Which of the following is one of the most common types of abnormal cardiac rhythm?

Abnormal heart rhythms (arrhythmias) are sequences of heartbeats that are irregular, too fast, too slow, or conducted via an abnormal electrical pathway through the heart.

• Heart disorders are the most common cause of an abnormal heart rhythm.

• Sometimes people are aware of abnormal heart rhythms, but many times they feel only their consequences, such as weakness or fainting.

• The diagnosis is based on electrocardiography.

• Treatment involves restoring the heart to a normal rhythm and preventing further episodes.

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 at a controlled speed. The electrical current that begins each heartbeat originates in the heart’s pacemaker (called the sinus node 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 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)

• Norepinephrine (noradrenaline)

Epinephrine and norepinephrine increase the heart rate. Thyroid hormone, which is released into the bloodstream by the thyroid gland, also increases the heart rate.

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), slow (called bradycardia), or irregular or when electrical impulses travel along abnormal pathways.

The electrical current from the sinoatrial node flows first through the right atrium and then through the left atrium, causing the muscles of these chambers to contract and blood to be pumped from the atria into the lower heart chambers (ventricles). The electrical current then reaches the atrioventricular node, located in the lower part of the wall between the atria near the ventricles. The atrioventricular node provides the only electrical connection between the atria and ventricles. Otherwise, the atria are insulated from the ventricles by tissue that does not conduct electricity. The atrioventricular node delays transmission of the electrical current so that the atria can contract completely and the ventricles can fill with as much blood as possible before the ventricles are electrically signaled to contract.

Tracing the Heart’s Electrical Pathway

The sinoatrial (sinus) node (1) initiates an electrical impulse that flows through the right and left atria (2), making them contract. When the electrical impulse reaches the atrioventricular node (3), it is delayed slightly. The impulse then travels down the bundle of His (4), which divides into the right bundle branch for the right ventricle (5) and the left bundle branch for the left ventricle (5). The impulse then spreads through the ventricles, making them contract.

After passing through the atrioventricular node, the electrical current travels down the bundle of His, a group of fibers that divide into a left bundle branch for the left ventricle and a right bundle branch for the right ventricle. The electrical current then spreads in a regulated manner over the surface of the ventricles, from the bottom up, initiating contraction of the ventricles, which eject blood from the heart.

The most common cause of arrhythmias is a heart disorder, particularly coronary artery disease Overview of Coronary Artery Disease (CAD) Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more

Overview of Heart Valve Disorders Heart valves regulate the flow of blood through the heart's four chambers—two small, round upper chambers (atria) and two larger, cone-shaped lower chambers (ventricles). Each ventricle has... read more

Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more

Sometimes no cause for an arrhythmia can be identified.

Fast arrhythmias (tachyarrhythmias) may start on their own or be triggered by exercise, emotional stress, excessive alcohol consumption, smoking, or use of drugs that contain stimulants, such as cold and hay fever remedies.

Slow arrhythmias (bradyarrhythmias) may be triggered by pain, hunger, fatigue, digestive disorders (such as diarrhea and vomiting), or swallowing, which can stimulate the vagus nerve excessively. With enough stimulation, which is rare, the vagus nerve can cause the heart to stop for a moment. In most of these circumstances, the arrhythmia tends to resolve on its own.

Arrhythmias have consequences that range from harmless to life threatening. The seriousness of an arrhythmia may not be closely linked with the severity of the symptoms it causes. Some life-threatening arrhythmias cause no symptoms, and some otherwise inconsequential arrhythmias may cause severe symptoms. The nature and severity of the underlying heart disorder are often more important than the arrhythmia itself.

When arrhythmias impair the heart’s ability to pump blood, they can cause weakness, a reduced capacity for exercise, shortness of breath, light-headedness, dizziness, fainting Fainting Light-headedness (near syncope) is a sense that one is about to faint. Fainting (syncope) is a sudden, brief loss of consciousness during which the person falls to the ground or slumps in a... read more (syncope), or death. Fainting occurs when the heart is pumping so inefficiently that it can no longer maintain adequate blood pressure. If such an arrhythmia persists, death may result. Arrhythmias may also aggravate the symptoms of an underlying heart disorder, including chest pain and shortness of breath. Arrhythmias that cause symptoms require prompt attention.

• Electrocardiography

Often, a person’s description of symptoms can help doctors make a preliminary diagnosis and determine the severity of the arrhythmia. The most important considerations are whether the palpitations are

• Fast or slow

• Regular or irregular

• Brief or prolonged

Another important consideration is whether the arrhythmia causes symptoms.

Doctors also need to know whether the palpitations occur at rest or only during strenuous or unusual activity and whether they start and stop suddenly or gradually.

Certain diagnostic procedures are usually needed to determine the exact nature of the arrhythmia and its cause.

Because arrhythmias are often intermittent, a portable ECG monitor (called a Holter monitor Holter Monitor: Continuous ECG Readings

To detect dangerous arrhythmias that occur very infrequently, doctors sometimes implant a recording device under the skin below the left collarbone (clavicle). The device can be left in place for long periods. It electronically transmits stored recordings of abnormal heart rhythms painlessly through the skin.

People with suspected life-threatening arrhythmias are usually hospitalized. Their heart rhythm is continuously recorded and displayed on a television-type monitor by the bedside or at the nursing station. Thus, any problems can be identified promptly.

Other diagnostic procedures include

• Blood pressure measurement during exercise

During electrophysiologic testing, catheters with tiny electrodes at their tip are inserted through a vein and threaded into the heart. The electrodes are used to stimulate the heart, and the heart’s response is monitored, so that the type of arrhythmia and the preferred treatment options can be determined.

ECG: Reading the Waves

An electrocardiogram (ECG) represents the electrical current moving through the heart during a heartbeat. The current's movement is divided into parts, and each part is given an alphabetic designation in the ECG.

Each heartbeat begins with an impulse from the heart's pacemaker (sinus or sinoatrial node). This impulse activates the upper chambers of the heart (atria). The P wave represents activation of the atria.

Next, the electrical current flows down to the lower chambers of the heart (ventricles). The QRS complex represents activation of the ventricles.

The electrical current then spreads back over the ventricles in the opposite direction. This activity is called the recovery wave, which is represented by the T wave.

Many kinds of abnormalities can often be seen on an ECG. They include a previous heart attack (myocardial infarction), an abnormal heart rhythm (arrhythmia), an inadequate supply of blood and oxygen to the heart (ischemia), and excessive thickening (hypertrophy) of the heart's muscular walls.

Certain abnormalities seen on an ECG can also suggest bulges (aneurysms) that develop in weak areas of the heart's walls. Aneurysms may result from a heart attack. If the rhythm is abnormal (too fast, too slow, or irregular), the ECG may also indicate where in the heart the abnormal rhythm starts. Such information helps doctors begin to determine the cause.

Most arrhythmias neither cause symptoms nor interfere with the heart’s ability to pump blood. Thus, they usually pose little or no risk, although they can cause considerable anxiety if a person becomes aware of them. However, some arrhythmias, harmless in themselves, can lead to more serious arrhythmias. Any arrhythmia that impairs the heart’s ability to pump blood adequately is serious. How serious depends in part on whether the arrhythmia originates in the sinoatrial node Regulation of the Heart The heart and blood vessels constitute the cardiovascular (circulatory) system. The heart pumps the blood to the lungs so it can pick up oxygen and then pumps oxygen-rich blood to the body.... read more , in the atria, in the atrioventricular node, or in the ventricles. Generally, arrhythmias that originate in the ventricles are more serious than those that originate in the atria, which are more serious than those that originate in the sinoatrial node or atrioventricular node. However, there are many exceptions.

• Antiarrhythmic drugs, usually for a fast heart rate

• Pacing, usually for a slow heart rate

• Delivering an electric shock, usually for a fast heart rate

For people who have a harmless yet bothersome arrhythmia, reassurance that the arrhythmia is harmless may be treatment enough. Sometimes arrhythmias occur less often or even stop when doctors change a person’s drugs or adjust the dosages. Avoiding alcohol, caffeine (in beverages and foods), and smoking may also help. Avoiding strenuous exercise may help if palpitations occur only during exercise. Sometimes people need to stop driving until doctors can determine whether treatment is effective.

Antiarrhythmic drugs are useful for suppressing fast arrhythmias that cause intolerable symptoms or pose a risk. No single drug suppresses all arrhythmias in all people. Sometimes several drugs must be tried until the response is satisfactory. Sometimes antiarrhythmic drugs can worsen or even cause arrhythmias. This effect is called proarrhythmia. Antiarrhythmic drugs may also cause other side effects.

Some people may be candidates for leadless pacemakers. With this type of pacemaker, no wires are needed to connect the pacemaker to the heart. Doctors make a small incision in the groin and use a catheter to insert the pacemaker directly into the bottom right heart chamber (the right ventricle).

New circuitry has almost completely eliminated the risk of interference from cell phones, automobile ignition systems, radar, microwaves, and airport security detectors. However, some equipment may interfere with pacemakers. Examples are electrocautery devices used to stop bleeding during surgery, diathermy (physical therapy treatments that use radiowaves to apply heat to muscles), and sometimes magnetic resonance imaging (MRI). MRI may be safe with certain types of pacemaker, depending on how they are constructed.

Keeping the Beat: Artificial Pacemakers

Artificial pacemakers are electronic devices that act in place of the heart’s natural pacemaker (the sinus or sinoatrial node). They generate electrical impulses that initiate each heartbeat. Pacemakers consist of a battery, an impulse generator, and wires that connect the pacemaker to the heart.

An artificial pacemaker is implanted surgically. After a local anesthetic is used to numb the insertion site, the wires that connect the pacemaker are usually inserted into a vein near the collarbone and threaded toward the heart. Through a small incision, the impulse generator, which is about the size of a silver dollar, is inserted just under the skin near the collarbone and connected to the wires. The incision is stitched closed. Usually, the procedure takes about 30 to 60 minutes. The person may be able to go home shortly afterward or may briefly stay in the hospital. The battery for a pacemaker usually lasts 10 to 15 years. Nevertheless, the battery should be checked regularly. Battery replacement is a quick procedure.

There are different types of pacemakers. Some take over the control of the heart rate, overriding the electrical impulses generated by the heart. Others, called demand pacemakers, allow the heart to beat naturally unless it skips a beat or begins to beat at an abnormal rate. Still others, called programmable pacemakers, can do either. Some pacemakers can adjust their rate depending on the wearer’s activity, increasing the heart rate during exercise and decreasing it during rest.

The most common use of pacemakers is to treat slow arrhythmias. When the heart slows below a set threshold, the artificial pacemaker begins to produce electrical impulses. Less commonly, pacemakers are used to treat fast arrhythmias by delivering a series of impulses to decrease the heart rate by converting the fast arrhythmia back to normal.

Sometimes an electrical shock to the heart can stop a fast arrhythmia and restore normal rhythm. Using an electrical shock for this purpose is called cardioversion, defibrillation, or electroversion, depending on the type of abnormal rhythm for which it is used.

An implantable cardioverter-defibrillator (ICD), which is about one half the size of a deck of cards, can be placed. Most devices are implanted through the blood vessels just as a pacemaker is, thus eliminating the need for open chest surgery. Another type of ICD is placed under the skin rather than through the blood vessels.

A wearable vest-like defibrillator is sometimes used if the person does not need an ICD for a long time.

ICDs continually monitor the rate and rhythm of the heart, automatically detect fast arrhythmias, and deliver either a pacing treatment or a shock to convert the arrhythmia back to a normal rhythm. Most commonly, these devices are used in people who might otherwise die of the arrhythmia. An ICD can also act like a pacemaker, sending electrical impulses to overcome a slow arrhythmia. When an ICD delivers a shock, it can feel like a mild thump in the chest. When a stronger shock is given, people may feel as if they have been kicked.

People who have ICDs can safely be around most home electronic devices, including microwaves, and airport security detectors. However, some equipment with strong magnetic fields or strong electric fields may interfere with ICDs. Examples are electrocautery devices used to stop bleeding during surgery, diathermy (physical therapy treatments that use radiowaves to apply heat to muscles), and sometimes MRI.

Because ICDs do not prevent arrhythmias, drugs often must be taken as well. These devices last for about 5 to 7 years. People with an ICD who experience a single shock from the device and who otherwise feel well should contact their ICD clinic or specialist within the week. The device records the person's heart rhythm, thus allowing the doctor to see why a shock was given. People who had other symptoms, such as shortness of breath, chest discomfort, or palpitations, immediately before or after the shock, or who had multiple shocks may have a more serious problem. Such people should go to the emergency department right away.

An automated external defibrillator (AED) Automated External Defibrillator: Jump-Starting the Heart

Certain types of arrhythmias can be controlled by doing surgical and other invasive procedures. An arrhythmia due to a localized abnormal area in the heart’s electrical system can be controlled by destroying or removing that area (ablation).

Ablation may also be done by freezing tissue (called cryoablation).

Less commonly, the area is destroyed or removed during open heart surgery. Sometimes surgery is needed because catheter-based ablation was not effective. Other times, surgery is used because people are having heart surgery for another reason, such as to replace a heart valve.

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

• American Heart Association: Arrhythmia: Information to help people understand their risks of arrhythmias as well as information on diagnosis and treatment

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