slurred speech - you may have suffered a stroke.

You feel light-headed and you are an older person, or it happens after exercising.

You feel light-headed frequently after standing up - you may have orthostatic hypotension.

Your dizziness is long-lasting.

How do I know if I have dizziness?

Because dizziness can involve so many parts of the body - ears, brain or heart, to name a few - your doctor will take a careful history of your symptoms, examine you, and make a referral to a specialist if necessary. Make sure you describe the sensation you feel thoroughly, since dizziness can be many things to many

dizziness: Symptoms, diagnosis and treatment

What are the treatments for dizziness?

Treatment depends on the type of dizziness you are experiencing. In general, treatment involves finding the underlying cause of the dizziness, whether a disease, a behaviour or an environmental factor.

People with dizziness caused by a physical injury almost always recover. If there is no physical cause, the problem is of emotional or mental health origin. In that case treatment may involve psychological therapy.

If the dizziness is caused by medication, your doctor may reduce the amount you take or change you to another medicine.

 For vertigo your doctor may prescribe bed rest or medications that suppress the activity of the inner ear such as antihistamines or sedatives.

 Disequilibrium or imbalance can be treated with balance therapy, which uses sophisticated devices to make a person relearn their sense of balance, but psychological therapy may also be necessary. Stress management and relaxation therapy may help.

 Treatment for severe light-headedness may involve decreasing the amount of blood pooling in the legs. This may be done through raising the legs as often as possible, wearing compression stockings, or medications to improve the functioning of the heart or reduce body fluid volume.

 Surgery may be necessary for more severe cases such as those caused by Meniere's disease.

 Accidents are more likely to occur while you are dizzy so use caution while driving or operating machinery.

Self-care at home for dizziness

Dizziness may be a symptom of something serious and should always be discussed with a doctor.

  At home:

Get plenty to drink, have regular meals, and get plenty of rest.

Standing up more slowly may help dizziness associated with position changes.

Reassurance can help an anxious person who feels dizzy.

Make your home safe to lessen the risk of falls and injury.

Rails, a walking stick or frame, and bathtub mats are safety measures that may help avoid falls and injuries.

Secure mats and carpet to avoid falls.

A doctor may recommend a home occupational therapy assessment

Medical treatment

Treatment depends on the cause of the patient's dizziness.

Doctors may start emergency treatment, for example for heart attack or stroke, an emergency blood transfusion or surgery.

Often, IV fluids are given to treat dehydration.

The patient may receive medications to control fever or treat infection.

The patient may be given oxygen right away.

If blood tests reveal abnormal blood chemistry (electrolyte levels), this will be corrected.

Other treatments for a specific disease may be started.

Sometimes, the only treatment may be a discussion of a likely cause and home safety

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