Sinus Arrhythmia

sinus-arrhythmia

Cardiac dysrhythmia (also known as arrhythmia or irregular heartbeat) is any of a group of conditions in which the electrical activity of the heart is irregular or is faster or slower than normal. The heart beat may be too fast (over 100 beats per minute) or too slow (less than 60 beats per minute), and may be regular or irregular. A heart beat that is too fast is called tachycardia  and a heart beat that is too slow is called bradycardia.  Although many arrhythmias are not life-threatening, some can cause cardiac arrest.

Arrhythmias can occur in the upper chambers of the heart, (atria), or in the lower chambers of the heart, (ventricles). Arrhythmias may occur at any age. Some are barely perceptible, whereas others can be more dramatic and can even lead to sudden cardiac death.

Signs and symptoms: The term cardiac arrhythmia covers a very large number of very different conditions.

The most common symptom of arrhythmia is an abnormal awareness of heartbeat, called palpitations. These may be infrequent, frequent, or continuous. Some of these arrhythmias are harmless (though distracting for patients) but many of them predispose to adverse outcomes.

Some arrhythmias do not cause symptoms, and are not associated with increased mortality. However, some asymptomatic arrhythmias are associated with adverse events. Examples include a higher risk of blood clotting within the heart and a higher risk of insufficient blood being transported to the heart because of weak heartbeat. Other increased risks are of embolisation and stroke, heart failure and sudden cardiac death.

If an arrhythmia results in a heartbeat that is too fast, too slow or too weak to supply the body’s needs, this manifests as a lower blood pressure and may cause lightheadedness or dizziness, or syncope (fainting).Some types of arrhythmia result in cardiac arrest, or sudden death.Medical assessment of the abnormality using an electrocardiogram is one way to diagnose and assess the risk of any given arrhythmia.

Diagnostic approach: Cardiac dysrhythmias are often first detected by simple but nonspecific means: auscultation of the heartbeat with a stethoscope, or feeling for peripheral pulses. These cannot usually diagnose specific dysrhythmias, 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 EKG recorded over a 24-hour period, to detect dysrhythmias that may happen briefly and unpredictably throughout the day.

A more advanced study of the heart’s electrical activity can be performed to assess the source of the aberrant heart beats. This can be accomplished in an Electrophysiology study.  A minimally invasive procedure that uses a catheter to “listen” to the electrical activity from within the heart, additionally if the source of the arrhythmias is found, often the abnormal cells can be ablated and the arrhythmia can be permanently corrected.

Management: The method of cardiac rhythm management depends firstly on whether or not the affected person is stable or unstable. Treatments may include physical maneuvers, medications, electricity conversion, or electro or cryo cautery.

(a)Physical maneuvers: A number of physical acts can increase parasympathetic nervous supply to the heart, resulting in blocking of electrical conduction through the AV node. This can slow down or stop a number of arrhythmias that originate above or at the AV node (see main article: supraventricular tachycardias). Parasympathetic nervous supply to the heart is via the vagus nerve, and these maneuvers are collectively known as vagal maneuvers.

(b)Antiarrhythmic drugs: There are many classes of antiarrhythmic medications, with different mechanisms of action and many different individual drugs within these classes. Although the goal of drug therapy is to prevent arrhythmia, nearly every antiarrhythmic drug has the potential to act as a pro-arrhythmic, and so must be carefully selected and used under medical supervision.

(c)Other drugs: A number of other drugs can be useful in cardiac arrhythmias. Several groups of drugs slow conduction through the heart, without actually preventing an arrhythmia. These drugs can be used to “rate control” a fast rhythm and make it physically tolerable for the patient. Some arrhythmias promote blood clotting within the heart, and increase risk of embolus and stroke. anticoagulant medications such as warfarin and heparins, and anti-platelet drugs such as aspirin can reduce the risk of clotting.

(d)Electricity: Dysrhythmias may also be treated electrically, by applying a shock across the heart — either externally to the chest wall, or internally to the heart via implanted electrodes. Cardioversion  is either achieved pharmacologically or via the application of a shock synchronised to the underlying heartbeat. It is used for treatment of supraventricular tachycardias. In elective cardioversion, the recipient is usually sedated or lightly anesthetized  for the procedure. Defibrillation differs in that the shock is not synchronised. It is needed for the chaotic rhythm of ventricular fibrillation and is also used for pulseless ventricular tachycardia. Often, more electricity is required for defibrillation than for cardioversion. In most defibrillation, the recipient has lost consciousness so there is no need for sedation. Defibrillation or cardioversion may be accomplished by an implantable cardioverter-defibrillator (ICD).Electrical treatment of dysrhythmia also includes cardiac pacing. Temporary pacing may be necessary for reversible causes of very slow heartbeats, or bradycardia, (for example, from drug overdose or myocardial infarction). A permanent pacemaker may be placed in situations where the bradycardia is not expected to recover.

(e)Electrical cautery: Some cardiologists further sub-specialise into electrophysiology. In specialised catheter laboratories, they use fine probes inserted through the blood vessels to map electrical activity from within the heart. This allows abnormal areas of conduction to be located very accurately, and subsequently destroyed with heat, cold, electrical or laser probes. This may be completely curative for some forms of arrhythmia, but for others, the success rate remains disappointing.AV nodal reentrant tachycardia is often curable. Atrial fibrillation can also be treated with this technique (e.g. pulmonary vein isolation), but the results are less reliable.

Reference:

  1. Davidson’s Principle and Practice of Medicine, 21st edition.
  2. Wikipedia the free encyclopedia.

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