What is an abnormal heart rhythm (arrhythmia)?

When the heart's electrical system malfunctions, the normal rhythm of the heart can
be affected. Depending upon the abnormality, the heart may begin to beat too fast,
too slow, irregularly, or not at all. Heart rhythm disorders are often referred to as
cardiac arrhythmias (cardiac = heart; a = lack of) but this is technically incorrect,
since in most cases there is a heart rhythm, but it is abnormal. Cardiac dysrhythmia
(dys = abnormal or faulty + rhythm) might be a better term.

Dysrhythmias may occur because of problems directly associated with the electrical
"wiring," the SA node, the AV node, or ventricular conducting system. The issue may
also be due to influences on the conducting system from outside the heart. These
can include electrolyte abnormalities in the bloodstream, abnormal hormone levels
(for example thyroid function that is too high or too low), and medication or drug
ingestions.

Any abnormality of the electrical cycle within the heart that generates an abnormal
beat, whether it is too fast, too slow, skipped, or irregular is considered a
dysrhythmia.

Dysrhythmias are usually classified as originating from above the AV

node (supraventricular ) or below, from the ventricle. They are either fast, slow, or
irregular and persistent or intermittent.

How does the heart work?

The heart is a two-stage electric pump whose job it is to circulate blood through the
body. The initial electrical impulse that begins the process of a heartbeat is
generated by a group of cells located in the upper chamber of the heart, the atrium.
These cells act as an automatic pacemaker, starting the electric signal that spreads
along the "wiring" within the heart muscle, allowing a coordinated squeeze so that
the pump can function.

The heart has four chambers. The upper chambers are the right and left atria
(singular = atrium) while the lower chambers are the right and left ventricles. The
right side of the heart pumps blood to the lungs while the left side pumps it to the
rest of the body.

Blood from the body depleted of oxygen and containing carbon dioxide is collected
in the right atriumand then pushed into the right ventricle with a small beat of the
upper chamber of the heart. The right ventricle pumps the blood to the lungs to pick
up oxygen and release the carbon dioxide. The oxygen-rich blood returns to the left
atrium where the small atrial beat pushes it to the left ventricle. The left ventricle is
much thicker than the right because it needs to be strong enough to send blood to
the entire body.

There are special cells in the right atrium called the sinoatrial node (SA node) that
generate the first electrical impulse, allowing the heart to beat in a coordinated way.
The SA node is considered the "natural pacemaker" of the heart. This pacemaker
function begins the electrical impulse, which follows pathways in the atrial walls,
almost like wiring, to a junction box between the atrium and ventricle called
the atrioventricular node (AV node). This electric signal causes muscle cells in both
atria to contract at once. At the AV node, the electric signal waits for a very short
time, usually one- to two-tenths of a second, to allow blood pumped from the atria
to fill up the ventricles. The signal then passes through electric bundles in the
ventricle walls to allow these chambers to contract, again in a coordinated way, and
pump blood to the lungs and body.
The SA node generates an electric beat about 60 to 80 times a minute, and each
should result in a heartbeat. That beat can be felt as an external pulse. After a
heartbeat, the muscle cells of the heart need a split second to get ready to beat again,
and the electrical system allows a pause for this to happen.

Picture of the great vessels of the heart.

 Picture of the heart's electrical system.

The heart and its electrical activity work within a narrow range of normal.
Fortunately, the body tends to protect the heart as best as it can. Rhythm
disturbances may be normal physiologic responses, but some may be potentially life
threatening.

Every cell in the heart can act as a pacemaker. A healthy SA node has an intrinsic
heart beat generation rate of 60 to 80. If the atrium fails to generate a heartbeat,
then a healthy AV node can do so at a rate of about 40, and if needed, the ventricles
themselves can generate heartbeats at a rate of about 20 per minute. This may occur
if the cells of the upper chamber fail to generate an electrical impulse or if the
electrical signals to the ventricle are blocked. However, these lower rates may be
associated with the inability of the heart to pump blood to the body to meet its
needs and may result in shortness of breath, chest pain, weakness, or passing out.
Quick GuideAtrial Fibrillation: Heart Symptoms, Diagnosis, & Afib
Treatment

Cardiac Arrhythmia Treatment: Ablation

Ablation is used to treat abnormal heart rhythms, or arrhythmias. The type of arrhythmia and the presence of
other heart disease will determine whether ablation can be performed surgically or non-surgically.

 Non-surgical ablation, used for many types of arrhythmias, is performed in a

special lab called the electrophysiology (EP) laboratory.
 Surgical ablation procedures used for treating atrial fibrillation can be
"minimally invasive" or traditional "open" surgery and may be combined with
other surgical therapies such as bypass surgery, valve repair, or valve
replacement. Surgical ablation procedures include:
o The Maze procedure
o Minimally invasive surgical ablation
o The modified Maze procedure
hat causes heart rhythm disorders?
Heart rhythm disturbances may occur because of problems within the heart itself or
be the result of abnormalities in the body's environment that can affect the heart's
ability to conduct electricity.

Cardiac or heart muscle cells become irritated when they are depleted of oxygen.
This can occur during a heart attack, in which the coronary arteries, the blood
vessels that supply the heart with blood, are blocked. Lack of oxygen can occur
when the lungs are unable to extract oxygen from the air. Significant anemia, or low
red blood cell count, decreases the oxygen-carrying capacity of the blood and may
prevent adequate oxygen delivery. Rapid heart rates may be due to "wiring"
problems with the electrical pathways in the heart. This can cause "short circuits"
making the heart speed up and beat 150 beats a minute or more. The abnormality
can be due to a physical extra electrical pathway such as that seen in Wolff-
Parkinson-White (WPW) syndrome, or it can be due to changes in the electrical
physiology between a few cells, like in atrial flutter.

Rapid heart rates can also occur because of environmental issues that affect the
heart. These can be intrinsic to the body, like anemia, abnormal electrolyte levels, or
abnormal thyroid hormone levels. They may also be due to reactions to outside
influences like caffeine, alcohol, over-the-counter coldremedies, or stimulants such
as amphetamines. To the cardiac muscle cell, they all appear to be adrenaline-like
substances that can cause cell irritation.

Slow dysrhythmias can also be problematic. If the heart beats too slowly, the body
may not be able to maintain an adequate blood pressure and supply the body's
organs with enough oxygen-rich blood to function.
Slow heart rates may be due to aging of the SA node and its inability to generate an
electrical pacemaker signal. Often though, it is due to the side effects of medications
used to control high blood pressure. Side effects of beta blocker and certain calcium
channel blocker drugs include a slowing of the heart rate.

Body environment is also important with slow heart rhythm

abnormalities. Hypothermia, or low body temperature, is a potential cause.

What are the different types of heart rhythm disorders?

Heart rhythm disorders are classified according to where they occur in the heart
and how they affect the heartbeat.

What are the signs and symptoms of heart rhythm

disorders?
Many people may have heart rhythm disturbances and never be aware of them.
Premature atrial contractions (PACs) and premature ventricular
contractions (PVCs) are variations of normal and most often, people are unaware
that an extra beat has occurred. However, some patients are keenly aware of any
extra heartbeat, even if it is a normal variant and requires no treatment.

That said, the initial symptom of dysrhythmia is often palpitations, a sensation that
the heart is beating too quickly, too slowly, beating irregularly, or skipping a beat.
The palpitations may be intermittent or may require medical intervention to
resolve.

Because of the heart rhythm abnormality, other symptoms may occur because of
decreased cardiac output (the amount of blood that the heart pushes out to meet the
body's demand for oxygen and energy). The patient may complain
of lightheadedness, weakness, nausea and vomiting, chest pain, and shortness of
breath.

In critical situations, the patient may fall to the ground or lose consciousness. This
may be due to life-threatening dysrhythmias like ventricular fibrillation or
ventricular tachycardia. It may be due to heart rates so fast that there isn't enough
blood pressure generated to supply the brain with what it needs. The same result
can also occur if the heart beats too slowly and insufficient blood pressure is
generated.

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 Atrial fibrillation (A-fib)
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Atrial fibrillation occurs when the atrium has lost the ability to beat in a coordinated
fashion. Instead of the SA node generating a single electrical signal, numerous areas
of the atrium become irritated and produce electrical impulses. This causes the
atrium to jiggle, or fibrillate, instead of beating. The AV node sees all the electrical
signals, but because there are so many, and because they are so erratic, only some of
the hundreds of signals per minute are passed through to the ventricle. The
ventricles then fire irregularly and often very quickly.

As in PSVT, the symptoms may include palpitations, lightheadedness, and shortness

of breath. The cause of atrial fibrillation, however, may be more significant, since it
may be due to aging of the conducting system of the heart and there may be
associated atherosclerotic heart disease. Therefore, atrial fibrillation with rapid
ventricular response associated with chest pain or shortness of breath may need
emergent cardioversion (a procedure that uses electricity to shock the heart back
into a normal rhythm) or intravenous medications to control the heart rate.

One significant complication of atrial fibrillation is the formation of blood clots along
the inside of the heart wall. These clots may break off and travel to different organs
in the body (embolize), blocking blood vessels and causing the affected organs to
malfunction because of the loss of blood supply. A common complication is a clot
traveling to the brain, resulting in a stroke.

The treatment of atrial fibrillation depends upon many factors including how long it
has been present, what symptoms it causes, and the underlying health of the
individual. The patient and his or her doctor will decide whether or not to restore a
normal sinus rhythm or to simply keep the heart rate under control.

Atrial fibrillation can be a safe rhythm and not life threatening when the rate is
controlled. Medications are used to slow the electrical impulses through the AV
node, so that the ventricles do not try to capture each signal being produced. The
reason to return people to a regular rhythm has to do with cardiac output. In atrial
fibrillation, the atria do not beat and pump blood to the ventricles. Instead, blood
flows into the ventricles by gravity alone. This lack of atrial kick can decrease the
heart's efficiency and cardiac output by 10% to 15%.

Blood thinning, or anticoagulation, may be recommended for those patients with

atrial fibrillation and elevated risk for stroke. Oral drugs that anticoagulate
are warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto),
and apixaban (Eliquis). There are other injectable drugs that are used in a hospital
setting. If the patient is at low risk, the doctor may recommend aspirin alone
for stroke prevention. If atrial fibrillation is poorly tolerated due to symptomatic
palpitations or symptoms of reduced cardiac output, or if there are concerns with
lifelong anticoagulation therapy, more definitive therapy may include specific
medications, electrical cardioversion, or catheter based ablation (sometimes with a
pacemaker inserted). Atrial fibrillation is a common condition, with many
implications, and the best plan for each patient should be discussed at length with
one's physician.

Atrial flutter
Atrial flutter is similar to atrial fibrillation except that instead of having chaotic
electrical firing from all points in the atrium, one point has become irritated and can
fire 300 times per minute or more. Many issues that exist for atrial fibrillation apply
to atrial flutter. Atrial flutter may degenerate into atrial fibrillation, and the two can
often coexist.

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Sinus bradycardia
The heart, its cells, and its electricity may come under the many outside influences
causing it to beat more slowly. Sinus bradycardia (brady = slow + cardia = heart) by
definition, is a heartbeat generated by the SA node at a rate slower than 60 beats per
minute. This may be normal in people who are active and athletic or in patients
taking medications designed to slow the heart such as beta blockers and
some calcium channel blockers.

Vasovagal syncope is an episode of profound sinus bradycardia associated with a

noxious stimulus that causes the vagal system of the body to kick in and slow the
heart rate. While the sympathetic system of the body is mediated by adrenaline, the
parasympathetic system is mediated by the vagus nerve and the chemical
acetylcholine, which promotes the exact opposite body reaction than adrenaline. In
some people, exposure to pain or a difficult emotional situation can stimulate the
vagus nerve, slow the heart, and dilate blood vessels (veins), causing cardiac output
to decrease and making a person feel lightheaded or faint. The vagus nerve also can
be stimulated to slow the heart when one bears down to urinate (micturition
syncope) or have a bowel movement.

Tachycardia
Rapid heart rates can originate from either the atrium or the ventricle, but rhythms
from the ventricle are more often life threatening. The initial approach to rapid
heart rates is to quickly identify the rhythm, and if blood pressure is maintained and
there is no evidence of a failing heart, then treatment is directed to rate control with
the eventual return of the heart back to normal sinus rhythm. If, however, there is
evidence that the heart is failing because of the rapid rate, then emergency
measures, including using electricity to shock the heart back into a regular rhythm,
may be necessary.

Sinus tachycardia
The heart, its cells, and its electricity may come under many outside influences that
may cause it to beat more quickly. Sinus tachycardia (sinus = from the SA node +
tachy = rapid + cardia = heart), or a rapid regular heartbeat, is a common rhythm
issue. It occurs when the body signals the heart to pump more blood, or when the
electrical system is stimulated by chemicals.

The body needs increased cardiac output in times of physiologic stress. Cardiac
output is the amount of blood the heart pumps in the course of 1 minute. It can be
calculated by the amount of blood that the heart pumps with each beat (stroke
volume) multiplied by the heart rate.

Cardiac output = (stroke volume) x (heart rate)

The stroke volume tends to be relatively constant. When the body requires extra
oxygen delivery, the heart rate needs to increase to meet that demand. Examples
include:
  exercise, in which the muscles have greater oxygen requirements and the
heart rate speeds up to pump more blood to meet that need;
 dehydration, in which there is less fluid in the body and the heart rate has to
speed up to compensate; or
 in cases of acute bleeding that may occur after trauma.

The electrical system can be stimulated in a variety of ways to make the heart beat
faster. In times of stress, the body generates cortisol and adrenaline, causing an
increased heart rate in addition to other changes in the body. Think of being
frightened and feeling your heart race. Increased thyroid hormone levels in the body
can also cause a tachycardia. Ingestion of a variety of drugs can also cause the heart
to race, including caffeine, alcohol, and over-the-counter cold medications that
include chemicals such as phenylephrine and pseudoephedrine. These compounds
are metabolized by the body and act like an adrenaline stimulus to the heart. Illegal
drugs such as methamphetamine and cocaine can also cause a sinus tachycardia.

Atrial Fibrillation Slideshow: Causes, Tests and Treatment

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Heart Symptoms Never to Ignore Slideshow

Ventricular fibrillation (V-fib)

Ventricular fibrillation is technically not a rapid heart rhythm because the heart
ceases to beat. In ventricular fibrillation, the ventricles do not have a coordinated
electrical pattern and the ventricles, instead of beating, just jiggle, or fibrillate. Since
the heart doesn't beat, blood is not circulated to the body or brain and all bodily
functions stop. Without a coordinated impulse to signal the ventricle to beat, sudden
cardiac death occurs.

The treatment for V-fib is defibrillation with an electrical shock. Automated external
defibrillators (AEDs) in public places have helped decrease the mortality from
sudden cardiac death, but prevention remains the mainstay to survive this event.
Some people, such as those with a very weak heart muscle or who have a prior
history of ventricular fibrillation will require an implantable defibrillator to prevent
future episodes of sudden death and treat this rhythm.

This rhythm is often associated with a heart attack in which the heart muscle
doesn't get enough blood supply (myocardial ischemia), becomes irritated, and
causes secondary irritation of the electrical system. Aside from myocardial ischemia,
other causes of ventricular fibrillation may include severe weakness of the heart
muscle (cardiomyopathy), electrolyte disturbances, drug overdose, and poisoning.
Ventricular tachycardia (V-tach)
Ventricular tachycardia is another rapid heart rate that originates in the ventricle.
The causes are the same as those for ventricular fibrillation, but because of the
electrical conduction pattern in the heart pathways, an organized signal is provided
to the ventricles, potentially allowing them to beat. This remains an emergency,
since V-tach may degenerate into ventricular fibrillation.

Premature atrial contractions (PACs) and premature

ventricular contractions (PVCs)
Every person experiences the occasional palpitation in which the atrium or the
ventricle beats early. These premature atrial contractions (PACs) or premature
ventricular contractions (PVCs) are normal variants and most people are unaware
of their occurrence. However, some patients report a palpitation in the chest and
neck, often described as a "thump" or "thud." PACs and PVCs in otherwise healthy
individuals do not pose any health risks.

Quick GuideAtrial Fibrillation: Heart Symptoms, Diagnosis, & Afib

Treatment
Paroxysmal supraventricular tachycardia (PSVT)
Paroxysmal supraventricular tachycardia (PSVT) occurs when the pathways in the
AV node or atrium allow an altered conduction of electricity, and the atrium begins
firing in a fast but regular rate, sometimes more than 150 to 200 times per minute.
The ventricles, sensing the electrical activity coming through the AV node, try to
beat along with each electrical impulse and PSVT occurs.

This is rarely a life-threatening event, but people may feel uncomfortable when
PSVT occurs. They may become lightheaded, weak, have shortness of breath, and
describe a feeling of fullness in the throat. PSVT may also be tolerated and may stop
on its own. If this is a first time event, activating EMS (emergency medical services)
and calling 9-1-1 is important, since other tachycardias can be life threatening.

The treatment for PSVT includes attempts to stimulate the vagus nerve to slow the
heart (see vasovagal syncope above) by holding one's breath and bearing down as if
to have a bowel movement. Intravenous medications are often used to interrupt the
episode. Many patients have PSVT due to congenital abnormalities in the electrical
conduction system of the heart. External causes can include hyperthyroidism,
electrolyte imbalances, and the use of caffeine, alcohol, over-the-counter cold
medications containing stimulants, or illegal drugs like cocaine and
methamphetamine.

Wolff-Parkinson-White (WPW) syndrome

Wolff-Parkinson-White syndrome is a specific type of PSVT, in which an inborn
error of wiring has occurred near the AV node, and an accessory electrical pathway
exists. The diagnosis is made by electrocardiogram (EKG) or electrophysiologic
testing, and the treatment may include medication or destruction of the accessory
electrical pathway by invasive catheter ablation.

Atrial Fibrillation Slideshow: Causes, Tests and Treatment

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Heart Symptoms Never to Ignore Slideshow

Bradycardia
Aside from medications that are meant to slow the heart for treatment of a variety
of medical problems, bradycardia (brady = low + cardia = heart) is usually due
to heart block and the aging of the electrical wiring of the heart. This is no different
than the aging of your home's electrical system; but instead of being able to rewire
the heart, these conditions may need to be treated with an implantable pacemaker.

Heart blocks

Heart blocks involving the ventricle may be asymptomatic and of little consequence
except to point to underlying heart or lung disease. They are diagnosed by EKG.

Heart blocks involving the atrium can be classified as first-, second-, and third-
degree.

 First-degree heart block is common and usually of little significance. There is

a slight delay in getting the electrical signal from the SA node to the AV node,
but the heart functions normally.
 There are two types of second-degree heart block (Mobitz I and Mobitz II,
with Type II being more serious than Type I.
  Third-degree heart block describes the complete loss of connection between
the electrical activity of the atria and the ventricles. Second- and third-degree
heart blocks are diagnosed by analyzing heart rhythm strips and EKGs.

Heart blocks are symptomatic because the heart beats so slowly that cardiac output
is decreased. The symptoms may include lightheadedness or passing out (syncope),
weakness, shortness of breath, and chest pain.

Diagnosis and treatment of life-threatening heart block happen at the same time.
Often, the patient with bradycardia may be taking medications that can slow the
heart including beta blockers and certain calcium channel blockers. If the patient is
stable, time can be taken to have the medications wear off while the patient is
monitored. If the bradycardia remains, a pacemaker may be needed. In certain
situations, a temporary pacemaker can be placed to stabilize the patient, while
decisions are made as to a permanent solution.

Quick GuideAtrial Fibrillation: Heart Symptoms, Diagnosis, & Afib

Treatment
When to seek medical care
Unexplained palpitations are not normal, especially when associated with shortness
of breath, sweating, feelings of chest pressure, or passing out. The person should be
made comfortable and laid flat, and EMS (emergency medical service) should be
activated by calling 9-1-1 or the emergency number in your area.

If the person is unconscious or unresponsive, Basic life support (American Heart

Association) should be initiated. Call 9-1-1, get an AED, and decide whether CPR
should be initiated.

If the episode is short-lived and resolves spontaneously, the primary care

professional should be contacted urgently to seek advice.

If the episode is a recurrent problem, the diagnosis is known, and the rhythm
disturbance resolves itself, then a less urgent call to the primary care professional is
warranted.
 It is reasonable to seek emergent medical care any time that a heart rhythm
disturbance occurs or if there is concern that a heart problem is present.

How are heart rhythm disorders diagnosed?

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The mainstay of diagnosis remains the EKG and heart rhythm monitoring. These are
often done immediately in the ambulance or upon arrival in the emergency
department. In many patients, the palpitations or symptoms may have resolved, and
no acute rhythm abnormalities can be found.

Depending on the associated symptoms and the history, observation and monitoring
of the heart may occur in hospital or as an outpatient. In patients who have passed
out, admission to the hospital often occurs. Those patients with chest pain and
shortness of breath may also be admitted to evaluate their heart. In patients who
are not admitted, a heart monitoring device may be placed to monitor the rhythm
for a duration of time. Monitors may be worn for 24 hours or up to 1 month. In some
instances, rhythm identification is elusive and may take months or years to capture
and identify. Implantable cardiac monitors may be placed for periods greater than 1
year.

If the rhythm is known, then tests to identify potential causes may be done. These
are dependent on the specific rhythm abnormality and can range from blood tests to
lung evaluations and sleep studies to echocardiograms and electrophysiologic
testing.

What is the treatment for heart rhythm disorders?

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There is no one treatment for a heart rhythm abnormality. When the patient is
unstable, with no pulse or blood pressure, or when they are unconscious, American
Heart Association guidelines are available to direct care to hopefully restore the
heart rhythm to normal and return a pulse.

For V-fib and V-tach, electricity may be the most important drug, and the heart is
shocked back into a heart rhythm, hopefully compatible with life. Other common
medications used in crises situations depend upon the life-threatening rhythm and
may include epinephrine (adrenalin), atropine, and amiodarone.

For patients with supraventricular tachycardia (SVT), the goal is not only to slow
down the heart rate but also to identify which rhythm is present. Vasovagal
maneuvers, like holding one's breath and bearing down as if to have a bowel
movement may resolve the situation, or it may slow the rate temporarily to make
the diagnosis. Adenosine can be injected and may convert SVT to normal sinus
rhythm by slowing the electrical impulse at the AV node. It can also be used as a
diagnostic challenge to help identify atrial fibrillation or atrial flutter with rapid
ventricular response.

For atrial fibrillation with rapid ventricular response, the initial goal is to slow the
rate and maintain normal blood pressure. Calcium channel clockers
like diltiazem and beta blockers like metoprolol may be used intravenously to
control rate. Digoxin is a second-line medication that may be helpful when first-line
medications fail. In unstable patients, with chest pain, shortness of breath, or
decreased consciousness, cardioversion with an electric shock may be required. The
decision to electively convert A-fib to normal sinus rhythm depends upon the
patient and situation and is often a decision left to the primary care professional.
The question regarding anticoagulation also will need to be addressed.

What is the prognosis for heart rhythm disorders?

While most heart dysrhythmias can be treated and controlled, ventricular
fibrillation or tachycardia can be fatal. Their recognition and treatment are true
emergencies, and there is no guarantee that sudden cardiac death can be reversed.

For all other rhythm abnormalities, there may be time to make the diagnosis and
design a treatment plan. The goal is to minimize the effect that the dysrhythmia has
on daily activity and quality of life.

Can heart rhythm disorders be prevented?

Minimizing risk factors for heart disease will be helpful, including controlling blood
pressure, lowering cholesterol, keeping diabetes under control, and not smoking.

For those with rapid palpitations that are intermittent, avoiding stimulants like
alcohol, caffeine, over-the-counter cold medications, and illicit drugs are important
preventive measures.