Arrhythmia Treatment
In many cases, no treatment is necessary for arrhythmia. But in the cases where your doctor determines that the heart abnormality should be corrected, there are several options, ranging from self-treatment to medication to surgery. The treatment depends on what kind of arrhythmia you have.
This section discusses treatment options for Bradycardias (slow heartbeat), including:
Tachycardias (fast heartbeat), including:
Bradycardias are often treated with implantable pacemakers. A pacemaker is a device that gives your heart an electrical stimulus when your heart's natural pacemaker (called the sinus node) or the conduction pathways do not work as they should. When the pacemaker senses that the heart is not beating at the proper time, it sends an electrical impulse to make the heart beat. The implanted pacemaker does not compete with your natural pacemaker, but rather replaces it when needed. The electrical impulses are usually not felt. A pacemaker may be used alone or with medications.
A pacemaker has several parts. The microprocessor, or logic circuit, is the "brains" of the device. A battery provides power, and the leads send the electrical impulse from the pacemaker to the electrode, which senses each beat of the heart and delivers the electrical impulse when needed. Rate-adaptive pacemakers can also sense increased activity—walking, running, or other types of exercise. These pacemakers monitor your heart rate and increase the rate to the right level for the activity. Sometimes a temporary pacemaker is inserted before a permanent pacemaker is implanted. It may be used for a short time, ranging from hours to days. It remains outside your body, and you have to stay in bed while the temporary pacemaker is in place. It will be removed after the permanent pacemaker is in place.
The type of permanent pacemaker used depends on your heart rhythm. The types include the following:
- Single-chamber pacemakers have one lead, which is placed in an upper or lower chamber of the heart.
- Dual-chamber pacemakers have two leads. One is placed on an upper chamber on one side of the heart, the other in a lower chamber.
- Biventricular pacemakers have leads in both lower chambers and usually also in an upper chamber of the heart.
There are risks associated with pacemaker implantation, including some serious risks, so ask your doctor about them before the procedure.
Implantation procedure
Most pacemaker implantations are performed using local anesthesia to numb the area of any incisions. You may receive additional IV medication to help you relax. Children usually receive general anesthesia. The implantation procedure is done with special X-ray equipment. The doctor inserts a lead (or leads) into a vein under your collarbone and passes it to your heart using X-rays to follow its progress. After the leads are in place, the pacemaker is slipped into a small, surgically created pocket under the skin in the upper chest.
Usually you will stay in the hospital overnight. The pacemaker will be programmed to fine-tune it to your specific heart rhythm. This is done with a device called a programmer, which works the way a TV remote control does. You'll be able to shower or bathe 48 hours after the implantation procedure; a pain reliever containing acetaminophen, such as Tylenol, can relieve discomfort (medications containing aspirin, ibuprofen, or naproxen may interfere with blood clotting). After the pacemaker is implanted, you should be able to maintain a lifestyle similar to the one you had before. This includes exercise, work, and sexual activity. Your doctor will probably tell you to avoid vigorous activity or heavy lifting for about a month after the procedure.
You will receive a card that identifies you as having a pacemaker. Keep this card with you at all times. You and your family should remember the name of your pacemaker's manufacturer (in case of an unexpected visit to the emergency room).
Living with a pacemaker
Your doctor may recommend that you not drive for at least 10 days following the placement of your pacemaker. Specific driving restrictions will depend on your health. You should also check with your doctor before starting an exercise program. And you should always tell all your health-care providers, including dentists, that you have a pacemaker.
Electrical equipment may disrupt your pacemaker:
- At the airport: The pacemaker could activate an airport security metal detector, though this won't harm the pacemaker. You will have to show security personnel the ID card you received that identifies you as having a pacemaker. A security agent can pass a hand-held security-scanning device over the pacemaker without damaging it, but the device should not be held in place over it or there could be problems.
- Electrical equipment: Avoid standing in the entryway of a store with shoplifting detectors. Hold your cellphone at least six inches from your pacemaker (use the ear on the opposite side). You should also avoid leaning over a running engine. Avoid powerful magnets and heavy industrial equipment. Microwave ovens, household appliances, and woodworking tools usually will not cause interference if kept in good repair.
- Medical equipment: Magnetic resonance imaging (MRI) uses a powerful magnet that could damage your pacemaker. Tell your doctor you have a pacemaker before any medical procedure, especially lithotripsy (used to remove kidney stones) or anything involving cautery (using heat or electricity to burn tissues).
Your pacemaker can transmit data to a hospital over the phone for evaluation. The battery will last for many years, but when it wears out, the pacemaker's generator will need to be replaced in a simple medical procedure. The leads may need to be repositioned or replaced as well.
Your doctor may recommend vagal maneuvers as a first attempt to control the arrhythmia known as supraventricular tachycardia (SVT). The maneuvers are done on your own to halt a speedy heartbeat; they work by affecting the group of nerves that control your heartbeat. These nerves are called the vagal nerves. Some techniques include holding your breath and straining as if passing a bowel movement, blowing against your thumb as if blowing a trumpet, coughing, dunking your head in ice water, holding ice to your face, or doing a headstand. Your doctor may recommend other techniques.
There are many medications available to treat different types of tachycardia. Options include antiarrhythmic drugs, beta blockers, calcium channel blockers, and digitalis. Most of these medications slow the heart rate, either by calming the sinus node, the body's natural pacemaker, or by slowing down the electrical activity in the heart. The type of medication your doctor recommends will depend on the type of arrhythmia you have. For example, the majority of people treated for inherited LQTS are helped by beta blockers. People with atrial fibrillation will also most likely take a blood thinner to cut the risk of stroke or blood clots.
Drugs can be inconvenient. It is important to take medications regularly and on time; this may be difficult for some people. In addition, side effects may occur, depending on the medication and the individual. With most arrhythmia medications, there is a 0.5 percent to 2 percent chance that the drug itself will make the rhythm worse or cause a life-threatening rhythm problem called a proarrhythmia.
The medication may also simply be ineffective.
It is important to discuss with your doctor the risks and benefits of any drug recommended.
Cardioversion is an electrical impulse delivered to your heart to help it return to a normal rhythm--a treatment for atrial flutter and atrial fibrillation.
Before the procedure you will need to make some dietary changes, which your doctor will outline.
During the procedure, you'll be sedated. Electrode patches will be placed on your back and your chest. One large, circular patch is placed on your chest to the right of your sternum, and a rectangular patch is placed on your back to the left of the spine. These patches are attached to a heart monitor. Smaller patches are placed to monitor your heart on an electrocardiogram (ECG).
After you're sedated, an electrical impulse will be delivered to your heart through the two large patches. If necessary, several impulses will be given to return your heart to a normal rhythm. Most likely you will have no awareness or memory of the procedure. Serious complications are rare but include the development of an even more serious arrhythmia during the procedure or suffering a stroke. The risk of stroke is reduced by using blood thinning medications and having a transesophageal echocardiogram (TEE) before the procedure.
After the procedure you will remain in the hospital for a few hours after the procedure. The only discomfort may come from skin burn on your chest and back where the patches were placed.
During radio-frequency catheter ablation, a catheter positioned next to the abnormal pathway in the heart ablates, or destroys, abnormal tissue. The doctor inserts a catheter into a vein or artery and positions it next to the extra, abnormal pathway in the heart found in patients suffering from such arrhythmias as atrial flutter, SVTs (including Wolff-Parkinson-White syndrome, and ventricular tachycardia. The procedure may also be used to treat atrial fibrillation. Energy is delivered from the catheter tip to heat up and destroy, or ablate, the abnormal tissue. When this tissue is eliminated, the circuit for the rapid heart rhythm is interrupted, or blocked, and those rhythms should not occur. Usually radio-frequency catheter ablation is done at the same time as an electrophysiology study (discussed in the Tests section).
The success of the treatment ranges from 85 to 95 percent, depending on the location of the abnormal tissue and the type of arrhythmia. Besides the catheter used to ablate the abnormal tissue, several other catheters may be used to map the way electrical impulses travel through your heart. X-rays are used to determine where to put the catheters. A transesophageal echo may also be used before the procedure to be sure there are no blood clots in the heart.
The procedure is done under sedation and uses local anesthesia. It may take from three to seven hours, but the recovery time is short. Most people are hospitalized one or two days and return to their usual activities within seven days of the procedure. The risks are generally related to inserting the catheters into the veins, and will be discussed with you by the doctor performing the procedure. The procedure is used to treat many arrhythmias previously treated with surgery.
Implantable cardioverter defibrillators (ICDs)
Ventricular tachycardia (VT) and ventricular fibrillation (VF) are the two heart rhythms responsible for most sudden cardiac deaths in the United States. Implantable cardioverter defibrillators (ICDs) are used in people who survive a life-threatening heart rhythm or are at high risk of developing one. An ICD is a small electronic device implanted in your body to monitor your heart rhythm at all times. It acts as a pacemaker for slow heart rates; when fast rhythms occur, it treats the rhythm by delivering the appropriate type of electrical therapy needed: rapid-pacing, low-energy shock or high-energy shock. The two kinds of shocks may be used in combination.
About the size of a stopwatch, an ICD pulse generator is a small metal case containing a battery, a microprocessor, and electrical circuits. It is implanted in the upper chest. The ICD system also includes one or more insulated wires (called "leads"), electrodes, and patches. Most implantations are done using local anesthesia. You may also receive a sedative. The leads are inserted into a vein under your collarbone and passed to your heart using X-ray equipment to follow the progress. Then the lead is positioned and tested before being connected to the ICD. It must be tested to be sure it works properly; the heart is shocked to create a fast rhythm, which is then detected and converted by the ICD. During this test, you will receive general anesthesia. You won't feel the fast rhythm or the shock. You may have further testing of the ICD to program or adjust it to your specific needs.
Eventually the ICD battery will wear down and the generator will need to be replaced. The battery will be checked at each follow-up visit. Usually the replacement will be done as an outpatient procedure.
Living with an ICD
After recovering from the implantation, you should be able to return to normal activities, including exercise, work, and sexual activities. For four weeks after implantation, avoid raising your arm on the side of the ICD above the shoulder. You should also avoid vigorous activity and heavy lifting. You shouldn't drive until your doctor says you can, which may be several months after implantation. In some cases, you may not be allowed to return to driving, since you might become dizzy during an arrhythmia before the ICD delivers its electrical therapy. In addition, you should talk with your doctor before taking up strenuous exercise. Avoid contact sports. And tell your healthcare providers, including dentists, about your ICD.
Your ICD may be affected by electrical equipment.
- At the airport: The ICD may activate an airport security metal detector, though this won't harm the ICD. You will have to show security personnel the ID card you received that indicates that you have an ICD. Hand-held security scanning devices may be passed over the ICD, but should not be held in place over it or they could damage it.
- Electrical equipment: Avoid standing in the entryway of a store with shoplifting detectors. Hold cellphones at least six inches away from your ICD (use the ear on the opposite side of the implant). You should also avoid leaning over a running engine. Avoid powerful magnets and heavy industrial equipment., Microwave ovens, household appliances, and woodworking tools usually will not cause interference if kept in good repair.
- Medical equipment: You are not a candidate for magnetic resonance imaging (MRI); the MRI's powerful magnet could damage your ICD. Tell your doctor you have an ICD before any medical procedure, especially radiation therapy, lithotripsy (used to remove kidney stones), or anything involving cautery (using heat or electricity to burn tissues).
ICD shock
If you feel faint or dizzy, sit or lie down immediately. Your heart rhythm may be abnormal. It may take between five and 10 seconds for the ICD to deliver electrical therapy or a shock to your heart when it detects the abnormal rhythm. Symptoms usually go away after the ICD delivers its therapy. Ask your doctor under what circumstances you should contact him or her after a shock or shocks.
In some cases, a doctor will recommend surgery to treat arrhythmias, usually after other options have failed to work. Several procedures are used, depending on the type of arrhythmia and other heart problems. The types of surgery include:
- Maze procedure: This surgical procedure is used to treat atrial fibrillation. The surgeon makes several cuts in the atria that, when healed into scars, will direct electrical activity in the properly organized manner. The impulse will have only one way—the correct way—to travel, as if passing through a maze. Newer techniques use radio-frequency ablation or extreme cold to create the same scars.
- Ventricular aneurysm surgery: After a heart attack or other damage to the ventricular wall, the wall may become thin and weak and thus unable to fully pump. This is called a ventricular aneurysm, and it may cause an arrhythmia. Surgically removing this thinning wall will often correct the arrhythmia.
- Coronary bypass surgery: People with serious coronary artery disease and ventricular tachycardia may be helped by coronary bypass surgery, which involves rerouting the blood flow around the clogged or diseased section or artery. The extra blood flow to the heart may reduce the incidence of tachycardia.
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