Arrhythmias
Abnormal heart rhythms; Bradycardia; Tachycardia; Fibrillation
An arrhythmia is a disorder of the heart rate (pulse) or heart rhythm. The heart can beat too fast (tachycardia), too slow (bradycardia), or irregularly.
An arrhythmia can be harmless, a sign of other heart problems, or an immediate danger to your health.
The interior of the heart is composed of valves, chambers, and associated vessels.
The external structures of the heart include the ventricles, atria, arteries and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.
An electrocardiogram (ECG) test measures the electrical activity of the heart. A normal resting heart rate is 60 to 100 beats per minute.
Bradycardia heart rhythms are characterized by a slowness of the heartbeat, usually at a rate under 60 beats per minute (normal resting rate is 60 to 100 beats per minute).
Ventricular tachycardia is a rapid resting heart rate initiated within the ventricles, typically at 160 to 240 beats per minute (normal resting rate is 60 to 100 beats per minute).
This picture shows an ECG (electrocardiogram, EKG) of a person with an abnormal rhythm (arrhythmia) called an atrioventricular (AV) block. P waves show that the top of the heart received electrical activity. Each P wave is usually followed by the tall (QRS) waves. QRS waves reflect the electrical activity that causes the heart to contract. When a P wave is present and not followed by a QRS wave (and heart contraction), there is an atrioventricular block, and a very slow pulse (bradycardia).
The intrinsic conduction system sets the basic rhythm of the beating heart by generating impulses which stimulate the heart to contract.
Causes
Normally, your heart works as a pump that brings blood to the lungs and the rest of the body.
To help this happen, your heart has an electrical system that makes sure it contracts (squeezes) in an orderly way.
- The electrical impulse that signals your heart to contract begins in an area of the heart called the sinoatrial node (also called the sinus node or SA node). This is your heart's natural pacemaker.
- The signal leaves the SA node and travels through the heart along a set electrical pathway.
- Different nerve messages signal your heart to beat slower or faster.
Arrhythmias are caused by problems with the heart's electrical conduction system.
- Abnormal extra signals may occur.
- Electrical signals may be blocked or slowed.
- Electrical signals travel in new or different pathways through the heart.
Some common causes of abnormal heartbeats are:
- Abnormal levels of potassium, magnesium, or other substances in the body
- Heart attack, or a damaged heart muscle from a past heart attack
- Heart disease that is present at birth (congenital)
- Heart failure or an enlarged heart
- Overactive thyroid gland
Arrhythmias may also be caused by some substances or drugs, including:
- Alcohol or stimulant drugs
- Certain medicines
- Cigarette smoking (nicotine)
Some of the more common abnormal heart rhythms are:
- Atrial fibrillation or flutter
- Atrioventricular nodal reentry tachycardia (AVNRT)
- Heart block or atrioventricular block
- Multifocal atrial tachycardia
- Paroxysmal supraventricular tachycardia
- Sick sinus syndrome
- Ventricular fibrillation or ventricular tachycardia
- Wolff-Parkinson-White syndrome
The cardiac conduction system is a group of specialized cardiac muscle cells in the walls of the heart that send signals to the heart muscle causing it to contract. The main components of the cardiac conduction system are the SA node, AV node, bundle of His, bundle branches, and Purkinje fibers. The SA node (anatomical pacemaker) starts the sequence by causing the atrial muscles to contract. From there, the signal travels to the AV node, through the bundle of His, down the bundle branches, and through the Purkinje fibers, causing the ventricles to contract. This signal creates an electrical current that can be seen on a graph called an electrocardiogram (EKG or ECG). Doctors use an EKG to monitor the cardiac conduction system's electrical activity in the heart.
Symptoms
When you have an arrhythmia, your heartbeat may be:
- Too slow (bradycardia)
- Too quick (tachycardia)
- Irregular, uneven, possibly with extra or skipped beats
An arrhythmia may be present all of the time or it may come and go. You may or may not feel symptoms when the arrhythmia is present. Or, you may only notice symptoms when you are more active.
Symptoms can be very mild, or they may be severe or even life threatening.
Common symptoms that may occur when the arrhythmia is present could include:
- Chest pain
- Fainting
- Lightheadedness, dizziness
- Paleness
- Palpitations (feeling your heart beat fast or irregularly)
- Shortness of breath
- Sweating
Exams and Tests
The health care provider will listen to your heart with a stethoscope and feel your pulse. Your blood pressure may be low or normal or even high as a result of being uncomfortable.
An ECG will be the first test done.
Heart monitoring devices are often used to identify the rhythm problem, such as a:
- Holter monitor (where you wear a device that records and stores your heart rhythm for 24 or more hours)
- Event monitor or loop recorder (worn for 2 weeks or longer, where you record your heart rhythm when you feel an abnormal rhythm)
- Other long-term monitoring options
An echocardiogram is sometimes ordered to examine the size or structure of your heart.
In selected cases, coronary angiography may be performed to see how blood flows through the arteries in your heart.
A special test, called an electrophysiology study (EPS), is sometimes done to take a closer look at the heart's electrical system.
If your heart has been beating too fast, or you've been having chest pain, both you and your doctor will want to find out what's causing the problem so you can get it treated. One way to diagnose heart problems is with a test of the heart's electrical activity, called an electrocardiogram or ECG, or EKG for short. Your heart is controlled by an electrical system, much like the electricity that powers the lights and appliances in your home. Electrical signals make your heart contract so that it can pump blood out to your body. Heart disease, abnormal heart rhythms, and other heart problems can affect those signals. Using an ECG, your doctor can identify problems in your heart's electrical system and diagnose heart disease. So, how is an ECG done? First you'll lie down on a table. You'll have to lie very still while the test is done. Small patches, called electrodes, will be attached to several places on your arms, legs, and chest. The patches won't hurt, but some of the hair in those areas may be shaved so the patches will stick to your skin. The patches are then attached to a machine. You'll notice that when the machine is turned on, it produces wavy lines on a piece of paper. Those lines represent the electrical signals coming from your heart. If the test is normal, it should show that your heart is beating at an even rate of 60 to 100 beats per minute. Many different heart conditions can show up on an ECG, including a fast, slow, or abnormal heart rhythm, a heart defect, coronary artery disease, heart valve disease, or an enlarged heart. An abnormal ECG may also be a sign that you've had a heart attack in the past, or that you're at risk for one in the near future. If you're healthy and you don't have any family or personal history of heart disease, you don't need to have an ECG on a regular basis. But if you are having heart problems, your doctor may recommend getting this test. An ECG is pretty accurate at diagnosing many types of heart disease, although it doesn't always pick up every heart problem. You may have a perfectly normal ECG, yet still have a heart condition. If your test is normal but your doctor suspects that you have a heart problem, he may recommend that you have another ECG, or a different type of test to find out for sure.
Treatment
When an arrhythmia is serious, you may need urgent treatment to restore a normal rhythm. This may include:
- Electrical therapy (defibrillation or cardioversion)
- Implanting a short-term heart pacemaker
- Medicines given through a vein or by mouth
Sometimes, better treatment for your angina or heart failure will lower your chance of having an arrhythmia.
Medicines called anti-arrhythmic drugs may be used:
- To prevent an arrhythmia from happening again
- To keep your heart rate from becoming too fast or too slow
Some of these medicines can have side effects. Take them as prescribed by your provider. Do not stop taking the medicine or change the dose without first talking to your provider.
Other treatments to prevent or treat abnormal heart rhythms include:
- Cardiac ablation, used to target areas in your heart that may be causing your heart rhythm problems
- An implantable cardioverter defibrillator, placed in people who are at high risk of sudden cardiac death
- Permanent pacemaker, a device that senses when your heart is beating too slowly. It sends a signal to your heart that makes your heart beat at the correct pace.
Outlook (Prognosis)
The outcome depends on several factors:
- The kind of arrhythmia you have.
- Whether you have coronary artery disease, heart failure, or valvular heart disease.
When to Contact a Medical Professional
Call your provider if:
- You develop any of the symptoms of a possible arrhythmia.
- You have been diagnosed with an arrhythmia and your symptoms worsen or do not improve with treatment.
Prevention
Taking steps to prevent coronary artery disease may reduce your chance of developing an arrhythmia.
References
Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2018;15(10):e190-e252. PMID: 29097320
Olgin JE. Approach to the patient with suspected arrhythmia. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 56.
Nattel S, Tomaselli GF. Mechanisms of cardiac arrhythmias. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 62.
Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60(14):1297-1313. PMID: 22975230
Version Info
Last reviewed on: 5/8/2022
Reviewed by: Fang JC, O'Gara PT. History and physical examination: an evidence-based approach. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier Saunders; 2022: chap 13.
