Arrhythmias (Heart Rhythm issues)

What is Arrhythmia?

Arrhythmias are heart rhythm or conduction issues whereby the electrical conduction of the heart is affected. These rhythms can take many different forms and can affect both the upper and lower chambers of the heart. The diagnosis of heart rhythm issues is usually done through an ECG, or a Holter monitor (prolonged ECG recording) to get an understanding of the heart rhythm. Regular ECGs will be conducted to ensure that treatments are successful and effective

Dr. Jogiya is an expert in Arrhythmia treatment and management of abnormal heart rhythms. Below you can find some of the most common arrhythmias that Dr. Jogiya deals with, as well as some common treatment methods:

Atrial Arrhythmias

Atrial heart rhythm issues affect the upper chambers of the heart (atria). These chambers primarily receive blood into the heart before it is pumped by the lower chambers (ventricles) to either the lungs or the rest of the body. Atrial arrhythmias can cause a wide range of symptoms including shortness of breath, palpitations, and dizziness.

Atrial Fibrillation - Atrial Fibrillation, commonly known as AF, is a condition where the atria (or upper chambers of the heart) fire chaotic electrical impulses leading the muscle to 'quiver' (or fibrillate) instead of beat. This is one of the most common heart rhythm issues which affects roughly 1.4 million people in the UK alone.

Effective treatment for AF begins with medication to control the heart rate and regulate heart function. Patients diagnosed with AF may often also be commenced on blood thinning medication to prevent the risks of stroke or other blood clot formations in the heart.

Other treatments can include DC Cardioversion and Ablation procedures to try and 'reset' the heart to its natural rhythm or to implant a pacemaker to regulate the heart rhythm at a set pace.

Atrial Flutter - Atrial Flutter is another condition that affects the upper chambers of the heart (atria). However, Atrial Flutter is a regular but rapid beat in the atria as opposed to an irregular chaotic impulse. The impulses during a flutter maybe 4-5 times faster than that of the ventricles, and so blood is not efficiently pumped from the top to the bottom chambers as there is not enough time for chambers to fill, which is what leads to shortness of breath.

Effective treatment for Atrial Flutter begins with medication to control the heart rate and regulate heart function. Other treatments can include DC Cardioversion and Ablation procedures to try and 'reset' the heart to its natural rhythm.

Supra-ventricular Tachycardias (SVT) - An SVT (or supra-ventricular tachycardia) is a fast heart rhythm that originates above the ventricles, but not always in the same way as an atrial tachycardia. Symptoms for SVTs will vary widely from one person to another, and treatment options are personalised to the patient and the symptoms they experience.

Atrial Tachycardia is a form of SVT that occurs when an electrical signal emerges from another section of the Atria (upper heart chambers) and causes a rapid repeating beat which means that the atria beat very fast. Atrial Tachycardias can be worrying if they continue for a long period, because the rapid signals may be transmitted to the ventricles so the heart would beat too fast and blood would not be pumped around the body effectively.

Short bouts of SVTs or ATs can be common, and can usually be treated very easily. Vagal Manoeuvres such as coughing or an ice pack on the face can stimulate the vagus nerve and often relaxes and resolves the atrial tachycardia. Other treatments such as medication are a good way to manage the condition, with beta-blockers or calcium channel blockers proving effective at controlling the condition.

Another form of SVT which is commonly seen is a condition known as Wolff-Parkinson-White syndrome where electrical conduction in the atria does not follow the normal 'pathway' and uses an extra electrical connection to conduct impulses. The 'short circuit' then forms which triggers a rapid heart rhythm or tachycardia. This condition might be congenital (from birth) but most symptoms are not present until later on in life.

Sometimes, patients may just have a WPW pattern on their ECG but do not suffer from WPW syndrome, i.e., they do not have irregular heart rhythms. Treatment options are thus based on individual cases, and again can range from vagal manoeuvres to medication and if necessary a cardioversion or EP (Electrophysiology) study.

Atrial Arrhythmias

Ventricular heart rhythm issues affect the lower chambers of the heart (ventricles). These chambers are the main pumping chambers of the heart. The right ventricle pumps blood to the lungs to exchange carbon dioxide for fresh oxygen, while the left ventricle delivers freshly oxygenated blood to the body. Ventricular arrhythmias a very rare but can be life-threatening if not treated appropriately.

Ventricular Ectopics - Ventricular Ectopics are 'extra' heartbeats produced in the lower chambers of the heart. These beats are completely harmless but can affect people in different ways, with some experiencing symptoms and others not feeling these beats at all. This may feel like a 'skipped' beat, but most people will feel palpitations. Most ectopics can resolve themselves but in cases where treatment is required, medication can be used to reduce the ectopics and manage symptoms.

Sometimes, procedures might be required to isolate and disable the parts of the heart that cause the ectopics if they become too frequent.

Ventricular Tachycardia - Ventricular Tachycardia is a condition where the lower chambers of the heart beat too fast. This means that blood cannot be pumped efficiently and can lead to a vast array of symptoms. Ventricular Tachycardias are rare but do occur in patients of all ages. VTs do need to be monitored and can be dangerous if they continue for long periods as they are likely to progress to ventricular fibrillation (VF).

Short bouts of VT can be treated with medication. Other treatments can include Ablation procedures to remove or isolate the parts from which the abnormal rhythm originates. Alternatively, a pacemaker can be implanted to regulate the heart rhythm and suppress VTs occurring.

Conduction Delays and Heart Blocks

A Heart Block refers to a delay to the conduction system in the heart, usually in the AV (atrioventricular) Node. This node controls the synchronisation of beats being delivered from the atria to the ventricles. In patients with a heart block, the impulse being sent to the ventricles might be delayed or completely out of sync with the signals being received from the atria. Heart blocks can occur for different reasons which include some medications, previous heart attacks, and even infections. Treatment options will depend on the type of heart block you are diagnosed with and the degree to which any symptoms affect your quality of life:

1st Degree Heart Block - 1st Degree Heart Block is the most common conduction issue and can affect everyone, no matter what age. This heart block is common to occur at night time and is the least serious, but some people can still have very minor symptoms during the day. This type of heart block is usually diagnosed when testing for an unrelated condition. 1st Degree Heart Block does not require treatment for asymptomatic patients, but for those with symptoms, medical management is the main treatment method.

2nd Degree Heart Block - There are two types of second-degree heart block, known as Mobitz type I and II. Mobitz I is also known as Wenckebach and is the least serious of the two types. Close monitoring is often required but usually asymptomatic patients

Mobitz I (Wenckebach) - This form of second-degree heart block is when the conduction between the atria and ventricles is delayed more and more with each beat, which leads to one of the atrial impulses not being sent to the ventricles at all (what some people might call a skipped beat). With each beat, the AV node continues to become fatigued leading to slower action with each impulse received. Mobitz I usually has a lower risk of disease progression and symptomatic patients respond to treatment with atropine.

Mobitz II - This form of heart block describes an intermittent failure of conduction between the Bundle of His and the Purkinje Fibres (parts of the conduction system located below the AV node). This type of conduction defect is more likely due to a structural issue within the conduction system, either from infection or muscular death, whereas Mobitz type I is more likely to be caused by the effects of medicines and other chemicals on the AV node. Sometimes Mobitz II can present itself in a pattern, whereas other times there may not be a regular relationship between the impulses of the atria and the ventricles.

Mobitz II is a more dangerous condition and can be associated with hemodynamic compromise, increased symptoms, and a higher likelihood of progressing to 3rd Degree Heart Block. There is an increased risk of sudden cardiac death and blackouts, and the risk of cardiac arrest or 'asystole' is around 35% each year. Mobitz II requires the insertion of a permanent pacemaker whether the patient experiences any symptoms or not.

3rd Degree Heart Block - 3rd degree, or Complete Heart Block (CHB) is an absence of any atrioventricular conduction which leads to a complete dissociation between the impulses being fired in the atria and the ventricles. The ventricles therefore contract with ventricular beats or other conduction pathways known as junctional beats. 3rd degree blocks are usually the end point of Mobitz I or II blocks, and signal the failure of the AV node or the ventricular conduction system to perform its necessary tasks.

3rd degree heart block can be caused by heart attacks, infections, medication, and the general degeneration of the AV node. All patients will likely experience symptoms including shortness of breath, palpitations, chest pain, and sometimes dizziness. The risk of ventricular standstill (asystole) or sudden cardiac death is much greater, and so requires immediate treatment.

All patients with 3rd-degree heart block will require urgent admission for monitoring and will require a permanent pacemaker to control the conduction between the atria and ventricles. Sometimes, other types of heart block might be presented as 3rd degree, so it is important to monitor a patient in case any other diagnoses can be made.

Bundle Branch Block - Bundle branch blocks describe a block in a part of the conduction system of the heart known as the bundle branches. These branches deliver the conduction impulses from the AV node to each ventricle (left and right). This conduction delay means that one side of the heart receives the impulse before the other, meaning that the contraction in the ventricles is not synchronised.

Causes for bundle branch block can be varied and can include: Heart Disease, Aortic Stenosis, some medications, previous heart attacks, and structural heart issues such as Cardiomyopathies. Bundle branch block in patients with chest pain might suggest a risk of an acute heart attack.

Bundle branch blocks might be presented as 'incomplete', where impulses are sometimes intermittently delivered through the bundle branches, and at other times are blocked. Repeat ECGs or monitoring might be required to diagnose the correct type of bundle branch block.

Mostly, bundle branch blocks require monitoring with ECGs and heart monitoring, However, if bundle branch blocks affect the function of the heart or increase symptoms then medication can be used to increase cardiac function. In more serious cases, cardiac resynchronisation therapy (CRT) or biventricular pacing can be used to put both ventricles back into a synchronised rhythm and thus increase the heart's function.

Sick Sinus Syndrome - Sick Sinus Syndrome (SSS) or Sinus Node Disease (SND) is a condition where the sinus node (sinoatrial node) is not functioning properly and is malfunctioning. Sometimes the node will send impulses, and sometimes it may not fire an impulse at all or the impulses may be out of sync. Some patients with sick sinus syndrome may experience symptoms such as palpitations and shortness of breath. This condition is not to be confused with AF or other atrial conditions as they refer mostly to an overactive or irregular atrial impulse, whereas sick sinus syndrome refers mostly to a non-functional sinus node.

The common treatment for sick sinus syndrome is a single chamber (atrial) pacemaker which regulates the impulses being sent from the atria to ventricles and promotes regular cardiac function. Sometimes a dual-chamber pacemaker might be implanted to further regulate and manage the heart rhythm in both the atria and ventricles.

Tachy-Brady Syndrome - Tachybrady syndrome is a phenomenon by which the heart rate increases (tachycardia) and decreases (bradycardia) spontaneously without any external influence. Normally this is diagnosed as a period of bradycardia (low heart rate) with alternating spontaneous paroxysmal supra-ventricular beats. Normally the heart reacts to its surrounding environments and the heart rate will only increase or decrease if required by the level of activity (i.e. exercise would increase the heart rate, and sleeping would decrease the heart rate).

This condition occurs mostly with AF and occurs because of the conduction of abnormal automated impulses through the atrial tissue. At least 50% of patients with Sinus Node Disease (SND) are affected by Tachybrady syndrome. Treatments for Tachybrady syndrome will relate to the more serious problem. A lower heart rate will require a pacemaker to increase and regulate impulses being delivered to the atria. Fast heart rates can be treated with medication, but sometimes a specialised pacemaker or internal defibrillator may be implanted to regulate the heart rhythm and control fast heart rates.