Heart Arrhythmias

DEFINITION

Heart rhythm problems (heart arrhythmias) occur when the electrical impulses in your heart that coordinates your
heartbeats don't work properly, causing your heart to beat too fast, too slow or irregular. It may feel like a fluttering or
racing heart, and they're often harmless. However, some heart arrhythmias may cause bothersome — sometimes even life-
threatening — signs and symptoms.

Heart arrhythmia treatment can often control or eliminate irregular heartbeats. In addition, because troublesome
heart arrhythmias are often made worse — or are even caused — by a weak or damaged heart, you may be able to reduce
your arrhythmia risk by adopting a heart-healthy lifestyle.

CAUSES

Many things can lead to, or cause, an arrhythmia, including:

 A heart attack that's occurring right now

 Scarring of heart tissue from a prior heart attack
 Changes to your heart's structure, such as from cardiomyopathy
 Blocked arteries in your heart (coronary artery disease)
 High blood pressure
 Diabetes
 Overactive thyroid gland (hyperthyroidism)
 Smoking
 Drinking too much alcohol or caffeine
 Drug abuse
 Stress
 Medications
 Dietary supplements and herbal treatments
 Electrical shock
 Air pollution

What's a normal heartbeat?

When your heart beats, the electrical impulses that cause it to contract follow a precise pathway through your
heart. Any interruption in these impulses can cause an arrhythmia.

Your heart is divided into four chambers. The chambers on each half of your heart form two adjoining pumps,
with an upper chamber (atrium) and a lower chamber (ventricle).

During a heartbeat, the atria contract and fill the relaxed ventricles with blood. This contraction starts when the
sinus node — a small group of cells in your right atrium — sends an electrical impulse causing your right and left atria to
contract.

The impulse then travels to the center of your heart, to the atrioventricular node that lies on the pathway between
your atria and your ventricles. From here, the impulse exits the atrioventricular node and travels through your ventricles.

In a healthy heart, this process usually goes smoothly, resulting in a normal resting heart rate of 60 to 100 beats a
minute. Conditioned athletes at rest commonly have a heart rate less than 60 beats a minute because their hearts are so
efficient.
TYPES OF ARRHYTHMIAS

Doctors classify arrhythmias not only by where they originate (atria or ventricles) but also by the speed of heart
rate they cause:

(1) Tachycardia
 This refers to a fast heartbeat — a resting heart rate greater than 100 beats a minute.
(2) Bradycardia
 This refers to a slow heartbeat — a resting heart rate less than 60 beats a minute.

Tachycardias in the atria

Tachycardias originating in the atria include:

 Atrial fibrillation
 This fast and chaotic beating of the atrial chambers is a common arrhythmia. It often affects older people.
Your risk of developing atrial fibrillation increases with age, mostly due to wear and tear on your heart,
especially if you've had high blood pressure or other heart problems. During atrial fibrillation, the
electrical signal that causes your heart to beat becomes uncoordinated. The atria beat so rapidly — as fast
as 300 or more beats a minute — that instead of producing a single forceful contraction, they quiver
(fibrillate). Atrial fibrillation can be dangerous, for over time it can cause more-serious conditions, such
as stroke.
 Atrial flutter
 Atrial flutter is similar to atrial fibrillation. Both can occur, coming and going in an alternating fashion.
The heartbeats in atrial flutter are more-organized and more-rhythmic electrical impulses than in atrial
fibrillation.
 Supraventricular tachycardia (SVT)
 SVT is a broad term that includes many forms of arrhythmia originating above the ventricles
(supraventricular). SVTs usually cause a burst of rapid heartbeats that begins and ends suddenly and can
last from seconds to hours. These bursts often start when the electrical impulse from a heartbeat begins to
circle repeatedly through an extra pathway. Although SVT is generally not life-threatening in an
otherwise normal heart, symptoms from the racing heart may feel quite uncomfortable.
 Wolff-Parkinson-White syndrome
 One cause of SVT is known as Wolff-Parkinson-White syndrome. People with this condition have an
extra electrical pathway between the atria and the ventricles. This pathway may allow electrical signals to
pass between the atria and the ventricles without passing through the atrioventricular node, leading to
short circuits and rapid heartbeats.

Tachycardias in the ventricles

Tachycardias occurring in the ventricles include:

 Ventricular tachycardia (VT)

 This fast, regular beating of the heart is caused by abnormal electrical impulses that start in the ventricles.
Often these are due to a problem with the electrical impulse travelling around a scar from a previous heart
attack. VT can cause the ventricles to contract more than 200 beats a minute. An episode of sustained VT
is a medical emergency. Without prompt medical treatment, sustained ventricular tachycardia often
worsens into ventricular fibrillation.
 Ventricular fibrillation
 In ventricular fibrillation, rapid, chaotic electrical impulses cause your ventricles to quiver uselessly
instead of pumping blood. Without an effective heartbeat, your blood pressure plummets, cutting off
blood supply to your vital organs — including your brain. Most people lose consciousness within seconds
and require immediate medical assistance, including chest compressions, defibrillation and
cardiopulmonary resuscitation (CPR). Your chances of survival are better if chest compressions are
delivered until your heart can be shocked back into a normal rhythm with a device called a defibrillator.
Without CPR or defibrillation, death results in minutes. Most cases of ventricular fibrillation are linked to
some form of heart disease. Ventricular fibrillation is frequently triggered by a heart attack.
  Long QT syndrome
 Long QT syndrome (LQTS) is a heart disorder that carries an increased risk of fast, chaotic heartbeats.
The rapid heartbeats, caused by changes in the electrical system of your heart, may lead to fainting, which
can be life-threatening. In some cases, your heart's rhythm may be so erratic that it can cause sudden
death.

Bradycardia- a slow heartbeat

Although a heart rate below 60 beats a minute while at rest is considered bradycardia, a low resting heart rate doesn't
always signal a problem. If you're physically fit, you may have an efficient heart capable of pumping an adequate supply
of blood with fewer than 60 beats a minute at rest. However, if you have a slow heart rate and your heart isn't pumping
enough blood, you may have one of several bradycardias, including:

 Sick sinus
 If your sinus node, which is responsible for setting the pace of your heart, isn't sending impulses properly,
your heart rate may be too slow, or it may speed up and slow down intermittently. Sick sinus can also be
caused by scarring near the sinus node that's slowing, disrupting or blocking the travel of impulses.
 Conduction block
 A block of your heart's electrical pathways can occur in or near the atrioventricular node, which lies on
the pathway between your atria and your ventricles. A block can also occur along other pathways to each
ventricle. Depending on the location and type of block, the impulses between the upper and lower halves
of your heart may be slowed or blocked. If the signal is completely blocked, certain cells in the
atrioventricular node or ventricles can make a steady, although usually slower, heartbeat. Some blocks
may cause no signs or symptoms, and others may cause skipped beats or bradycardia.
 Premature heartbeats
 Although it often feels like a skipped heartbeat, a premature heartbeat is actually an extra beat. Even
though you may feel an occasional premature beat, it seldom means you have a more serious problem.
Still, a premature beat can trigger a longer lasting arrhythmia — especially in people with heart disease.
Premature heartbeats are commonly caused by stimulants, such as caffeine from coffee, tea and soft
drinks; over-the-counter cold remedies containing pseudoephedrine; and some asthma medications.

SIGNS AND SYMPTOMS

Arrhythmias may not cause any signs or symptoms. In fact, your doctor might find you have an arrhythmia before you
do, during a routine examination. Noticeable signs and symptoms don't necessarily mean you have a serious problem,
however. Noticeable arrhythmia symptoms may include:

 A fluttering in your chest

 A racing heartbeat (tachycardia)
 A slow heartbeat (bradycardia)
 Chest pain
 Shortness of breath
 Lightheadedness
 Dizziness
 Fainting (syncope) or near fainting

RISK FACTORS

Certain factors may increase your risk of developing an arrhythmia. These include:

 Coronary artery disease, other heart problems and previous heart surgery
 Narrowed heart arteries, heart attack, abnormal valves, prior heart surgery, cardiomyopathy and other
heart damage are risk factors for almost any kind of arrhythmia.
  High blood pressure
 This increases your risk of developing coronary artery disease. It may also cause the walls of your left
ventricle to become stiff and thick, which can change how electrical impulses travel through your heart.
 Congenital heart disease
 Being born with a heart abnormality may affect your heart's rhythm.
 Thyroid problems
 Your metabolism speeds up when your thyroid gland releases too much thyroid hormone. This may cause
fast or irregular heartbeats and may be linked to atrial fibrillation. Your metabolism slows when your
thyroid gland doesn't release enough thyroid hormone, which may cause a bradycardia.
 Drugs and supplements
 Over-the-counter cough and cold medicines containing pseudoephedrine and certain prescription drugs
may contribute to arrhythmia development.
 Diabetes
 Your risk of developing coronary artery disease and high blood pressure greatly increases with
uncontrolled diabetes.
 Obstructive sleep apnea
 This disorder, in which your breathing is interrupted during sleep, can increase your risk of bradycardia,
atrial fibrillation and other arrhythmias.
 Electrolyte imbalance
 Substances in your blood called electrolytes — such as potassium, sodium, calcium and magnesium —
help trigger and conduct the electrical impulses in your heart. Electrolyte levels that are too high or too
low can affect your heart's electrical impulses and contribute to arrhythmia development.
 Drinking too much alcohol
 Drinking too much alcohol can affect the electrical impulses in your heart or increase the chance of
developing atrial fibrillation. In fact, development of atrial fibrillation after an episode of heavy drinking
is sometimes called \"holiday heart syndrome.\" Chronic alcohol abuse may cause your heart to beat less
effectively and can lead to cardiomyopathy.
 Caffeine or nicotine use
 Caffeine, nicotine and other stimulants can cause your heart to beat faster and may contribute to the
development of more-serious arrhythmias. Illegal drugs, such as amphetamines and cocaine, may
profoundly affect the heart and lead to many types of arrhythmias or to sudden death due to ventricular
fibrillation.

COMPLICATIONS

Certain arrhythmias may increase your risk of developing conditions such as:

 Stroke
 When your heart quivers, it's unable to pump blood effectively, which can cause blood to pool. This can
cause blood clots to form. If a clot breaks loose, it can travel to and obstruct a brain artery, causing a
stroke. This may damage a portion of your brain or lead to death. For people who have atrial fibrillation,
the medications warfarin (Coumadin) or dabigatran (Pradaxa) or rivaroxaban (Xarelto) may help prevent
blood clots, which can cause a stroke.
 Heart failure
 This can result if your heart is pumping ineffectively for a prolonged period due to a bradycardia or
tachycardia, such as atrial fibrillation. Sometimes controlling the rate of an arrhythmia that's causing heart
failure can improve your heart's function.
TESTS AND DIAGNOSIS

To diagnose a heart arrhythmia, your doctor may ask about — or test for — conditions that may trigger your
arrhythmia, such as heart disease or a problem with your thyroid gland. Your doctor may also perform heart-monitoring
tests specific to arrhythmias. These may include:

 Electrocardiogram (ECG)
 During an ECG, sensors (electrodes) that can detect the electrical activity of your heart are attached to
your chest and sometimes to your limbs. An ECG measures the timing and duration of each electrical
phase in your heartbeat.
 Holter monitor
 This portable ECG device can be worn for a day or more to record your heart's activity as you go about
your routine.
 Event monitor
 For sporadic arrhythmias, you keep this portable ECG device at home, attaching it to your body and
pressing a button when you have symptoms. This lets your doctor check your heart rhythm at the time of
your symptoms.
 Echocardiogram
 In this noninvasive test, a hand-held device (transducer) placed on your chest uses sound waves to
produce images of your heart's size, structure and motion.

If your doctor doesn't find an arrhythmia during those tests, he or she may try to trigger your arrhythmia with
other tests, which may include:

 Stress test
 Some arrhythmias are triggered or worsened by exercise. During a stress test, you'll be asked to exercise
on a treadmill or stationary bicycle while your heart activity is monitored. If you have difficulty
exercising, your doctor may use a drug to stimulate your heart in a way that's similar to exercise.
 Tilt table test
 Your doctor may recommend this test if you've had fainting spells. Your heart rate and blood pressure are
monitored as you lie flat on a table. The table is then tilted as if you were standing up. Your doctor
observes how your heart and the nervous system that controls it respond to the change in angle.
 Electrophysiological testing and mapping
 In this test, thin, flexible tubes (catheters) tipped with electrodes are threaded through your blood vessels
to a variety of spots within your heart. Once in place, the electrodes can map the spread of electrical
impulses through your heart. In addition, your cardiologist can use the electrodes to stimulate your heart
to beat at rates that may trigger — or halt — an arrhythmia. This allows your doctor to see the location of
the arrhythmia and what may be causing it.

TREATMENTS AND DRUGS

If you have an arrhythmia, treatment may or may not be necessary. Usually it's required only if the arrhythmia is
causing significant symptoms or if it's putting you at risk of a more serious arrhythmia or arrhythmia complication.

Treating slow heartbeats

If slow heartbeats (bradycardias) don't have a cause that can be corrected — such as low thyroid hormone levels
or a drug side effect &dmash; doctors often treat them with a pacemaker because there aren't any medications that can
reliably speed up your heart. A pacemaker is a small device that's usually implanted near your collarbone. One or more
electrode-tipped wires run from the pacemaker through your blood vessels to your inner heart. If your heart rate is too
slow or if it stops, the pacemaker sends out electrical impulses that stimulate your heart to beat at a steady, proper rate.
Treating fast heartbeats

For fast heartbeats (tachycardias), treatments may include one or more of the following:

 Vagal maneuvers
 You may be able to stop an arrhythmia that begins above the lower half of your heart (supraventricular
tachycardia, or SVT) by using particular maneuvers that include holding your breath and straining,
dunking your face in ice water, or coughing. These maneuvers affect the nervous system that controls
your heartbeat (vagus nerves), often causing your heart rate to slow.
 Medications
 Many types of tachycardias respond well to anti-arrhythmic medications. Though they don't cure the
problem, they can reduce episodes of tachycardia or slow down the heart when an episode occurs. Some
medications can slow down your heart so much that you may need a pacemaker. It's very important to
take any anti-arrhythmic medication exactly as directed by your doctor in order to minimize
complications.
 If you have atrial fibrillation, your doctor will likely prescribe blood-thinning medication — such as
warfarin (Coumadin) or dabigatran (Pradaxa) or rivaroxaban (Xarelto) — to help keep dangerous clots
from forming. These drugs can cause excessive bleeding. Dabigatran isn't recommended for the treatment
of atrial fibrillation in anyone who has mechanical heart valves.
 Cardioversion
 If you have a tachycardia that starts in the top half of your heart (atria), including atrial fibrillation, your
doctor may use cardioversion, which is an electrical shock used to reset your heart to its regular rhythm.
Usually this is done externally in a monitored setting, and you're given medication to relax you during the
procedure, so there's no pain involved. Emergency cardioversion (defibrillation) is also used for
ventricular tachycardia and fibrillation.
 Ablation therapy
 In this procedure, one or more catheters are threaded through your blood vessels to your inner heart.
They're positioned on areas of your heart that your doctor believes are the sources of your arrhythmia.
Electrodes at the catheter tips are heated with radiofrequency energy. Another method involves cooling
the tips of the catheters, which freezes the problem tissue. Either method destroys (ablates) a small spot of
heart tissue and creates an electrical block along the pathway that's causing your arrhythmia. Usually this
stops your arrhythmia.
 Implantable devices
Treatment for heart arrhythmias also may involve use of an implantable device:
 Pacemaker
 A pacemaker is an implantable device that helps regulate slow heartbeats (bradycardia).
A small device is placed under the skin near the collarbone in a minor surgical procedure.
An insulated wire extends from the device to the heart, where it's permanently anchored.
 If a pacemaker detects a heart rate that's too slow or no heartbeat at all, it emits electrical
impulses that stimulate your heart to speed up or begin beating again. Most pacemakers
have a sensing device that turns them off when your heartbeat is above a certain level. It
turns back on when your heartbeat is too slow.
 Implantable cardioverter-defibrillator (ICD)
 Your doctor may recommend this device if you're at high risk of developing a
dangerously fast or irregular heartbeat in the lower half of your heart (ventricular
tachycardia or ventricle fibrillation).
 An ICD is a battery-powered unit that's implanted near the left collarbone. One or more
electrode-tipped wires from the ICD run through veins to the heart. The ICD
continuously monitors your heart rhythm. If it detects a rhythm that's too slow, it paces
 the heart as a pacemaker would. If it detects VT or VF, it sends out low- or high-energy
shocks to reset the heart to a normal rhythm.
 Surgical treatments
In some cases, surgery may be the recommended treatment for heart arrhythmias:
 Maze procedure
 This involves making a series of surgical incisions in the upper half of your heart (atria).
These heal into carefully placed scars in the atria that form boundaries that force
electrical impulses in your heart to travel properly to cause the heart to beat efficiently.
The procedure is effective, but because it requires surgery, it's usually reserved for people
who don't respond to other treatments or for those who are having heart surgery for other
reasons. The surgeon may use a an instrument for applying extreme cold to tissue
(cryoprobe) or a hand-held radiofrequency probe, rather than a scalpel, to create the scars.
 Coronary bypass surgery
 If you have severe coronary artery disease in addition to frequent ventricular tachycardia,
your doctor may recommend coronary bypass surgery. This may improve the blood
supply to your heart and reduce the frequency of your ventricular tachycardia.

LIFESTYLE AND HOME REMEDIES

Many arrhythmias can be blamed on underlying heart disease, so your doctor may suggest that, in addition to
other treatments, you make lifestyle changes that will keep your heart as healthy as possible. Making healthy lifestyle
changes can also help prevent heart arrhythmias from developing in the first place. These lifestyle changes may include:

 Eating heart-healthy foods

 Increasing your physical activity
 Quitting smoking
 Cutting back on caffeine and alcohol consumption
 Finding ways to reduce the amount of stress in your life
 Avoiding stimulant medications, such as medications found in over-the-counter treatments for colds and nasal
congestion
 The role of omega-3 fatty acids, a nutrient found mostly in fish, in the prevention and treatment of arrhythmias
isn't yet clear. But it appears as though this substance may be helpful in preventing and treating some arrhythmias.

NURSING INTERVENTIONS

1. Document any arrhythmias in a monitored patient.

2. Notify the doctor if a change in pulse pattern or rate occurs in an unmonitored patient.
3. As ordered, obtain an ECG tracing in an unmonitored patient to confirm and identify the type
of arrhythmia present.
4. Be prepared to initiate cardiopulmonary resuscitation, if indicated, when a life threatening arrhythmia occurs.
5. Administer medication as ordered, monitor for adverse effect, and perform nursing interventions related to
monitoring vital signs, hemodynamic monitoring, and appropriate laboratory work.
6. Provide adequate oxygen and reduce heart workload while carefully maintaining metabolic, neurologic,
respiratory, and hemodynamic status.
7. Evaluate the monitored patient’s ECG regularly for arrhythmia.
8. Monitor for predisposing factors, such as fluid and electrolyte imbalance, and signs of drug toxicity, especially
with digoxin.
9. Teach the patient how to take his pulse and recognize an irregular rhythm and instruct him to report alterations
from his baseline to the doctor.
10. Emphasize the importance of keeping laboratory and physician’s appointments.