Arrhythmia, Palpitations and the Risk of Stroke

An arrhythmia is a heartbeat that is too fast, too slow or irregular because the heart's electrical signals misfire. Some arrhythmias are harmless extra beats. Others, such as atrial fibrillation, let clots form and cause strokes. The pattern of the beat and the cause behind it decide how serious yours is.

What do palpitations feel like?

Palpitations are an awareness of your own heartbeat, nothing more complicated than that. Patients describe thumping, racing, fluttering, or a beat that seems to trip and then thud. It can last seconds or hours, and it may sit in the chest, the throat or the neck.

Common descriptions from patients:

• A racing heartbeat
• A beat that seems to skip or drop
• Fluttering in the chest or throat
• Uneasiness along with a fast pulse, what patients often call dil ghabrana
• Dizziness, or vision greying out
• Breathlessness and less stamina than usual
• Fainting or nearly fainting

Two things matter more than the sensation itself. First, whether the pulse is regular or completely irregular. Second, whether anything else happens alongside it. Fainting, chest pain or breathlessness change the picture entirely.

What are the main types of arrhythmia?

Arrhythmias fall into three families: fast rhythms, slow rhythms and single extra beats. The type decides both the risk and the treatment. An occasional extra beat may need nothing at all, while atrial fibrillation needs stroke prevention. That is why recording the rhythm during symptoms matters so much.

What causes an arrhythmia, and who is at risk?

Arrhythmias come either from a heart that has been damaged or stretched, or from something outside the heart stirring up the electrical system: thyroid, anaemia, fever, stimulants, salt disturbance. Both groups turn up regularly in our clinics, and treatment for the two differs completely, so the cause has to be found rather than guessed.

Risk factors include:

• High blood pressure over years, which stretches the top chambers and sets up atrial fibrillation.
• Heart valve disease, especially rheumatic mitral valve disease, still frequently seen in Pakistan and a classic cause of atrial fibrillation in younger adults.
• A previous heart attack or heart failure, where scarred or stretched muscle disturbs conduction.
• An overactive thyroid and anaemia, both common and both easily tested for.
• Caffeine load, meaning repeated cups of strong chai or coffee, and energy drinks above all.
• Smoking, naswar and stimulant or weight-loss preparations, including unlabelled herbal products.
• Dehydration and salt imbalance, which matter in summer heat and during illness.
• Sleep apnoea, where heavy snoring and pauses in breathing at night drive rhythm problems in the small hours.

Why is atrial fibrillation taken so seriously?

Because it is a stroke risk that frequently causes no symptoms at all. In atrial fibrillation the top chambers quiver instead of contracting, so blood stagnates in a small pouch of the left atrium. A clot forms there, breaks loose, and lodges in a brain artery.

The American Heart Association explains that atrial fibrillation raises the risk of stroke several times over compared with a normal rhythm. The part worth holding on to is that this is preventable. European Society of Cardiology guidelines recommend scoring each patient's stroke risk and, where the score justifies it, prescribing an anticoagulant: warfarin monitored with INR blood tests, or one of the newer oral anticoagulants. Many strokes in Pakistan happen in people whose atrial fibrillation was already known but untreated, or whose blood thinner was stopped without advice.

When is an irregular heartbeat an emergency?

Call 1122 or go straight to DHQ Hospital Abbottabad Emergency if palpitations come with fainting or collapse, chest pain, breathlessness at rest, or if a very fast irregular beat carries on for more than a few minutes and you feel unwell with it.

Treat these as emergencies too:

• Sudden weakness or numbness of the face, arm or leg on one side, drooping of the face, or slurred speech. This may be a stroke, where treatment is time-critical.
• Collapse without warning, particularly in a young person or someone with known heart disease.
• Palpitations in a person who already has heart failure and who suddenly becomes much more breathless.

If someone collapses and is not breathing normally, call 1122 and start chest compressions immediately. Ordinary short palpitations with nothing else attached to them are not an emergency. They need a clinic appointment and a recording, not an ambulance.

How is an arrhythmia diagnosed?

The aim is to catch the rhythm while the symptoms are happening. A standard ECG takes about ten seconds, so it often looks perfectly normal between episodes. That is not reassurance. It is a missed moment, and longer recordings solve it.

Tests commonly used:

• An ECG at the time of symptoms, the fastest route to a diagnosis if you can reach a facility while it is happening.
• Holter monitoring, a portable recorder worn for 24 hours or longer during your normal routine.
• Echocardiography, to check the heart's structure, valves and pumping strength, since these drive many arrhythmias.
• An ETT (Exercise Tolerance Test) when symptoms come on with exertion.
• Blood tests for thyroid function, blood count, kidney function and salts.
• 24-hour ambulatory blood pressure monitoring where uncontrolled hypertension is part of the picture, and angiography when coronary disease is the suspected cause.

Dr. Muhammad Ali Khan, Consultant Cardiologist, assesses palpitations and rhythm disorders at his clinics in Abbottabad, starting with the pattern of your symptoms and then choosing the recording most likely to catch them.

How are arrhythmias treated?

Treatment answers three questions. Is the heart rate safe? Can a normal rhythm be restored? Is a stroke being prevented? Not every arrhythmia needs medicine. Harmless extra beats often need only reassurance and fewer triggers, while atrial fibrillation usually needs both rate control and stroke protection.

• Rate control with beta-blockers or certain calcium channel blockers slows fast atrial fibrillation to a comfortable range.
• Rhythm control with anti-arrhythmic medicines, or an electrical cardioversion under brief sedation, restores a normal rhythm in selected patients.
• Anticoagulation prevents the strokes atrial fibrillation causes, guided by your risk score.
• Catheter ablation treats the abnormal electrical circuit directly and works particularly well for SVT.
• A pacemaker is the answer for symptomatic slow rhythms and heart block.
• An implantable defibrillator (ICD) is considered where dangerous ventricular rhythms threaten.
• Treating the cause, whether that is thyroid disease, anaemia, blood pressure, valve disease or sleep apnoea, sometimes removes the arrhythmia altogether.

How do you live with an arrhythmia?

Most people with a diagnosed and treated arrhythmia live an entirely normal life, work, travel and exercise included. The routine that keeps it that way is small: know your pulse, know your triggers, and never stop rhythm or blood-thinning medicines on your own.

Practical habits:

• Check your pulse for a full minute now and then, and note the rate and the regularity.
• Keep a short symptom diary. Date, time, how long it lasted, what you were doing, what you had eaten or drunk.
• Cut out energy drinks, heavy caffeine, cigarettes and naswar.
• Sleep properly and stay hydrated, especially in hot weather or during illness.
• If you take warfarin, keep your INR appointments, keep your green-vegetable intake steady rather than swinging, and tell every dentist and surgeon before any procedure.
• Tell your doctor about every new medicine, including herbal and over-the-counter products, since many interact with rhythm drugs and anticoagulants.
• Attend follow-up so rate, rhythm and stroke prevention are reviewed as your heart changes over time.