Angeles University Foundation

Angeles City
College of Nursing

CARDIAC ARRHYTHMIAS

A Case Report: Review of Management

In Partial Fulfilment of the Course Requirement in

Nursing Care Management – Related Learning Experience 105,
during the Third Rotation of the Second Semester

Presented By
Kevin Edward K. Manansala, SN
Bachelor of Science in Nursing IV-11, Group 41

Presented To
Dennison Jose C. Punsalan, RN, MN
Clinical Instructor, Emergency Room,
Jose B. Lingad Memorial Regional Hospital

Academic Year 2010-2011

January 2011
The heart is a muscular organ with four chambers designed to work efficiently, reliably, and
continuously over a lifetime. The muscular walls of each chamber contract in a regulated
sequence, pumping blood as required by the body while expending as little energy as possible
during each heartbeat. Contraction of the muscle fibers in the heart is controlled by electricity
that flows through the heart in a precise manner along distinct pathways and at a controlled
speed. The electrical current that begins each heartbeat originates in the heart's pacemaker (sinus
or sinoatrial node), located in the top of the upper right heart chamber (right atrium). The rate at
which the pacemaker discharges the electrical current determines the heart rate. This rate is
influenced by nerve impulses and by levels of certain hormones in the bloodstream.

The heart rate is regulated automatically by the autonomic nervous system, which consists of the
sympathetic and parasympathetic divisions. The sympathetic division increases the heart rate
through a network of nerves called the sympathetic plexus. The parasympathetic division
decreases the heart rate through a single nerve, the vagus nerve. Heart rate is also influenced by
hormones released into the bloodstream by the sympathetic division: epinephrine (adrenaline)
and norepinephrine (noradrenaline), which increase the heart rate. Thyroid hormone, which is
released into the bloodstream by the thyroid gland, also increases the heart rate.

The heart is one of the most important organs in the entire human body for the
reason that it is the major circulatory organ. It is, composed of muscle which pumps
blood throughout the body, beating approximately 72 times per minute of our lives.
The heart pumps the blood, which carries all the vital supplies which help our bodies
function and removes the waste products that we do not need. For example, the
brain requires oxygen and glucose, which, if not received continuously, will cause it
to loose consciousness. Muscles need oxygen, glucose and amino acids, as well as
the proper ratio of sodium, calcium and potassium salts in order to contract
normally. The glands need sufficient supplies of raw materials from which to
manufacture the specific secretions. If the heart ever ceases to pump blood the body
begins to shut down and after a very short period of time will die.

Cardiac arrhythmia is a term that denotes a disturbance of the heart rhythm. Cardiac
arrhythmias can range in severity from entirely benign to immediately life-threatening. If
arrhythmia is suspected, a cardiologist should be consulted for confirmation. Besides,
the use of natural substances for arrhythmia should always be supervised by a doctor.
A cardiac arrhythmia, also called cardiac dysrhythmia, Abnormal rhythm in hearts that contract
in an irregular way (Gale Encyclopedia of Medicine, 2008)

In normal adults, the heart beats regularly at a rate of 60 to 100 times per minute, and
the pulse matches the contractions of the heart's ventricles, thus called the normal sinus
rhythm. The heart's atria also contract to help fill the ventricles, but this milder
contraction occurs just before the ventricles contract, and it is not reflected in the pulse.
Under normal circumstances, the signal for a heartbeat comes from the heart's sinus
node, the natural pacemaker located in the upper portion of the right atrium. From the

2|Cardiac Arrhythmias: A Case Report

sinus node, the heartbeat signal travels to the atrioventricular node and through the
bundle of His to the muscles of the ventricles. This triggers a contraction of the
ventricles and produces a heartbeat.

Cardiac arrhythmias sometimes are classified according to their origin as either

ventricular arrhythmias (originating in the ventricles) or supraventricular arrhythmias
(originating in heart areas above the ventricles, typically the atria). They also can be
classified according to their effect on the heart rate, with bradycardia indicating a heart
rate of less than 60 beats per minute and tachycardia indicating a heart rate of more
than 100 beats per minute.

According to US Census Bureau, International Data Base, (2004) there are 4,570,810 cases of
arrhythmias in the Philippines. Worldwide, there are 53 cases of heart rhythm
disorders per 1000.

DYSRRHYTHMIAS
Arrhythmias can develop from either altered impulse formation or altered impulse conduction. The
former concerns changes in rhythm that are caused by changes in the automaticity of pacemaker cells or
by abnormal generation of action potentials by sites other than the SA node (termed ectopic foci).
Altered impulse conduction is usually associated with complete or partial block of electrical conduction
within the heart. Altered impulse conduction commonly results in reentry, which can lead to
tachyarrhythmias.

In an adult at rest, the normal heart rate is usually between 60 and 100 beats per minute.
However, lower rates may be normal in young adults, particularly those who are physically fit. A
person's heart rate varies normally in response to exercise and such stimuli as pain and anger.
Heart rhythm is considered abnormal only when the heart rate is inappropriately fast (called
tachycardia) or slow (called bradycardia), or is irregular or when electrical impulses travel along
abnormal pathways.

There are many different types of arrhythmias. The heart may beat too rapidly (tachycardia) or
too slowly (bradycardia), or it may beat irregularly. Atrial fibrillation and atrial flutter are
common arrhythmias, which lead to an irregular and sometimes rapid heart rate. These atrial
arrhythmias may interfere with the heart’s ability to pump blood properly from its upper
chambers (atria). The atria may not always empty completely, and blood remaining there too

3|Cardiac Arrhythmias: A Case Report

long may stagnate and clot. Such clots may travel to other parts of the body, where they may
cause blockages in the blood vessels that lead to the limbs, brain, or heart. In ventricular
fibrillation, the lower chambers of the heart (ventricles) quiver feebly instead of contracting
powerfully. This is the most severe type of arrhythmia, causing death in minutes unless medical
assistance is obtained immediately.

ETIOLOGY AND RISK FACTORS

Cardiac Arrhytymias occur when the heart beats improperly, as a result of incorrect impulse generation, (at the
Sino-Atrial (SA) node) or impulse conduction. The heart organ broadly differentiates into two types of cell, pacemaker
cells, and non-pacemaker cells. Pacemaker cells beat with their own independent rhythm, in synchrony with their
neighbours (a heart attack results when these cells get out of synch with each other). The non-pacemaker cells
require stimulus to beat, this stimulus comes from the pacemaker cells.

Incorrect impulse generation is the fault of the pacemaker cells, which are beating either too slow, too fast, or not
totaly in rhythm (asynchrous). Impulse conduction problems are caused because the nervous signal from the
pacemaker cells (located primarily at the SA node) fails to reach the non-pacemaker cells correctly. This problem falls
into two further categories, a nodal block whereby the signal from the SA node fails to reach the AV node, and a re-
entry pathway.

A re-entry pathway occurs when a section of nervous tissue (which conducts the impulse) is damaged in some
manner (eg/ Physical trauma, Cardiac infarction (Heart attack)). Part of the tissue only conducts the impulse in a
single direction, in the example shown left this is in the opposite direction to the genuine impulse direction. This will
set up a loop in the nervous tissue, as the impulse keeps going round and round the junction, stimulating the non-
pacemaker cells to contract, and ultimatley disturbing the rate of heartbeat.

Regardless of the specific arrhythmia, the pathogenesis of arrhythmias falls into one of three basic mechanisms.
These include enhanced or suppressed automaticity, triggered activity, or re-entry. Automaticity is a natural property
of all myocytes. Ischemia, scarring, electrolyte disturbances, medications, advancing age, and other factors may
suppress or enhance automaticity in various areas. Suppression of automaticity of the sinoatrial node can result in
sinus node dysfunction and sick sinus syndrome. Sick sinus syndrome is still the most common indication for
permanent pacemaker implantation.

In contrast to suppressed automaticity, enhanced automaticity can result in multiple arrhythmias, both atrial and
ventricular. Triggered activity occurs when early afterdepolarizations and delayed afterdepolarizations initiate
spontaneous multiple depolarizations precipitating ventricular arrhythmias. Examples of this include torsades de
pointes and ventricular arrhythmias due to digitalis toxicity.

Finally, probably the most common mechanism of arrhythmogenesis results from re-entry. Requisites for re-entry
include bi-directional conduction and uni-directional block. "Micro-" level re-entry occurs with VT from conduction
around the scar of myocardial infarction and "macro-" level re-entry occurs via conduction through manifest (Wolff-
Parkinson-White syndrome—WPW) or concealed accessory pathways.

Electrolyte Imbalances
"Medical Surgical Nursing" authors Joyce M. Black, Ph.D., RN, and Jane Hokanson Hawks, DNSc, RN, state that
both hypercalcemia and hypocalcemia (high and low calcium levels, respectively) may cause heart block and
cardiac arrest. Hypernatremia (high sodium level) may result in an erratic heart rate as sodium and calcium ions
compete with one another to influence the heart. Imbalances in potassium and magnesium, however, are the usual
culprits of cardiac arrhythmia when an electrolyte imbalance occurs.

Hyperkalemia (high potassium levels) initially causes tachycardia and then bradycardia as the heart fatigues in
response to the high sustained heart rate and weak cardiac contraction. Hypokalemia (low potassium levels) results
in bradycardia and a slow, weak pulse. 

4|Cardiac Arrhythmias: A Case Report

Hypermagnesemia (high magnesium) causes premature ventricular contractions (PVCs), which may be noticed only
if there are several PVCs in a row. Hypomagnesemia (low magnesium) may result in PVCs, atrial fibrillation
(sustained heart rate faster than 140) or ventricular fibrillation (a lethal and very high sustained heart rate, over 220.

In summary, arrhythmias may be caused by many different factors, including: (1) Coronary artery disease; (2)
Electrolyte imbalances in your blood (such as sodium or potassium); (3) Changes in your heart muscle; (4) Injury
from a heart attack; (5) Healing process after heart surgery. But also remember this, Irregular heart rhythms can also
occur in "normal, healthy" hearts.

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS

The symptoms of cardiac arrhythmia are not specifically life-threatening, unless left untreated, Cardiac
arrhythmia can lead to more fatal forms of rhythm disturbance, eg/ premature ventricular
depolarization may lead to ventricular fibrillation (resulting in a heart attack). The signs and symptoms
of cardiac arrhythmias can range from completely asymptomatic to loss of consciousness or sudden
cardiac death. In general, more severe symptoms are more likely to occur in the presence of structural
heart disease. For example, sustained monomorphic VT, particularly in a normal heart, may be
hemodynamically tolerated without syncope. In contrast, even non-sustained VT may be poorly
tolerated and cause marked symptoms in patients with severe LV dysfunction. Complaints such as
lightheadedness, dizziness, quivering, shortness of breath, chest discomfort, heart fluttering or
pounding, and forceful or painful extra beats are commonly reported with a variety of arrhythmias.
Frequently patients notice their arrhythmia only after checking peripheral pulses. Certain symptoms
raise the index of suspicion and can give clues to the type of arrhythmia. The presence of sustained
regular palpitations or heart racing in young patients without any evidence of structural heart disease
suggests the presence of an SVT due to atrioventricular nodal re-entry, or SVT due to an accessory
pathway. Such tachycardias may frequently be accompanied by chest discomfort, diaphoresis, neck
fullness, or a vasovagal type of response with syncope, diaphoresis, and nausea. It has been shown that
the hemodynamic consequences of SVT and VT can have an autonomic basis, recruiting vasodepressor
reflexes similar to that observed in neurocardiogenic syncope. Isolated or occasional premature beats
suggest PACs or PVCs and are benign in the absence of structural heart disease.

Syncope in the setting of noxious stimuli such as pain, prolonged standing, and venepuncture,
particularly when preceded by vagal-type symptoms (diaphoresis, nausea, vomiting), suggests
neurocardiogenic (vasovagal) syncope. Occasionally, patients may report abrupt syncope
without prodromal symptoms, suggesting the possibility of the "malignant" variety of
neurocardiogenic syncope. Malignant neurocardiogenic syncope denotes syncope in the absence
of a precipitating stimulus, with a short or absent prodrome, often resulting in injuries, and is
associated with marked cardioinhibitory and bradycardic responses spontaneously or provoked
by head-up tilt-table testing. The presence of sustained or paroxysmal sinus tachycardia,
frequently associated with chronic fatigue syndrome and fibromyalgia, suggests the possibility
of POTS (postural orthostatic tachycardia syndrome). This syndrome, which may be a form of
autonomic dysfunction, is currently unexplained. It is characterized by a markedly exaggerated
chronotropic response to head-up tilt-table testing and stress testing. POTS frequently has

5|Cardiac Arrhythmias: A Case Report

 associated systemic signs such as muscle aches (fibromyalgia), cognitive dysfunction, and
weight loss. Inappropriate sinus tachycardia syndrome is similar in presentation, but probably
represents a separate disorder with alternative etiology, possibly due to atrial tachycardias in the
sinus node area or dysregulation of sinus node automaticity.

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

When symptoms occur, they may include:

 Palpitations (a feeling of skipped heart beats, fluttering).

 Pounding in your chest.
 Dizziness or feeling light-headed.
 Fainting.
 Shortness of breath.
 Chest discomfort.
 Weakness or fatigue (feeling very tired).

DIAGNOSTIC PROCEDURES

NON INVASIVE RECORDING

1. ELECTROCARDIOGRAPHY

It is a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail.
Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can
vary from minor to life threatening.

An electrocardiogram (ECG) is a test that records the electrical activity of the heart.

2. HOLTER MONITORS

Holter monitor: A type of portable heart monitor. The Holter monitor is a small
portableelectrocardiogram (ECG). The device is worn in a pouch around the neck or waist. It keeps a
record of the heart rhythm, typically over a 24-hour period, while the patient keeps a diary recording
their activities and any symptoms they may feel. The ECG recording is then correlated with the person's
record of their activities and symptoms. The Holter monitor is useful for identifying disturbances which
are sporadic and which are not readily identified with the usual resting electrocardiogram test.

INVASIVE ELECTROPHYSIOLOGIC ACTIVITY

In electrophysiological studies, recording and stimulating electrodes are inserted via right- or left-sided
cardiac catheterization into all 4 cardiac chambers. Atria are paced from the right or left atrium, ventricles
are paced from the right ventricular apex or right ventricular out-flow tract, and cardiac conduction is

6|Cardiac Arrhythmias: A Case Report

 recorded. Programmed stimulation techniques may be used to trigger and terminate a reentrant
arrhythmia.

Electrophysiologic studies are indicated primarily for evaluation and treatment of arrhythmias that are
difficult to capture, serious, or sustained. These studies may be used to make a primary diagnosis, to
evaluate the efficacy of antiarrhythmic drugs, or to map arrhythmia foci before radiofrequency catheter
ablation; various mapping techniques are available.

CLASSIFICATIONS OF ARRYTHMIAS – The Abnormal Heart Rhythms

Bradycardia. Bradycardia is defined as a slow heart rhythm. It is generally divided into 2 categories, sick sinus
syndrome or heart block. These slow heart rhythms are usually treated by the implantation of a permanent
pacemaker, which takes over the work of the hearts normal pacemaker.

Sick sinus syndrome

Sick sinus syndrome, also called Bradycardia-tachycardia syndrome is a group of abnormal heartbeats
(arrhythmias) presumably caused by a malfunction of the sinus node, the heart's "natural" pacemaker.
Sick sinus syndrome is a disorder of the sinus node of the heart, which regulates heartbeat. With sick
sinus syndrome, the sinus node fails to signal properly, resulting in changes in the heart rate.Sick sinus
syndrome is a type of bradycardia in which the sinoatrial node is not functioning as it should.

Sick Sinus Syndrome. With sick sinus syndrome, the sinus node (the natural pacemaker of the heart) is damaged.
It may not send electrical signals to the chambers often enough, it may skip some signals or it may send too many
signals at once. The result may be a heart that beats too slowly (sinus bradycardia), experiences long pauses (sinus
pauses) that may cause symptoms of dizziness or fainting spells, or alternates between beating too quickly and then
too slowly (tach-brady syndrome).

 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/or symptoms
associated with them, should be evaluated by a heart doctor. However, in most people, PVCs are usually
harmless and rarely need treatment.

 Atrial fibrillation. AF is a very common irregular heart rhythm that causes the atria, the upper chambers of
the heart to contract abnormally.

Atrial fibrillation
Atrial fibrillation (AF) is an electrical rhythm disturbance of the heart affecting the atria. Abnormal
electrical impulses in the atria cause the muscle to contract erratically and pump blood inefficiently.
Atrial fibrillation is associated with many cardiac conditions, including cardiomyopathy, coronary artery
disease, valvular heart disease, ventricular hypertrophy and other associated conditions. Atrial
fibrillation has been associated with hyperthyroidism, acute alcohol intoxication, changes in the

7|Cardiac Arrhythmias: A Case Report

 autonomic nervous system and is common after cardiac surgery.
 
Atrial Fibrillation. In patients with atrial fibrillation, multiple sites in the atria (top chamber) send electrical impulses
in an uncoordinated fashion. As a result, the atria beat very quickly and ineffectively. The AV node, which acts as a
relay station, allows only some of these impulses to travel down the electrical system and stimulate the ventricles.
As a result, the heart rhythm is irregular, erratic, and usually (but not always) rapid. Atrial fibrillation may occur once
in a while or it may be chronic.
 Atrial flutter. This is an arrhythmia caused by one or more rapid circuits in the atrium. Atrial flutter is
usually more organized 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.

Atrial flutter
Atrial flutter is a rhythmic, fast rhythm that occurs in the atria of the heart. This rhythm occurs most
often in individuals with organic heart disease (ie: pericarditis, coronary artery disease, and
cardiomyopathy). Atrial flutter is a regular, rhythmic tachycardia originating in the atria. The rate in the
atria is over 220 beats/minute, and typically about 300 beats/minute. The morphology on the surface
EKG is typically a sawtooth pattern. Atrial flutter can sometimes degenerate to atrial fibrillation.

Bundle branch block

Bundle branch block (BBB) is a disruption in the normal flow of electrical pulses that drive the heart
beat. Bundle branch block belongs to a group of heart problems called intraventricular conduction
defects (IVCD). There are two bundle branches, right and left. The right bundle carries nerve impulses
that cause contraction of the right ventricle (the lower chamber of the heart) and the left bundle
carries nerve impulses that cause contraction of the left ventricle. Bundle heart block may be caused by
damage to the heart muscle resulting from a heart attack.
 
 
Supraventricular tachycardia
Supraventricular tachycardia (SVT), also known as paroxysmal narrow complex tachycardia (PNCT), is a
disturbance of heart rhythm as a result of rapid electrical activity of the upper parts of the heart. In
these attacks the heart is beating very fast, usually at a rate between 140 and 240 per minute. In most
cases, the heart is normal and the heart rhythm is benign although uncomfortable. Palpitation is much
the commonest symptom, but there also may be dizziness or even, very occasionally, fainting.
 
 
Ventricular arrhythmias
Ventricular arrhythmias are common and are usually benign, at least in those with a structurally normal
heart. In patients with structural heart disease (usually coronary heart disease), however, ventricular
arrhythmia is an adverse prognostic factor associated with cardiac arrest and cardiac mortality.
Ventricular arrhythmias range from asymptomatic ventricular ectopy to sustained ventricular

8|Cardiac Arrhythmias: A Case Report

 tachycardia and cardiac arrest. Ventricular tachycardia and ventricular fibrillation are the most life-
threatening arrhythmias that require emergency treatment.
 
Ventricular tachycardia
Ventricular tachycardia (VT) is a wide complex cardiac rhythm originating in the ventricles. The rate is
usually between 150 and 200 beats/minute and regular. There is dissociation between atrial and
ventricular activity. The rapid rate and A-V dissociation may lead to reduced cardiac filling and low
cardiac output, hypotension, and cardiac arrest. Ventricular tachycardia is a potentially lethal
disruption of normal heartbeat (arrhythmia) that may cause the heart to become unable to pump
adequate blood through the body.

  Ventricular tachycardia (V-tach). 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 doctor should evaluate this arrhythmia.

Ventricular fibrillation
Ventricular fibrillation is a condition in which disordered electrical activity causes the chambers of your
heart, ("ventricles"), to contract chaotically. When this occurs, little or no blood is pumped from the
heart. Ventricular fibrillation (VF) is an abnormal heart rhythm that causes death. It is responsible for
75% to 85% of sudden deaths due to heart problems. Normally, heart muscle cells squeeze (contract) in
rhythm at the same time to pump blood. These groups of cells are located in the bottom two pumping
chambers of the heart (ventricles).

 Ventricular fibrillation. An erratic, disorganized 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.

 
Heart block
Heart block is a disorder of the heartbeat. It occurs when electrical impulses can't pass from the atria
(upper chambers of the heart) to the ventricles (the heart's lower chambers). This may keep the
contractions of the atria from coordinating with the contractions of the ventricles , and may cause a
very slow heart rate. Heart block is common in elderly people as their hearts have undergone
degenerative (wear and tear) changes. Heart block has a variety of causes. It can sometimes be a result
of a congenital defect.
 
Brugada syndrome
Brugada syndrome (also known by some investigators as idiopathic ventricular fibrillation, IVF), is a
disease associated with an electrocardiographic abnormality of right bundle branch block with ST-
elevation in the right precordial leads (Figure). It has been added to the list of possible causes of
sudden death in otherwise healthy, young individuals. These patients have a propensity for life-
threatening ventricular tachyarrhythmias, particularly during sleep, but no structural heart

9|Cardiac Arrhythmias: A Case Report

 abnormalities are found. Treatment for people at high risk of sudden death is with an implantable
defibrillator.
 
Long QT syndrome
The long QT syndrome (LQTS) is a heart condition in which there is an abnormally long delay between
the electrical excitation (or depolarization) and relaxation (repolarization) of the ventricles of the heart.
It is associated with syncope (loss of consciousness) and with sudden death due to ventricular
arrhythmias. Arrhythmias in individuals with LQTS are often associated with exercise or excitement.
The cause of sudden cardiac death in individuals with LQTS is ventricular fibrillation.
 

 Long QT syndrome. The QT interval is the area on the electrocardiogram (ECG) 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 antiarrhythmic drugs, pacemaker, electrical cardioversion,
defibrillation, implanted cardioverter/defibrillator or ablation therapy.

Short QT syndrome
Short QT syndrome is a genetic disease of the electrical system of the heart. It is made up of a
constellation of signs and symptoms, made up of a short QT interval interval on EKG (≤ 300 ms) that
doesn't significantly change with heart rate, tall and peaked T waves, and a structurally normal heart.
Short QT syndrome appears to be inherited in an autosomal dominant pattern, and a few affected
families have been identified. Individuals with short QT syndrome frequently complain of palpitations
and may have syncope (loss of consciousness) that is unexplained.
 
Wolff-Parkinson-White syndrome (WPW syndrome)
Wolff-Parkinson-White syndrome (WPW) is a syndrome of pre-excitation of the ventricles due to an
accessory pathway known as the bundle of Kent. This accessory pathway is an abnormal electrical
communication from the atria to the ventricles. Wolff-Parkinson-White syndrome is characterised by
attacks of rapid heart rate (tachycardia). The heartbeat is regulated by electrical impulses that travel
through the atria (upper chambers of the heart) to a knot of tissue known as the atrioventricular node,
and then to the ventricles.
Arrhythmias (abnormal heart rhythms or dysrhythmias) are problems that affect the electrical system
of the heart muscle, producing abnormal heart rhythms. They can cause the heart to pump less
effectively. Arrhythmias are disturbances in the normal rhythm of the heartbeat. An occasional
palpitation or fluttering is usually not serious, but a persistent arrhythmia may be life-threatening.

Wolff-Parkinson-White (WPW) Syndrome. An abnormal bridge of tissue connects the atria (top chamber) and
ventricles (lower chamber). This extra pathway, called an accessory pathway, makes it possible for electrical
impulses to travel from the atria to the ventricles without going through the AV node. Patients with Wolff-Parkinson-
White Syndrome (WPW) experience arrhythmias when an impulse travels down the AV node to the ventricles, and
then up through the necessary pathway to the atria. If the impulse continues to travel in a circular pattern, it may
cause the heart to contract with each cycle. This could result in a very rapid heartbeat, which could allow extremely
rapid and potentially serious rhythms to occur. 

10 | C a r d i a c A r r h y t h m i a s : A C a s e R e p o r t
 Paroxysmal supraventricular tachycardia (PSVT). 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 reentrant tachycardias (see below).
 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. A slow heart rhythm due to an abnormal SA (sinus) node. Sinus node dysfunction
is treated with a pacemaker.
 Heart block. 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.

Supraventricular Tachycardia. Supraventricular tachycardia (SVT) is a series of very rapid heartbeats that begin in
the heart's upper chambers. Generally supraventricular tachycardia is not a life-threatening problem although it can
be quite bothersome and frightening. SVT may occur when an extra pathway exists in the atria (top chamber), the AV
node or between the atria and ventricles (bottom chamber). An electrophysiology study can be used to identify the
origination site of the SVT. 
SVT is commonly treated/controlled with medications called anti-arrhythmics. A procedure called a catheter
radiofrequency ablation can cure or eliminate SVT. Your doctor will know if this might be an option for you. Two
specific categories of SVT are Wolff-Parkinson-White syndrome (WPW) and Atrial Fibrillation. 

Ventricular Tachycardia (VT). Rapid heart beating, which arises in the ventricles (bottom chambers of the heart),
is known as ventricular tachycardia, and can be life threatening. Ventricular fibrillation (VF) exists when the  
ventricles are quivering and cannot pump blood, collapse and sudden death can follow unless medical help is
provided immediately. This is referred to as a 'cardiac arrest'. If treated in time, ventricular tachycardia and ventricular
fibrillation can be interrupted with an electrical shock, restoring the heart to a normal rhythm. The most common
treatment today for people who have experienced VT or VF is the implantation of an internal cardioverter defibrillator
machine also known as an ICD.Medication (anti-arrhythmic drugs) may also be used to treat VT, alone or in
conjunction with an ICD.

A-V block or heart block. In this family of arrhythmias, there is some problem in conducting the heartbeat signal
from the sinus node to the ventricles. There are three degrees of A-V block: first-degree A-V block, where the signal
gets through, but may take longer than normal to travel from the sinus node to the ventricles; second-degree A-V
block, in which some heartbeat signals are lost between the atria and ventricles; and third-degree A-V block, in which
no signals reach the ventricles, so the ventricles beat slowly on their own with no direction from above. Some
common causes of A-V block include coronary artery disease, myocardial infarction (heart attack), or an overdose of
the heart medication digitalis.

Sinus node dysfunction. This usually produces a bradycardia (slow heart rate), with a heat rate of 50 beats per
minute or less. The most common cause is replacement of the sinus node by scar tissue. Why this happens is not
known. Sinus node dysfunction also can be caused by coronary artery disease, hypothyroidism, severe liver disease,
hypothermia, typhoid fever, or other conditions. It also can be the result of vasovagal hypertonia, an unusually active
vagus nerve.

DIAGNOSTIC PROCEDURES

11 | C a r d i a c A r r h y t h m i a s : A C a s e R e p o r t
 How are arrhythmias diagnosed?
Tests used to diagnose an arrhythmia or determine its cause include:

 Electrocardiogram
 Holter monitor
 Event Monitor
 Stress Test
 Echocardiogram
 Cardiac catheterization
 Electrophysiology study (EPS)
 Head-up tilt table test

Cardiac arrhythmias are often first detected by simple but nonspecific means: auscultation of the heartbeat with a
stethoscope, or feeling for peripheral pulses. These cannot diagnose specific arrhythmias, but can give a general
indication of the heart rate and whether it is regular or irregular. Not all the electrical impulses of the heart produce
audible or palpable
beats; in many cardiac arrhythmias, the premature or abnormal beats do not produce an effective pumping action
and are experienced as "skipped" beats.  

The simplest specific diagnostic test for assessment of heart rhythm is the electrocardiogram (abbreviated ECG or
EKG). A Holter monitor is an ECG recorded over a 24-hour period, to detect arrhythmias that may happen briefly and
unpredictably throughout the day. However, because cardiac arrhythmias may come and go, a one-time office EKG
may be normal. If this is the case, an ambulatory EKG may be required. During an ambulatory EKG, the patient
wears a portable EKG machine called a Holter monitor, usually for 24 hours. Alternatively, you may wear a device for
much longer. You will be taught to press a button to record the EKG reading whenever you experience symptoms.
This approach is especially useful if you experience infrequent symptoms of arrhythmia.

In rare cases, invasive electrophysiological studies are necessary to determine the exact location responsible for an
arrhythmia. These involve introducing electrical sensors into the body, close to or within the heart, rather than sensing
electrical waves from the surface of the body as an ECG does. An electrophysiology (EP) study provides the
physician with more accurate and detailed information about the hearts electrical function than the other studies.
Based on the information gathered during the EP study, your physician can diagnose your particular arrhythmia
problem and select the appropriate treatment.

This test is performed in a specially equipped room, usually referred to as the EP Lab. During the study, doctors
place special electrode catheters (long, flexible wires) into the veins and guide them into the heart. These catheters
are used to measure the electrical conduction system of the heart. They are also used to stimulate different regions of
the heart (known as pacing) to attempt to induce an arrhythmia. The procedure is very safe and effective in
diagnosing cardiac arrhythmias. A team of highly trained physicians and nurses care for you during the procedure.

After being positioned on an X-ray table, you will be connected to a variety of monitors that measure heart rate, blood
pressure and oxygen level. A medication is given through an IV to relax you and to make you feel sleepy (this is
called conscious sedation). A local anesthetic is used to numb the area where the physician will place the catheters.
After the area is numb (the groin, arm or neck), catheters will be inserted into the vein(s) and positioned in the heart
using X-ray imaging. Once the catheters are positioned, you may feel a sensation in the chest as the physicians are
pacing your heart. This is often felt as a fluttering sensation.Most patients sleep through the procedure and tolerate it
nicely. After the EP study, which generally takes 1-2 hours, the catheters are removed and pressure is held at the site
where the catheters entered the body. From the EP lab, you are brought back to your room and asked to remain on
bed rest for 4-6 hours while the vein(s) heals. Your cardiologist will discuss the results of the study with you and
recommend an appropriate course of action.

MEDICAL MANAGEMENT

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 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.

The teaching of the pathophysiology and pharmacological treatment of cardiac arrhythmias

can be a challenging task. The integrated modular system (for description see reference 1)
utilized at Ohio Northern University (ONU) allows for the pathophysiology and pharmacology
to be followed by the medicinal chemistry and therapeutic principles involved in the
management of cardiac arrhythmias. Background material necessary for the comprehension
of cardiac arrhythmias is provided in the Biomedical Science Modules. Before entering the
Cardiovascular Module, where cardiac arrhythmias are covered in detail, students have been
instructed in ion-channel function in muscle contraction, action potential physiology and the
basics of ECG. The following text is a summary of a fourhour lecture sequence presented in
the Cardiovascular Module on the pathophysiology and pharmacological treatment of cardiac
arrhythmias. These lectures are supplemented by a web site that contains primary literature
references in a downloadable format, animations of cellular mechanisms and practice case
reports, ECG strips, and Powerpoint(R), lecture presentations. This manuscript is written in
a fashion to complement a web site created specifically for the readers of the American
Journal of Pharmaceutical Education that contains all the above and can be accessed at
(http://www.onu.edu/user/ fs/jsprague/AJPE.html). General references utilized in developing
these lectures included references 2-4.

The pharmacological treatments consist of agents that interfere with sodium, pottasium, and calcium pump systems,
which are used by the heart to control heart rate. These agents tend to result in longer times between each impulse,
by prolonging repolarisation (the heart cells pump Na+ across their membranes during a contraction, and then pump
Na+ back in ready for another contraction, this is called repolarisation). Another important class is the Beta blockers,
which block the action of 
adrenaline (a naturally produced hormone, which increases heart rate). Antiarrhythmic medications help to change
the electrical signals within the heart to suppress or prevent the arrhythmia. These medications can be used to
control SVT (supraventricular tachycardia) and VT (ventricular tachycardia). It is important to be aware that  
medications are a treatment and not a cure. Your doctor will discuss the advantages and disadvantages of
antiarrhythmic therapy. Frequently medication is prescribed in addition to other therapies such as ICD or pacemaker.

Arrhythmias are also treated electrically. Cardioversion is the application of electrical current across the chest wall to
the heart and it is used for treatment of supraventricular or ventricular tachycardia. Defibrillation differs in that it is
used for ventricular fibrillation and more electricity is delivered with defibrillation than with cardioversion. In
cardioversion, the recipient is usually awake and may be sedated for the procedure. In defibrillation, the recipient has
lost consciousness so there is no need for sedation. Electrical treatment of arrhythmia includes cardiac pacing.
Pacing is usually done for very slow heartbeats from drug overdose or myocardial infarction.

What medications are used to treat arrhythmias?

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

 Antiarrhythmic drugs. These drugs control heart-rate, and include beta-blockers.

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

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 anesthesia, an electrical shock is delivered to your chest wall that
synchronizes the heart and allows the normal rhythm to restart.

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 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
optimize 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 prevent too slow of a heart rhythm.

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 surgery used to correct atrial fibrillation. During this procedure, a series (or "maze")of incisions are made in
the right and left atria to confine the electrical impulses to defined pathways. Some people may require a pacemaker
after this procedure.

PROGNOSIS
What lifestyle changes should be made?
 If you notice that your irregular heart rhythm 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, colas 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.

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