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The medical word for palpitations is arrhythmia(pronounced ‘ay-rith¬me-ar’) meaning a change in the beating rhythm of the heart.
All of us feel the heart pounding away when we have to run for a bus, have seen an exciting film or had a fright: this is the normal response to exertion or excitement which causes the adrenaline in the blood to increase and stimulate the heart to beat faster. Being aware of the heartbeat, when there is no obvious explanation, can be alarming and lead to anxiety and panic, all of which makes the situation worse.
What doctors mean by palpitations is an undue awareness of the heartbeat. People see it in less matter-of-fact terms: ‘missed beats’, ‘big beats’, ‘pounding’, ‘fluttering’, ‘as if my heart was going to jump out of my chest’ are some of my patients’ descriptions. Underlying these sensations the questions really bothering people are:
• Am I going to die?
• Will I have a heart attack?
• Will my heart stop beating?
• Will it damage me?
First, it is very rare for any form of palpitations to be dangerous or life-threatening. It is true that they are frightening and the fear can make them worse, but, for most people, all they have to fear is the fear, because palpitations do not usually mean disease.
For the vast majority of people, palpitations are just one of the ways that stresses and strains on the body show themselves, so they tend to be more common in people experiencing stress at home or work, in those with family anxieties and in those who are run down or overworked.
TYPES OF PALPITATIONS
I often feel that my heart has missed a beat. Is this serious?
Missed beats are a common sort of palpitation and are invariably harmless. They can be brought on by too much caffeine, for example in tea, coffee, Coca-Cola or chocolate. Of these, coffee is by far the most important source of caffeine. Sometimes alcohol is the cause. If there is another disease present, missed beats may well be important, for example after a heart attack (see your doctor if you get these), but in 9 out of 10 people the heart is sound.
I drink rather a lot of coffee. I have heard that caffeine is bad for the heart and I must admit that sometimes I feel that my heart has missed a beat. Am I about to have a heart attack?
The control of the heart is like an electric circuit with a master switch. Occasionally, short circuits cause extra beats but the master switch is always in charge, even though it lets one or two extra
beats escape. You may feel this more when your heart is slow, or when you are resting or just before going to sleep. It can also occur when the heart has been stimulated by caffeine, alcohol, stress, or as a side effect of medication, such as inhalers for asthma. The extra beat arrives early and there is then a pause (the missed beat) whilst the next normal beat comes along. The extra beat may not be felt (‘as if the heart skips a beat’) but, after the pause, the pump of the heart will be fuller than usual, so the next normal beat will feel like a big beat – a ‘kick’ or a ‘thump’. A beat hasn’t really been missed, it just feels like it, and the big beat is the heart making up for the one that came a bit early. This is not dangerous – the heart is compensating for the early beat.
When I was at work the other day, I suddenly felt my heart was working overtime – I hadn’t even been rushing up the stairs! What was happening?
Rapid palpitationsmay be normal, such as when you are running or excited, but sometimes they occur abruptly (‘out of the blue’) and can cause mainly fear, but also a sweaty feeling, light-headedness, breathlessness or, rarely, pain. Just as the cause of extra beats can be thought of as short circuits, so these palpitations are best thought of as caused by a sensitive area in the wiring of your heart. Again, it may be responding to stress, cigarettes, caffeine or alcohol. Remember that the wiring is only part of the building of the heart, a problem here or there is not going to affect the structure. However, palpitations which lead to chest pain, light-headedness or blackouts need a thorough medical check, so go to your doctor if you get these symptoms. Some people – a small number – have persistent trouble some rapid palpitations which carry on even when you have stopped drinking caffeine or alcohol or when you are no longer stressed. The cause can invariably be identified and treated and is rarely more than an awkward nuisance. Although there may be no major problem with the heart, there is no point in feeling ill if treatment can help you.
I’ve been very worried when I had two attacks of rapid heartbeats recently. Are there any types of palpitations that are dangerous?
Some very rare palpitations are so fast that a blackout occurs. If they occur because your heart muscle is not working very well (ventricular tachycardia– tachycardia just means rapid heartbeat), you will need medication to make them stop as they can be fatal. A common medication used is amiodarone. Your doctor will explain what is happening and it will be very important to follow his advice. You will need close hospital supervision. A defibrillator may also be advised (see p. 191). I must emphasise that this is rare.
I am in my twenties and am getting rapid heartbeats every so often. I work in the type of job where results are all important. My husband has just lost his job as well, so sometimes I feel really stressed. Should I go to the doctor?
Rapid palpitationsare a bit more of a problem because they are more scary. Again, younger people can be under stress, and the heart is behaving in an exaggerated variation of normal, as if you are running all the time, owing to higher adrenaline levels in the blood. A visit to your doctor and an ECG are necessary if symptoms are a problem (dizziness, breathlessness). The doctor will test you for various things such as anaemia, an overactive thyroid gland; he may also check to see whether you are pregnant, because pregnancy makes the heart beat faster in order to feed the baby. Very rarely, the ECG shows evidence of a specific ‘extra wire’ in the heart, which conducts beats much faster than the usual circuit; you will need to go to hospital in this case.
SELF-HELP
I occasionally get palpitations. Now that I am approaching 50 are they going to get worse?
The first thing to do is not to panic. Your doctor will have already told you about not smoking and not drinking excess caffeine or alcohol. As you get older it is a good idea also to try and keep your weight down. Make sure that you:
• take regularly any tablets you have been prescribed;
• attend your doctor for regular checks;
• report any change in how you feel.
I have just had three attacks of palpitations in a week, which made me very worried. By the time I got to see my doctor, they had gone away. What should I do if I get another attack?
When you experience palpitations, take deep breaths and try to relax. If you feel faint, sit down or lie down with your feet up. Try doing a deep cough. If the palpitations are missed beats or rapid beats, and you feel unwell or know that you have a heart condition, let your doctor know. If you are otherwise well and just afraid, ask yourself whether any of these factors might have caused it:
• stress;
• caffeine;
• workload;
• alcohol;
• smoking;
• family anxiety or grief;
• problems at work;
• no recent holiday;
• being generally run-down and anxious.
Try to help yourself by learning to relax more and avoid stimulants to the heart.
After you have tried the first-line principles of not panicking, taking deep breaths etc., try the following procedures, designed to stimulate a nerve called the vagus nerve which can switch rapid palpitations off. These include:
• drinking ice-cold liquid or eating ice-cream, or putting your hand in a bucket of cold water;
• coughing deeply;
• blowing your nose with it pinched, as if trying to make your ears pop, for 20 seconds;
• pressing the right artery in the neck (this is known as carotid sinus massage (CSM) and needs medical instruction);
Do not press your eyes as this can be dangerous.
If rapid palpitations are a more frequent problem or cause distress ¬ing symptoms, then medication will be needed to suppress them (see the section Treatment below). Many types are available and more than one may be necessary. Just because you may need more than one medication does not mean that palpitations are dangerous, just awkward. Treatment is a bit hit and miss, so be patient and ask your doctor about any side effects.
I have heart disease and am finding that I occasionally get attacks of palpitations. Is this serious?
Missed beatsin people with heart disease are not usually much to worry about but a check-up is a good idea. Those people on water pills (diuretics – see the question on diuretics in the section Risks of high blood pressurein Chapter 2), or blood pressure pills (see Chapter 2) may have a low potassium level. Although this is not a common cause of missed beats, the problem can easily be treated, so it should be considered if palpitations arise for no obvious reason when these medications are being taken. You should ask your doctor if your palpitations seem to arise for no apparent reason. Fresh fruit contains lots of potassium as does fruit juice, so the treatment is pleasant; however, it is best to avoid grapefruit juice as this affects the action of some medications.
There was something in the media about a problem with grapefruit juice interacting in some way with medications. Should I avoid the fruit or juice completely?
It is the concentrated juice that is a problem. The juice leaves the body via the liver where it shares the same breakdown system as some medications. It competes with the medications and stops them from being broken down (metabolised) so they may stay around much longer than normal and become more powerful.
I am in my sixties and have developed rapid heartbeats in the last few weeks. I like to drink with friends most evenings. Do you think I am drinking too much?
Rapid palpitations in older people may be caused by atrial fibrillation (see below). This is an irregular heartbeat caused by wear and tear but it is also more common in people with high blood pressure and those who drink a lot of alcohol. Sometimes it can be due to the coronary arteries becoming narrowed or to a thyroid problem (thyrotoxicosis).
If the rapid palpitations are other than normal speeding up (sinus tachycardia), your doctor may decide to treat you and base the treatment on how you feel. For instance, if your heart is sound and only one attack a month happens, then the main thing for you to do will be to cut down on your drinking which acts as a stimulant. Your doctor may treat you for high blood pressure.
I have tried all sorts of self-help methods but I keep getting palpitation attacks; when should I see the doctor?
Palpitations are common, mostly harmless but invariably worry ¬ing. Don’t be afraid, try to understand the reasons – have a good look at how you are living and seek medical advice if there is not an obvious cause or the attacks just won’t go away. If palpitations lead to symptoms of chest pain, light-headedness or blackouts, always get your doctor to check you over.
TESTS
I have been to the doctor because I was so worried about these rapid heartbeats that occurred. He has given me a little machine to record any attacks that I get in future. Can you tell me more about this please?
Because palpitations don’t usually occur when you visit the doctor, a 24-hour ECG (see Chapter 2) is often used. This is like a ‘Walkman’ but it records your heartbeats instead of playing music. The digital card is replayed through a computer and we see the results in a matter of minutes. It does not record any sound so you need not worry that Big Brother is listening in!
You can use this machine at home so that the doctors can watch what your heart is doing during normal daily life. You will be asked to keep a diary and the recording will be checked for times when you felt palpitations or became dizzy.
Four electrodes are attached to your chest and fastened with wires to the recorder which is worn on a belt round your waist (see Figure 6.1). The monitor is quiet and you should not be inconvenienced.
Whilst using the recorder, act normally and try to bring on the symptoms you have been having. You are not allowed to have a bath or shower without a special cover being used. You will be asked to return the recorder the next day so that we can analyse the recording to see if you need any special treatment. Sometimes we do several recordings over 2–5 days.
I think the machine that I am to be given is called an event recorder. Is this different to the ‘Walkman’-type recorder?
This is a small machine which you put on your chest to record a palpitation as it happens. It is about the size of a mobile phone and can be carried easily. The palpitation is then decoded over the telephone or in the technicians’ department, and printed out on an ECG. It is useful when attacks are infrequent but noticeable, and they have to be long enough for you to take action to record them. You will be shown how to use it by the technician at the outpatient department when you collect it.
There are now several recorders which you can activate yourself – some are very small so they are easy to live with. They store information which can then be downloaded and analysed on a computer. They are particularly useful when attacks are infrequent, and where a 24-hour ECG may miss them. Sometimes a device called a Reveal is inserted under the skin, under local anaesthetic. This is about the size of a PP3 battery and can be used to record infrequent episodes, being kept in place for up to a year.
An appointment has been made for me to go to hospital for electrophysiological (EPS) tests. What are these?
These are tests which have to be done in hospital, not at home. Pacemaker catheters (usually four)are passed via a vein at the top of your leg to the heart and the source of palpitations pinpointed and analysed with complex computers. It usually takes up to an hour but can take several hours; it generally needs to be done with X-ray guidance in the catheter laboratory. The only pain you should feel is the local anaesthetic in the groin, but as the doctor moves the catheters you may become aware of your palpitations as the doctor identifies them and tries to get them to occur again. It is usually done as a day case, or one night in hospital may be advised.
TREATMENT
I have a very stressful job and find that I get really nervous. My heart seems to miss a beat when I am stressed or anxious. Is there anything that can help me?
Missed beatsusually respond to self-help, perhaps with a doctor’s reassurance which might include taking an ECG at rest and recording the heartbeat for 24 hours (24-hour ECG see the section Testsabove). A lot of people, who get palpitations like this, are young and under stress, and are helped by beta-blockers which block the stimulation of adrenaline and caffeine to the heart (see the question on beta-blockers in the section Risks of high blood pressure in Chapter 2). These can be used for a month while you try and change your lifestyle where possible, and then as required, for instance before a stressful meeting. Try not to drink too much coffee at meetings and change to decaffeinated-type drinks.
I am going for tests at the hospital next week for palpitations. Will I be offered any medication to treat irregular heartbeats?
It will depend on what type of palpitations that you are found to have. There are a large number of medications used to slow down fast heartbeats and to suppress extra beats.
• Digoxin is most often used to control atrial fibrillation (see below). Doses vary according to how old you are and how good your kidneys are. Your body gets rid of digoxin through your kidneys so, if the kidney function is not as good as it should be, digoxin will build up in the blood. Commonest side effects are loss of appetite, nausea and vomiting. Your doctor may check the level of digoxin in the blood 6 hours after you have taken it to make sure it is not too high or too low. If you get side effects, these will probably disappear if the dose is reduced.(See the sectionTreatment in Chapter 5.)
• Beta-blockers are also used for controlling palpitations. They also help angina, heart failure and high blood pressure; they are especially useful if you have more than one of these conditions.(See under Treatmentin theRisks of high blood pressuresection in Chapter 2.)
• Thecalcium antagonists, verapamil and diltiazem, are alternatives to beta-blockers for palpitations and, like beta-blockers, can be combined with digoxin.
Other more specific medications can be used to suppress extra beats and these include flecainide and amiodarone. These are powerful drugs, used if the simpler medications such as beta-blockers are not proving effective.
• Flecainide is effective in 30 minutes, so is often used as and when the attacks have to be stopped immediately. It is a very effective medication when taken on a regular daily basis by people whose lives are made a misery by troublesome palpitations, but it is unsafe to use it at all if you have heart failure or soon after a heart attack. It can cause nausea, dizziness, and unsteady feelings. It can be used just to stop an attack, known as ‘pill in the pocket’ so you carry it and use it when needed.
• Amiodarone is a life-saving medication for some but, because of its side effects, it is not normally used as a long-term treatment unless there is no alternative. It is very effective in the management of atrial fibrillation (see below), extra beats and dangerous palpitations, and it can be used when you have heart failure and after a heart attack. It takes some time to start working and can take a long time to leave the body. Side effects include sensitivity to sunlight, skin reactions, lung problems and disturbances of the thyroid gland and liver. You will need regular supervision so that the doctor can check for side effects. Amiodarone increases the action of warfarin so extra care is needed by your doctor to monitor the blood-thinning effects of warfarin, if you are taking this.
• Other drugs less frequently used and mainly alternatives to flecainide include disopyramide,propafenone andmexiletene. All are effective drugs but side effects can be a problem. If you are prescribed any of these drugs, always read the package label and discuss the potential benefits and side effects with your doctor.
Reference:
1) http://www.PubMed.com
2) Jackson G. Heart Health, 4th edition, Class Publishing, London. |
