DYSRHYTHMIAS

Dysrhythmias are disorders of the formation or conduction of the electrical impulse within the heart. These disorders can cause disturbances of heart rate, the heart rhythm or both. 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 re-entry, 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.

Pathophysiology
Normal electrical activity Each heart beat originates as an electrical impulse from a small area of tissue in the right atrium of the heart called the sinus node or Sino-atrial node or SA node. The impulse initially causes both atria to contract, then activates the atrioventricular (or AV) node which is normally the only electrical connection between the atria and the ventricles (main pumping chambers). The impulse then spreads through both ventricles via the Bundle of His and the Purkinje fibres causing a synchronised contraction of the heart muscle and, thus, the pulse.

In adults the normal resting heart rate ranges from 60 to 80 beats per minute. The resting heart rate in children is much faster. In athletes though, the resting heart rate can be as slow as 40 beats per minute, and be considered as normal.

Bradycardias A slow rhythm (less than 60 beats/min), is labelled bradycardia. This may be caused by a slowed signal from the sinus node (sinus bradycardia), a pause in the normal activity of the sinus node (sinus arrest), or by blocking of the electrical impulse on its way from the atria to the ventricles (AV block or heart block). Heart block comes in varying degrees and severity. It may be caused by reversible poisoning of the AV node (with drugs that impair conduction) or by irreversible damage to the node. Bradycardias may also be present in the normally functioning heart of endurance athletes or other well-conditioned persons. Tachycardias In adults and children over 15, resting heart rate faster than 100 beats/minute is labelled tachycardia. Tachycardia may result in palpitation; however, tachycardia is not necessarily an arrhythmia. Increased heart rate is a normal response to physical exercise or emotional stress. This is mediated by the sympathetic nervous system on the sinus node and called sinus tachycardia. Other things that increase sympathetic nervous system activity in the heart include ingested or injected substances, such as caffeine or amphetamines, and an overactive thyroid gland (hyperthyroidism). Tachycardia that is not sinus tachycardia usually results from the addition of abnormal impulses to the normal cardiac cycle. Abnormal impulses can begin by one of three mechanisms: automaticity, re-entry or triggered activity. A specialised form of re-entry problem is termed fibrillation. Although the term "tachycardia" is known over one hundred year, basis for the classification of arrhythmias are still being discussed.

Heart defects causing tachycardia Congenital heart defects are structural or electrical pathway problems in the heart that are present at birth. Anyone can be affected with this because overall health does not play a role in the problem. Problems with the electrical pathway of the heart can cause very fast or even deadly arrhythmias. Wolf-Parkinson-White syndrome is due to an extra pathway in the heart that is made up of electrical muscle tissue. This tissue allows the electrical impulse, which stimulates the heartbeat, to happen very rapidly. Right Ventricular Outflow Tract Tachycardia is the most common type of ventricular tachycardia in otherwise healthy individuals. This defect is due to an electrical node in the right ventricle just before the pulmonary artery. When the node is stimulated, the patient will go into ventricular tachycardia, which does not allow the heart to fill with blood before beating again. Long QT Syndrome is another complex problem in the heart and has been labeled as an independent factor in mortality. There are multiple methods of treatment for these including cardiac ablations, medication treatment, or altering your lifestyle to have less stress and exercise. It is possible to live a full and happy life with these conditions. Automaticity Automaticity refers to a cardiac muscle cell firing off an impulse on its own. All of the cells in the heart have the ability to initiate an action potential; however, only some of these cells are designed to routinely trigger heart beats. These cells are found in the conduction system of the heart and include the SA node, AV node, Bundle of His and Purkinje fibers. The sinoatrial node is a single specialized location in the atrium which has a higher automaticity (a faster pacemaker) than the rest of the heart and, therefore, is usually responsible for setting the heart rate and initiating each heart beat. Any part of the heart that initiates an impulse without waiting for the sinoatrial node is called an ectopic focus and is, by definition, a pathological phenomenon. This may cause a single premature beat now and then, or, if the ectopic focus fires more often than the sinoatrial node, it can produce a sustained abnormal rhythm. Rhythms produced by an ectopic focus in the atria, or by the atrioventricular node, are the least dangerous dysrhythmias; but they can still produce a decrease in the heart's pumping efficiency, because the signal reaches the various parts of the

heart muscle with different timing than usual and can be responsible for poorly coordinated contraction. Conditions that increase automaticity include sympathetic nervous system stimulation and hypoxia. The resulting heart rhythm depends on where the first signal begins: If it is the sinoatrial node, the rhythm remains normal but rapid; if it is an ectopic focus, many types of dysrhythmia may ensue. Re-entry Re-entrant arrhythmias occur when an electrical impulse recurrently travels in a tight circle within the heart, rather than moving from one end of the heart to the other and then stopping. Every cardiac cell is able to transmit impulses of excitation in every direction but will only do so once within a short time. Normally, the action potential impulse will spread through the heart quickly enough that each cell will only respond once. However, if there is some essential heterogeneity of refractory period or if conduction is abnormally slow in some areas (for example in heart damage) so the myocardial cells are unable to activate the fast sodium channel, part of the impulse will arrive late and potentially be treated as a new impulse. Depending on the timing, this can produce a sustained abnormal circuit rhythm. As a sort of re-entry, the vortices of excitation in the myocardium (autowave vortices) is considered to be the main mechanism of life-threatening cardiac arrhythmias. In particular, the autowave reverberator is a typical in thin walls of the atria, with the atrial flutter producing. Re-entry is also responsible for most paroxysmal supraventricular tachycardia, and dangerous ventricular tachycardia. These types of re-entry circuits are different from WPW syndromes in which the real pathways existed. Although omega-3 fatty acids from fish oil can be protective against arrhythmias, in the case of re-entrant arrhythmias, fish oil can worsen the arrhythmia.

Fibrillation When an entire chamber of the heart is involved in a multiple micro-reentry circuits and, therefore, quivering with chaotic electrical impulses, it is said to be in fibrillation. Fibrillation can affect the atrium (atrial fibrillation) or the ventricle (ventricular fibrillation); ventricular fibrillation is imminently life-threatening. Atrial fibrillation affects the upper chambers of the heart, known as the atria. Atrial fibrillation may be due to serious underlying medical conditions and should be evaluated by a physician. It is not typically a medical emergency. Ventricular fibrillation occurs in the ventricles (lower chambers) of the heart; it is always a medical emergency. If left untreated, ventricular fibrillation (VF, or V-fib) can lead to death within minutes. When a heart goes into V-fib, effective pumping of the blood stops. V-fib is considered a form of cardiac arrest. An individual suffering from it will not survive unless cardiopulmonary resuscitation (CPR) and defibrillation are provided immediately. CPR can prolong the survival of the brain in the lack of a normal pulse, but defibrillation is the only intervention that can restore a healthy heart rhythm. Defibrillation is performed by applying an electric shock to the heart, which resets the cells, permitting a normal beat to re-establish itself. Triggered beats Triggered beats occur when problems at the level of the ion channels in individual heart cells result in abnormal propagation of electrical activity and can lead to sustained abnormal rhythm. They are relatively rare and can result from the action of anti-arrhythmic drugs. See early and delayed after depolarizations.

Normal Sinus Rhythm

In a normal heart rhythm, the sinus node generates an electrical impulse which travels through the right and left atrial muscles producing electrical changes which is represented on the electrocardiogram (ECG) by the p-wave. The electrical impulse then continues to travel through specialized tissue known as the atrioventricular node, which conducts electricity at a slower pace. This will create a pause (PR interval) before the ventricles are stimulated. This pause is helpful since it allows blood to be emptied into the ventricles from the atria prior to ventricular contraction to propel blood out into the body. The ventricular contraction is represented electrically on the ECG by the QRS complex of waves. This is followed by the T-wave which represents the electrical changes in the ventricles as they are relaxing. Therefore, on an ECG in normal sinus rhythm p-waves are followed after a brief pause by a QRS complex, then a T-wave. Normal sinus rhythm not only indicate that the rhythm is normally generated by the sinus node and traveling in a normal fashion in the heart, but also that the heart rate, i.e. the rate at which the sinus node is generating impulses is within normal limits. There is no one normal heart rate, but this varies by age. It is normal for a newborn to have a heart rate up to 150 beats per minute, while a child of five years of age may have a heart rate of 100 beats per minute. The adult's heart rate is even slower at about 60-80 beats per minute.

Types of Sinus Node

Sinus Tachycardia

Sinus tachycardia occurs when heart rate increases, usually due to some stimulus that has affected the heart muscle. Causes of sinus tachycardia include severe fright, distress, exercise, fever, and use of recreational, over-the-counter, or prescription drugs. In many cases, sinus tachycardia is considered normal, and the heart rate often lowers itself without treatment. If sinus tachycardia is more persistent, however, it may be the result of an underlying condition. When drugs of any type are implicated in increased heart rate, drug use habits may need to be reconsidered. The increase in heart rate known as sinus tachycardia typically occurs when the nerve bundle known as the sinoatrial (SA) node stimulates the heart to beat more rapidly. The SA node can be found in the upper portion of the right atrium of the heart. It normally produces the electrical impulses that regulate heartbeat. Most people have a normal resting heart beat of 60 to 70 beats per minute, but sinus tachycardia can cause the heart to beat much faster. While rapid heart rate can occur with this type of tachycardia, the heart continues to function normally. The interval between beats is usually regular and the heart beat itself is normally rhythmic. Rapid heart rate is typically the only symptom of this condition.

Many of the causes of sinus tachycardia require no treatment. It's considered normal for heart rate to increase during physical activity. Extreme fear, anxiety or emotional distress can also cause a rapid heart rate. The heart rate usually returns to normal after a suitable period of rest, or after the extreme emotions have dissipated. More dangerous causes of sinus tachycardia can include dehydration and severe bleeding. Both conditions can lead to severe fluid loss from the body. Heart rate may increase as the heart struggles to pump less blood through the veins and arteries. Both dehydration and severe bleeding can lead to serious health consequences and death. Use of prescription, over-the-counter and recreational drugs can also lead to sinus tachycardia. Caffeine, alcohol, and ephedrine-based respiratory remedies can stimulate the SA node and lead to rapid heart rate. Recreational or "street" drugs such as cocaine or methamphetamine can also raise the heart rate. Patients with heart problems are often strongly advised to consult a physician before using caffeine, alcohol, over-the-counter cold remedies, or any prescription drugs.

Sinus Bradycardia

People who have a very slow heartbeat may find that they actually have a condition known as sinus bradycardia. Patients with this condition may still have normal, regular heart beats, however, they are much slower than average heartbeats, at only 60 beats per minute or less while at rest. Some common causes of sinus bradycardia include rigorous physical exercise, irregular

sleep patterns, hypothermia, and the use of some medications. Aside from a rather slow heartbeat, some patients also experience additional symptoms such as light headedness, chest pain, and shortness of breath. Treatments vary depending on the severity of the case; some patients do not require treatment, others need medication, and still others require a pacemaker. Named after the sinus node in the heart that is responsible for maintaining a heartbeat, sinus bradycardia can actually be a positive health condition, indicative of good health. Many athletes develop the condition as a result rigorous conditioning through physical exercise, causing the heart to pump at a steady speed. Oftentimes, a healthy person whom does not exercise regularly can still have the condition with or without additional symptoms. Other, less healthy causes of sinus bradycardia can include conditions related to sleep such as irregular sleep patterns and sleep apnea. Hypothyroidism, hypothermia, hypoglycemia, seizures, and electrolyte disorders are some well-known conditions that may lead to sinus bradycardia. Exposure to certain toxins, such as atenolol, diltiazem, and organophosphate, can also be a cause of the condition. The use of some medications has also been known to create a slow heartbeat; common drugs that can cause the condition are normally heart medications such as beta-blockers, calcium channelblocking medicines, and digitalis glycosides. These are often prescribed to treat high blood pressure and other heart-related conditions. Some other drugs known to cause the condition include toluene, fentanyl, clonidine, lithium, topical ophthalmic acetylcholine, sufentanil, paclitaxel, alfentanil, dimethyl sulfoxide, and reserpine. Cases of severe sinus bradycardia may present more of a concern. These can be caused by a disease of the sinoatrial node, such as sick sinus syndrome, which usually occurs in the elderly, and has a poor prognosis. In rare cases, the condition may also be a symptom of another infection, such as viral myocarditis, diphtheria, and rheumatic fever. Sinus bradycardia symptoms can vary. Aside from a slow heart rate, patients may encounter dizziness, vertigo, light headedness, hypertension, and syncope; chest pain, shortness of breath, and an inability to exercise may also be experienced. Irregular heartbeats can also occur, including junctional, atrial, or ventricular ectopic rhythms. Fainting may also result should the

heart delay to a very slow beat. It can be caused by choking as well, which is known as the vasovagal reflex since sinus bradycardia patients already have a slow heartbeat, when the heart slows even further during choking, fainting can result. Health professionals may be able to diagnose this condition after doing a physical exam, questioning the patient regarding symptoms, and completing an electrocardiogram (EKG). It should be noted that an EKG will only show signs of the condition the heart rate is slowed during the actual test; this can be a problem for some patients as the condition seems to come and go. One possible solution is for patients to use a portable electrocardiogram device, also known as a Holter monitoring, to record the heart's rhythm.

Sinus Arrhythmia

Sinus arrhythmia is a disruption in the heartbeat that originates in the sinus node of the heart, where the heart's natural pacemaker is located. A number of problems involving the heart's natural pacing can cause the heartbeat to be irregular. Sinus arrhythmia is usually benign, but it can be a cause for concern in certain cases. Other arrhythmias located in this node such as sinus bradycardia, where the heart beats too slowly, or sinus tachycardia, where the heart beats too quickly, can be serious medical issues. Children and young adults commonly have a natural sinus arrhythmia that resolves with age. Another common form of sinus arrhythmia is a respiratory sinus arrhythmia, characterized by

small variations in the heartbeat associated with breathing in. In patients with this type of arrhythmia, the heartbeat changes slightly with each breath, but the patient is not in danger. Sinus arrhythmia can also occur in response to medications, stress, environmental factors, and recreational drugs. Some of these arrhythmias can become dangerous if they are not corrected. Patients who repeatedly expose themselves to common causes of cardiac arrhythmias over the long term can damage their hearts. This can lead to the development of a more serious arrhythmia that may put the patient at risk of a heart attack or other medical complications. A doctor may be able to hear a sinus arrhythmia during a physical exam. If a doctor identifies irregularities in a patient's heartbeat, an electrocardiograph may be recommended. In this test, leads are attached to the patient's chest and the electrical rhythms of the heart are measured. A printout shows the patterns of the patient's heartbeats and this information can be used to diagnose a patient or to learn more about a heart problem. If a cause for concern is identified, the patient can meet with the doctor to discuss the situation and talk about treatment options. If a patient has a history of sinus arrhythmia, it will be noted in the chart along with the outcome of any medical tests conducted on the heart. This information can be useful for other care providers, alerting them to the fact that the arrhythmia has been noted and worked up. Patients who are switching doctors should make sure to request copies of their medical records so they can bring them in on their first appointments. Having complete patient records increases the quality of care and will help a doctor provide continuity of care in the long term.

Premature atrial contractions (PACs)

Premature atrial contractions (PACs) are a type of heart arrhythmia. They are extremely common, with many people experiencing premature atrial contractions at some point in their lives. In some cases, the condition is benign, while in other cases, the PACs can indicate that the patient is at risk for a more serious problem, and it may be necessary to take steps to manage the heart rhythm. People with heart conditions who experience premature atrial contractions are a cause for special concern. This type of arrhythmia occurs when the atria, the two upper chambers of the heart, beat before they are supposed to. Many people never even notice that a premature atrial contraction is occurring, although some people feel the contraction as a faint flutter orpalpitation, as though the heart has skipped a beat. With the use of an electrocardiogram (ECG) or the wearing of a heart rate monitor, a doctor can track the contractions, determining how often and when they occur. In patients for whom premature atrial contractions are a mild concern, the condition may be managed with diet. Cutting down on caffeine often eliminates or greatly reduces the incidence of premature atrial contractions, and other diet and exercise changes can also be used to address the condition. Medications to manage heart rhythm are also available, although these are generally only used in more severe cases.

Atrial tachycardia

Atrial tachycardia is one of several heart problems which can cause heart arrhythmia. The problem stems from an abnormal cardiac rhythm which occurs when the electrical impulses which regulate the heartbeat originate in the wrong area of the heart. It does have a low morbidity rate, but in children who are born with this heart abnormality the death risk is somewhat higher. Within the heart is a small node of tissue known as the sinoatrial node, located in the right atrium, the upper right corner, of the organ. It is this node which originates the electrical impulses that cause the heart to beat, and which is responsible for setting the pace of the heartbeat. In a person with atrial tachycardia, these electrical impulses come from the upper chambers of the heart, called the atria, instead of from the sinoatrial node. A person who has atrial tachycardia may experience what amounts to some very frightening symptoms, such as heart palpitations, pain or pressure in the chest, difficulty breathing, fainting, and dizziness. A feeling of fatigue which may be persistent despite periods of resting is another common symptom of atrial tachycardia. Children who are experiencing abnormal heart rhythm or other symptoms may find it difficult to articulate these sensations, but may simply express a need to rest or may have problems keeping up with other children at play. Treatment for this condition may differ depending on what has caused the heart arrhythmia and accompanying symptoms. In the case of multiple atrial tachycardia (MAT), for example, the underlying cause is often chronic obstructive pulmonary disease, congestive heart failure, or another cardiac condition. In such cases treatment may be somewhat different from that prescribed for someone who experiences atrial tachycardia as a result of a structural heart abnormality. In general, the cardiac arrhythmia is treated with medication to suppress the abnormal rhythm and restore a normal heartbeat. Abnormal cardiac events of the kind that cause heart arrhythmia and rapid heartbeat can also be responsible for a much more benign condition called paroxysmal atrial tachycardia. This condition is characterized by an abrupt period of rapid heartbeat, typically between 160 and 200 beats per minute, along with other symptoms such as anxiety, dizziness, and heart palpitations. An episode of paroxysmal atrial tachycardia can occur in the complete absence of any heart

disease or defect, and this condition is not usually dangerous. It can be very frightening, but its important to remember that unless other cardiac symptoms are present, there is usually no cause for alarm. A visit to the doctor to rule out serious problems is still in order, of course, as its never a good idea to ignore cardiac symptoms.

Atrial fibrillation

Atrial fibrillation, also known as afib, is a term used to describe a disorder of the heart. Atrial fibrillation is a form of cardiac arrhythmia, which means that the hearts normal beating rhythm is interrupted. The condition may be permanent, may come and go without treatment, or may be stopped only with treatment. Atrial fibrillation can cause heart palpitations, chest pain, dizziness, shortness of breath, weakness, and fatigue, although many people experience no symptoms at all. It is estimated that approximately two million people in the United States experience atrial fibrillation. While the condition itself is not generally fatal, it can lead to increased risk of stroke, heart failure and heart attack. Heart disease and high blood pressure are the two main known causes of atrial fibrillation. Both of these conditions can cause damage to the heart, making it more susceptible to cardiac arrhythmia. Other common causes are heart abnormalities or defects, illness, sleep apnea, and metabolic or chemical imbalances in the body.

The heart is composed of four chambers. The top two chambers are known as the atria and the bottom two chambers are known as the ventricles. All of the chambers must contract or expand at precisely the right time to ensure that blood is received from the body, oxygenated and then pumped back out to the body effectively. After the body has depleted the oxygen in the blood, it enters the heart through the right atria. From the right atria the blood is pumped to the right ventricle, where it is pumped to the lungs, which replenishes the blood with oxygen. Once replenished with oxygen, the blood is transported from the lungs to the left atria, where it is pumped into the left ventricle. From the left ventricle, the oxygen-rich blood flows into the aorta, which is the largest artery in the body. From the aorta, blood reenters the bloodstream and is distributed throughout the body. In a healthy heart, regular electrical impulses tell the heart when to expand and contract. During atrial fibrillation, the electrical impulses are irregular and very rapid. This causes the left and right atria to quiver instead of beating effectively. As a result of the irregular heartbeat, the atria may not fully pump out all of the blood that is in it, possibly causing blood to pool and collect. When blood is allowed to collect, clots are more likely to form. If a piece of a formed blood clot breaks away and flows out of the heart, it may lodge in an artery of the brain causing a stoppage of blood flow to the brain, resulting in a stroke. It has been estimated that approximately 15% of patients who experienced a stroke also experienced atrial fibrillation. Treatment of atrial fibrillation generally consists of preventing blood clots from forming and restoring regular rhythm to the heart. Blood thinning and anti-clotting medication is often prescribed to reduce the risk of a stroke. Medication can also help regulate the rhythm and rate of the heart. In addition to medication, treatment may also consist of surgical and non-surgical procedures to restore normal rhythm to the heart.

Atrial flutter

An atrial flutter is arrhythmia, or abnormal rhythm, of the atria of the heart. The atria are the two upper chambers of the human heart. Atrial flutter occurs most commonly in people with cardiovascular problems, but it can also affect healthy people. It is usually short-lived, either going away, or degenerating into atrial fibrillation, another form of arrhythmia that is usually chronic. There are two types of atrial flutter, Type I and Type II; the latter is rarer, and causes faster arrhythmia. Atrial flutter is characterized by palpitations, or an abnormal awareness of the heart's beating, along with tachycardia, or an abnormally fast heartbeat. It is not necessarily something to worry about and may, for example, simply be a sign of mild overexertion that resolves itself within a few minutes of decreasing strenuous activity. If atrial flutter persists, however, especially in a person with any kind of cardiovascular illness or weakness, it may also be accompanied by dizziness, shortness of breath, chest pains, and nausea. In extreme cases, atrial flutter can lead to chronic breathlessness and even heart failure. It can also cause blood to pool in the atria and eventually form a blood clot in the heart. If the blood clot travels to the brain, stroke can result. A re-entrant rhythm in the right or left atrium causes atrial flutter. When the heart is functioning normally, a heartbeat will involve electrical impulses passing through each cell of the atrium only once. During atrial flutter, some cells are slow to respond to the impulse. This causes the

initial impulse to be misinterpreted, when the slow cells finally respond, resulting in a continued loop of electrical activity. The resulting heartbeat will not be as fast as the impulses in the atria, since heartbeat is measured by the contractions of the ventricles, the lower two chambers of the heart; however, it will be faster than normal. The atria transmit an electrical impulse to the ventricles via the atrioventricular node, which is able to slow down excessively fast impulses coming from the atria. When the atrio-ventricular node slows the impulse in this manner, heart block occurs, resulting in the symptoms that characterize atrial flutter. Atrial flutter may be treated with medication to prevent the formation of blood clots and to control the heart's rate or rhythm. Cardioversion, the application of a low current electrical energy to the heart, can also help return the heartbeat to normal in the case of atrial flutter.Ablation, in which a scar is surgically created to destroy the circuit in the heart causing atrial flutter, is another option. Types of Ventricular Arrhythmias A ventricular arrhythmia begins in the hearts ventricles. Types of ventricular arrhythmias include:

Premature ventricular contractions (PVCs)

Premature ventricular beats are heartbeats that originate in the ventricles, rather than the sinoatrial node of the heart, occurring shortly before a regular heartbeat would have happened. Many people experience them at some point during their lives, and in some people, they can be associated with a medical problem. Premature ventricular beats can feel like unusually strong heartbeats, skipped beats, or palpitations in the chest, although they are not always noticeable. In a premature ventricular beat, an electrical impulse triggers a contraction of the ventricles before they receive a signal from the sinoatrial node. This causes the heart to beat too early. Also known as premature ventricular contractions (PVCs), they are often the result of stress or environmental factors. An electrocardiograph will show premature ventricular beats. They show up on the readout as a distinctive spike. The doctor can determine how frequently they occur and collect other information to determine if a patient needs treatment. Patients with heart failure, valvedisorders, and coronary artery disease are more prone to premature ventricular beats, and a doctor may try to control the heart rhythm with treatment for the underlying medical condition. They can also be a response to stress or too much caffeine, in which case a doctor may recommend that a patient make some lifestyle changes to prevent complications. Adjusting caffeine intake and using techniques to limit stress can help eliminate the problem. Age is also a factor, with older adults being more likely to experience this abnormal heart rhythm. The risk with premature ventricular beats is that they could send the heart into an arrhythmia, where the heart does not beat normally. Some arrhythmias are very dangerous and could kill the patient. If a doctor has concerns about the patient's heart, he may recommend medications and exercise. Mechanical pacing is an option to control the heart's rhythm, as is implantation of a defibrillator to shock the heart if it enters a dangerous rhythm. Treatment for premature ventricular beats requires balancing the desire to prevent a fatal arrhythmia with the risks of the treatments. Some medications to control heart rhythm, for example, can also cause heart rhythm problems. If a doctor thinks the risks of treatment outweigh the benefits, a more conservative wait-and-see approach may be the best option for treatment.

Ventricular tachycardia (V-tach)

Ventricular tachycardia or V-tach is an abnormally rapid heartbeat. Three or more heartbeats at a rate of 100 beats per minute or above fit the diagnostic criteria for ventricular tachycardia. In some patients, the rapid heartbeat resolves on its own within 30 seconds, while in others, it may be sustained, lasting more than 30 seconds. This heart rhythm is a sign of an underlying cardiac problem and it can precede a serious medical emergency. As the name suggests, ventricular tachycardia originates in the ventricles of the heart. The part of the heart muscle responsible for regulating contractions of the ventricles fires prematurely, causing the ventricles to contract too soon. A distinctive heart rhythm can be seen on an electrocardiograph (ECG), allowing a doctor to diagnose ventricular tachycardia. Since the condition can be intermittent, patients at risk may be asked to wear a mobile monitor to record heart rhythms, allowing a doctor to identify periods of rapid heart rate as they occur over the course of the day. During bouts of ventricular tachycardia, patients can experience a variety of symptoms. Palpitations, where the heart feels like it is beating rapidly, can be observed, along with sweating, pallor, clammy skin, nausea, and a general feeling of malaise. Some causes of this abnormally fast heart rate include chronic heart conditions such as cardiomyopathy, along with scarring from myocardial infarctions. Ventricular tachycardia can also directly precede a heart attack.

If it persists, ventricular tachycardia sometimes leads to a very dangerous medical emergency called ventricular fibrillation. In this type of heart rhythm, the heart beats very rapidly and is not coordinated. Instead of circulating blood, it quivers in the chest. The patient can die within minutes as a result of poor blood circulation to the body. V-fib, as it is also known, produces a very recognizable rhythm on ECGs, making it easy to identify. Available treatments can include medications to regulate heart rhythm, ablation of damaged areas of the ventricles to restore normal heart rhythm, and the use of external pacing devices to shock the heart into the correct rhythm. Heart surgery may be required for some patients. It is also important to identify and treat the underlying cause, if possible, with the goal of preventing complications like ventricular fibrillation. Patients with a history of episodes of ventricular tachycardia should make sure their doctors are aware of it, especially if they are going into surgery.

Ventricular fibrillation (V-fib)

Ventricular fibrillation refers to an abnormal heart rhythm that changes the way the ventricles contract. It is usually sudden and always life threatening. It thus constitutes a medical emergency, requiring treatment right away, since the heart can easily stop and not restart. Most people arent likely to ignore the condition if it occurs in front of others, since it typically causes unconsciousness within a minute or two.

There are many potential causes of ventricular fibrillation. Structural anomalies in the heart may result in it, as can recent surgeries of any kind on the heart or cardiomyopathy. People who drown, experience a high voltage shock, or who go into anaphylactic shock could experience this condition too. Other causal factors include reduced blood levels of potassium, and sometimes the use of medications that may affect potassium. Most often though, a ventricular fibrillation episode occurs in conjunction with a heart attack and could be proceeded by heart attack symptoms like chest pain, or a feeling of rapid heartbeat and shortness of breath. The necessity of getting medical help right away cannot be underestimated. When ventricular fibrillation occurs, the person will become unconscious and within a few minutes, seizures can occur. Unconsciousness may change to coma as the brain continues to be deprived of oxygen, and death or extremely serious brain injury may occur. In hospital settings where the heart is monitored, ventricular fibrillation receives quick treatment and survival outcome can be very good. Treatment may not happen when people are simply living their daily lives and an episode occurs. It is absolutely necessary that CPR (cardiopulmonary resuscitation) begin immediately, with someone else contacting emergency services, if a person appears to have had an episode. Better yet, and with a greater survival rate is the use of a portable defibrillator, which may able to shock the heart back to a regular rhythm state. Some schools and athletic programs now have portable defibrillators at hand and employees receive training on them. Without this training, it may not be wise to try to use one. When emergency workers arrive, theyll almost certainly employ their defibrillator to provide this rhythm restart. In the interim, CPR is usually the best treatment. When people survive an episode of this condition, there are a couple of treatment options. One is using medications to avoid ventricular fibrillation in the future. A method that may be preferred is implantation of a defibrillator, which can arrest ventricular rhythm abnormalities as they occur so that the heart beats normally. There is high risk of the condition occurring again, so treatment is deemed necessary in the majority of patients.

Atrioventricular Blocks
An atrioventricular block (or AV block) involves the impairment of the conduction between the atria and ventricles of the heart. Under normal conditions, SA node in the atria sets the pace for the heart, and these impulses travel down to the ventricles. In an AV block, this message does not reach the ventricles or is impaired along the way. The ventricles of the heart have their own pacing mechanisms, which can maintain a lowered heart rate in the absence of SA stimulation. The causes of pathological AV block are varied and include ischaemia, infarction, fibrosis or drugs, and the blocks may be complete or may only impair the signaling between the SA and AV nodes. Certain AV blocks can also be found as normal variants, such as in athletes or children, and are benign. Strong vagal stimulation may also produce AV block. The cholinergic receptor types affected are the muscarinic receptors. First degree Atrioventricular Block First degree heart block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal Causes: hemodynamic effect causing a decrease in perfusion to vital organ, such as the brain, heart, kidneys, lungs, & skin Characteristics of First degree: Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: Depends on the underlying rhythm QRS shape and duration: usually normal, but maay be abnormal P wave: In front of the QRS complex: shows sinus rhythm, regular shape PR interval: Greater than 0.20 seconds: PR interval measurement is constant P: QRS ratio 1:1

Second degree atrioventricular Block, type I Second degree, type I heart block occurs when all but one of the atrial impulses are conducted through the AV node into the ventricles. Each atrial impulse takes a longer time for conduction than the one before, until one impulse is fully blocked. Atrial impulse, the AV node has time to fully repolarize, so that the next atrial impulse can be conducted within the shortest amount of time. Characteristics of 2nd degree: Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: The Pp interval is regular if the patient has an underlying normal sinus rhythm: the RR interval characteristically reflects a pattern of change. Starting from the RR that is the longer, the RR interval gradually shortens until there is another long RR interval again QRS shape & duration usually normal, but may be abnormal P wave: In front of the QRS complex, shape depends in underlying rhythm PR interval: PR interval becomes longer with each succeeding ECG complex until there is a P wave not followed by a QRS. The changes in the PR interval are repeated between each dropped QRS, creating a pattern in the irregular PR interval measurements. P: QRS ratio: 3:2, 4:3, 5:4 and so forth

Second Degree Alrioventicular Block, Type II Second degree, type II heart block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. Characteristics of 2nd degree Av block, type II: Ventricular & atrial rate: Depends on the underlying rhythm

Ventricular & atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. The RR interval is usually regular but may be irregular, depending on the P: QRS ratio

QRS shape & duration: usually abnormal, but may be normal P wave: In front of the constant for those P waves just before QRS complexes P: QRS ratio: 2:1, 3:1, 4:1, 5:1, and so forth

Third Degree Atrioventicular Block Third degree heart block occurs when no atrial impulse is conducted through the AV node into the ventricles. In third degree heart block, two impulses stimulate the heart: one stimulates the ventricles, represented by the QRS complex, & one stimulates the atria, represented by the P wave. P waves may be seen, but the atrial electrical activity is not conducted down into the ventricles to cause the QRS complex, the ventricular electrical activity this is called AV dissociation Characteristics of 3rd degree AV block: Ventricular & atrial rate: Depends on the escape and underlying Rhythm Ventricular and atrial rhythm: The PP interval is regular & the RR interval is regular: however, the PP interval is not equal to the RR interval QRS shape & duration: Depends on the escape rhythm; in junctional escape, QRS shape & duration are usually normal, and inventricular escape, QRS shape & duration are usually abnormal P wave: Depends on underlying rhythm PR interval: Very irregular P: QRS ratio: more P waves than QRS complexes

It is directed toward increasing the heart rate to maintain a normal cardiac ouput. If the patient is stable and has no symptoms, treatment is indicated other than decreasing or evadicating cause. If the patient does not respond to atrophine or has an acute m1, transcutaneous pacing should be stared

Diagnostic Procedures and Findings Electrocardiogram (ECG or EKG): A picture of the electrical impulses traveling through the heart muscle. An ECG is recorded on graph paper, through the use of electrodes (small, sticky patches) that are attached to your skin on the chest, arms and legs. Ambulatory monitors, such as: Holter monitor: A small portable recorder that is attached to electrodes on your chest. It continuously records your hearts rhythm for 24 hours. Transtelephonic monitor: A small monitor is attached to electrode leads, usually on your finger or wrist. With the help of this device, your hearts rhythm is transmitted over the phone line to your doctors office. Transtelephonic monitor with a memory loop: A small, portable recorder that is worn continuously for an extended period of time to record and save information about your hearts rhythm around the time you experience an arrhythmia. The recording is triggered by pushing a button (event button). The rhythm is recorded, saved and transmitted over the phone line. Stress test: A test used to record arrhythmias that start or are worsened with exercise. This test also may be helpful in determining if there is underlying heart disease or coronary artery disease associated with an arrhythmia. Echocardiogram: A type of ultrasound used to provide a view of the heart to determine if there is heart muscle or valve disease that may be causing an arrhythmia. This test may be performed at rest or with activity. Cardiac catheterization: Using a local anesthetic, a catheter (small, hollow, flexible tube) is inserted into a blood vessel and guided to the heart with the help of an X-ray machine. A contrast dye is injected through the catheter so X-ray movies of your coronary arteries, heart chambers and valves may be taken. This test helps your doctor determine if the cause of an arrhythmia is coronary artery disease. This test also provides information about how well your heart muscle and valves are working.

Electrophysiology study (EPS): A special heart catheterization that evaluates your hearts electrical system. Catheters are inserted into your heart to record the electrical activity. The EPS is used to find the cause of the abnormal rhythm and determine the best treatment for you. During the test, the arrhythmia can be safely reproduced and terminated. Tilt table test (also called a passive head-up tilt test or head upright tilt test): Records your blood pressure and heart rate on a minute-by-minute basis while the table is tilted in a head-up position at different levels. The test results may be used to evaluate heart rhythm, blood pressure and sometimes other measurements as you change position. Medical Management of Patient with Dysrhythmias A. Vagal Maneuvers Vagal stimulation to terminate supraventricular tachydysrhythmias Carotid Sinus Massage Valvasa Maneuver

B. Cardioversion Synchronized counter shock to convert an undesirable rhythm to stable rhythm.

C. Defribillation Asynchronous counter shocks use to terminate pulses VT or VF Three rapid consecutive shocks: 200 joules, 300 joules and 360 joules

D. Automatic external Defibrillator (AED) is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient, and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmia, allowing the heart to re-establish an effective rhythm.

E. Implanted Cardioverter Defibrillator is a small battery-powered electrical impulse generator that is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia. The device is programmed to detectcardiac arrhythmia and correct it by delivering a jolt of electricity. In current variants, the ability to revert ventricular fibrillation has been extended to include both atrial and ventricular arrhythmias. There also exists the ability to perform biventricular pacing in patients withcongestive heart failure or bradycardia. F. Anti-arrhythmic Class I : Na + channel blocker ( Quinidine, Procanamide, Disopyridamole, Lidocaine, Flocainaide, Profapenone) Class II : Beta - blockers ( propanolol, metopolol, aenolol, esmolo) Class III : K + channel blockers ( Amiodarone) Class IV : Calcium channel blockers ( Verapamil, Diltiazem)

G. Pacemakers Implanted on the anterior chest and connected to the heart devices that provide electrical stimulation to the heart to maintain the heart rate when the clients pacemakers fails. Types: Temporary Pacemakers - an electronic pacemaker used as an interim treatment when the heart rate is excessively low. It consists of either a pulse generator and battery attached outside the patient's body and connected to a transvenous electrode in the right ventricle or conductive pads placed on the chest and connected to an external pulse generator by cables. Permanent Pacemaker - any electric pacemaker implanted inside a patient's body for permanent use.

Sinus Node Dysrhythmias: Sinus bradycardia Administration of Atropine Sulfate (Symptomatic Bradycardia: Initially 0.5 - 1.0 mg rapid IV/IO push (minimum dose 0.3 mg), followed by incremental doses of 0.5 - 1.0 mg every 3 - 5 minutes, not to exceed a total dosage of 3.0 mg.) Oxygen administration, since heart beats at less than 60 per minute .Perfusion is lessened as also the oxygen supply. Increasing O2 increase perfusion and oxygen that the body demands. Insertion of pacemaker. Pacemaker is placed under or over the clients skin and put wirings into the heart as a resultant of restored normal rhythm. Sinus Tachycardia Beta blockers such as; atenolol, metoprolol, Calcium channel blockers like; Amlodipine Besylate (Norvasc)

Sinus Arrhythmia Sinus arrhythmia does not cause any significant hemodynamic effect and usually is not treated Atrial dysrhythmias Premature Atrial Complex If PAC are infrequent, no treatment is necessary. If PAC are frequent more than 6 per minute, this is a signal of worsening condition, treatment directed at the cause. May be caused by atrial fibrillation. Treatment of atrial fibrillation. Atrial Flutter Treatment includes administration of Diltiazem (Cardizem), BetaBlockers(Metoprolol,Atenolol), Digitalis(Digoxin) to slow the conduction to the AV node

Cardioversion, o Synchronized electrical cardioversion uses a therapeutic dose of electric current to the heart, at a specific moment in the cardiac cycle. o Pharmacologic cardioversion, also called chemical cardioversion, uses antiarrhythmia medication instead of an electrical shock.

Atrial Fibrillation Quinidine(Quinidex), Amiodarone(Cordarone), Digoxin(Digitalis), Verapamil(Calan) , Verapamil is used to achieve conversion to sinus rhythm

Ventricular Dysrhythmias Premature Ventricular Contractions Lidocaine is used to relax the premature ventricular contractions. It should be prepared accordingly to 1-1.5mg/kg. A 75 mg to 100mg bolus of lidocaine will maintain adequate blood levels for only 20 minutes. It is important to distinguish patterns of PVC's that are likely to lead to serious arrhythmias Ventricular Tachycardia For stable ventricular tachycardia IV procainenamide(Procan) 17 mg/kg discontinued when dysrhythmia is suppressed if hypotension ensues, the QRS complex widens by 50% or more, or the maximum dose is achieved. Patients suffering from pulseless VT or unstable VT are hemodynamically compromised and require immediate cardioversion. Synchronized electrical cardioversion, done to an unconscious or sedated pt. If the patient still has a pulse, it is usually possible to terminate a VT episode with a direct current shock across the heart, that is delivered from one side of the chest to the other, front to back. Ideally synchronized to the patient's heartbeat

Catheter ablation is an invasive procedure used to remove or terminate a faulty electrical pathway from sections of the hearts of those who are prone to developing cardiac arrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardias (SVT) and Wolff-Parkinson-White syndrome.

Nursing Management
ASSESSMENT A health history is obtained to identify any precious occurrences of decreased cardiac output, such as syncope (fainting), light headedness, dizziness, fatigue, chest discomfort and palpitations. Coexisting conditions that could be a possible cause of the dysrhythmia (e.g. heart disease, COPD) may also be identified. A;; medications prescribed and OTC (e.g. herbs and nutritional supplements), as well as route of administration, are reviewed. Some medications (e.g. Digoxin) can cause dysrhythmias. Laboratory results are reviewed to assess levels of medications as well as factors that could contribute to the dysrhythmia (e.g. anemia). A thorough psychosocial assessment is performed to identify the possible effects of the dysrhythmia, the patients perception of the dysrhythmia and whether anxiety is a contributing factor. The nurse conducts a physical assessment to confirm the data obtained fro the history and to observe for signs of diminished cardiac output during the dysrhythmic event, especially changes in the level of consciousness. The nurse assesses the patients skin which may be pale and cool. Signs of fluid retention such as neck vein distention and crackles and wheezes auscultated in the lungs, may be detected. The rate and rhythm of the apical and peripheral pulses are also assessed, and any pulse deficit is noted. The nurse also auscultates for extra heart sounds (especially s3 and s4) and for heart murmurs, measures blood pressure, and determines pulse pressure. A declining pulse pressure indicates reduced cardiac output. Just one assessment may not disclose significant changes in cardiac output; therefore, the nurse compares multiple assessment findings over time, especially those that occur with and without dysrhythmia.

DIAGNOSIS Nursing Diagnoses Decreased cardiac output Anxiety r/t fear of the unknown Deficient knowledge about the dysrhythmia and its treatment

PLANNING ANG GOALS Major goals include eliminating or decreasing the occurrence of the dysrhythmia (by decreasing contributory factors) to maintain cardiac output, minimizing anxiety, and acquiring knowledge about dysrhythmia and its treatment. NURSING INTERVENTION Monitoring and Managing the Dysrhythmia 1) Nurse evaluates blood pressure, pulse rate and rhythm, rate and depth of respirations, and breath sounds to determine dysrhythmias hemodynamic effect. 2) Ask about episodes of light headedness, dizziness, or fainting as part of ongoing assessment 3) If patient is hospitalized, a 12 lead ECG may be obtained to continuously monitor the patient and the nurse may analyze rhythm strips to track the dysrhythmia. 4) Antiarrhythmic medications used to control the occurrence or the effect of the dysrhythmia, or both. The nurse assesses and observes for beneficial and averse effects of each medication. The nurse also manages medication administration carefully so that a constant serum blood level of the medication is maintained. 5) Administration of a 6 minute walk test to identify patients ventricular rate in response to exercise. 6) Assessment for factors that contribute to the dysrhythmia (caffeine, stress and non adherence to the medication) and assistance in developing a plan to make lifestyle changes.

Minimizing anxiety When the patient experiences episodes of dysrhythmia, the nurse must maintain a calm and reassuring attitude. This assists in reducing anxiety (reducing the sympathetic response) and fosters trusting relationship with the patient. The nurses goal is to maximize the patients control and make the episode less threatening. Promoting Home and Community-Based Care Teaching patients self-care 1) When teaching patients, nurse must present information in terms that are understandable and in a manner that is not frightening or threatening. 2) The nurse must explain importance of maintaining therapeutic serum levels of antiarrythmic medications so that patient understands why medications should be taken regularly. 3) If the patient has a potentially lethal dysrhythmia it is important to establish with the patient and family a plan of action to take in case of emergency. 4) Health teaching regarding potential effects of the dysrhythmia and their signs and symptoms. Continuity of care A referral for home care usually is not necessary for the patient with a dysrhythmia unless the patient is hemo-dynamically unstable and has significant symptoms of decreased cardiac output.

Source: Textbook of Medical Surgical Nursing by Brunner & Suddarth pp. 840-842; www.slideshare.net/thinkm/dysrhythmias-nursing-lecture