An expert explains heart rhythm disturbances

Leading consultant cardiologist in Winchester and Basingstoke Dr Dominic Kelly speaks to Top Doctors all about heart rhythm disturbances, or arrhythmias, and just how important getting assessed is.    

What are the most common heart rhythm disturbances?

Lots of heart rhythm disturbances exist. Some of them are very dangerous; lots of them cause nuisance - symptoms that can be quite distressing, but I think the most important thing is to be aware of, is that the majority of heart rhythm disturbances are a nuisance rather than being dangerous. 

The most common heart rhythm disturbance that we see is something we call atrial fibrillation. That is a rhythm where the top end of the heart, what we call the atrium goes into a very erratic, irregular rhythm. That causes the ventricles, the pumping chambers of the heart, to become irregular. That in itself causes symptoms.

Heart rhythm disturbance symptoms can vary quite a lot; from:

Simple palpitations, which is what patients experience as fluttering in the heart, to;

breathlessness.

Atrial fibrillation can have dangerous consequences in some patients. There's an increased risk in clots forming in the heart, and in the worst-case scenario, those clots could break off and cause a stroke. One of the really important aspects of assessing patients with heart rhythm disturbances, especially atrial fibrillation, is to determine what that risk is and to manage and mitigate that risk as much as possible. 

Atrial fibrillation is very, very common. It becomes more frequent as you get older, and as our population gets older, we see more and more people in their 70s, 80s and 90s with atrial fibrillation. It's a really variable heart rhythm disturbance. Some patients don't even know they have it, but of course, even if it doesn't cause symptoms, it still may have some risks.

It's really important you get assessed if this is detected and some people will have this picked up incidentally through other tests such as blood pressure tests with their GP. 

When are heart rhythm disturbances considered to be severe?

There are two reasons why heart rhythm disturbances may be severe; 

• Number one is that they may be severe in terms of the risk to the patient;
• The second thing is, they may be severe in terms of symptoms to the patient.

It's really important to be aware that just because heart rhythm disturbances are causing terrible symptoms doesn't necessarily mean they are increased risk to the patient. 

Likewise, heart rhythm disturbances that might not necessarily cause a lot of symptoms to the patient can be associated with significant risk. If we're talking about more severe in terms of risk to the patient, some heart rhythm disturbances can, in the worst-case scenario, cause collapse or even cardiac arrest. You've seen fairly high-profile in the media over recent years such as Christian Eriksen, the footballer who collapsed and had a cardiac arrest on the football pitch. Thankfully those heart rhythm disturbances are small. We can identify patients that maybe increase risk of that, and that's one of the aspects of screening for cardiac disease. 

The other aspect of heart rhythm disturbances is those that might not necessarily have significant risk, but cause quite severe symptoms to patients. Those symptoms can be palpitations and breathlessness, which can be disturbing especially if the patient doesn't know what's going on. One of the aspects of heart rhythm problems is not just the symptoms that is causes but the anxiety those symptoms cause to the patient. Of course, if you feel your heart is out of rhythm the most common response to that, is to become very anxious this might be a risk to you. That's where we come in, in terms of assessing that risk, mitigating any risk and providing treatment to eliminate any symptoms. 

When should immediate medical attention be sought?

There are certain aspects that you need to take into consideration when you think about speaking to a cardiologist:

First of all, is there any risk for you. The things that signify increased risk in my mind, is certainly what we call red-flag issues. So, if there's any strong family history of cardiovascular disease, such as heart attack, collapse, cardiac arrest; if any of your relatives have known cardiac conditions that may run in the family, it's really important to be screened for those conditions.

You should also seek advice if you have other red-flag symptoms. So, palpitations causing blackouts, or the feeling you’re going to faint, is really significant. 

It's also important to address the symptoms that have an impact on your individual quality of life. If you're suffering with symptoms that relate to heart rhythm disturbances, whether that be palpitations, breathlessness or dizzy spells, we can help with that. The indication to come and have a chat with us within cardiology has two aspects to it:

To assess any risk to yourself;

To deal with those symptoms that will be interfering with your quality of life. 

What can happen if heart rhythm disturbances are left untreated?

As we've talked about already, heart rhythm disturbances can, and in some cases, be very dangerous. We've talked about examples of high-profile individuals suffering with cardiac arrest as a result of that. That is the worst-case scenario, and thankfully that is rare.

If heart rhythm disturbances are untreated, there are other aspects that could have an impact on you as an individual. As an example, if a heart rhythm disturbance causes fainting episodes, then even though may have only happened once, that will have an implication on your life. For example, the DVLA won't let you drive for six months. It may have an impact on your work, what you can do for a living and on your activities. 

There's the aspect of managing heart rhythm disturbances in terms of risk of major events like cardiac arrest. There's the risk of heart-rhythm disturbances having an impact upon your ongoing life, your quality of life and your work. Even if heart rhythm disturbances are not dangerous, as thankfully most of them aren't, it has an impact on your quality of life. Living with heart rhythm disturbances, as we've already said, can cause quite debilitating symptoms in some individuals. Those symptoms can impact on quality of life and physical activity, etcetera. 

It's really important you get these things looked at; you have an assessment. We first of all, in my mind, is there any risk to you? Second aspect, once we've eliminated or mitigated that risk, how can we manage symptoms?

Is surgery always required for heart rhythm disturbances?

The majority of heart rhythm disturbances can be managed fairly straightforwardly with medication. So pharmacological therapy with tablets like beta blockers, and other tablets like that. One of the aspects of my training, is that as well as being qualified in medicine, I also have degree in pharmacology, which is the study of how drugs work. I also have, I think, more of an insight in how we can manage heart rhythm disturbances using pills, medication.

Unfortunately, there isn't one medication that suits everyone. It's an important aspect of assessing people, first of all seeing who is appropriate to use tablet therapy as opposed to other more physical methods to manage heart rhythm disturbances. But also choosing the right medication or combination of medication for that individual.

In answer to the question, no not every heart rhythm disturbance requires surgery. In fact, the majority of heart rhythm disturbances will not require surgery, and the types of surgery that are required if needed are fairly what we'd label as minimally invasive.

These are procedures that might involve procedures through veins or arteries in your leg, or sometimes pacemaker devices which are inserted fairly straightforwardly with a small incision under your collarbone with a device that's inserted, again, through the veins rather than any major cardiac surgery.

The majority of heart rhythm disturbances don't require any kind of surgery and can usually be managed, either conservatively and by that, I mean reassurance to the patient that there's nothing dangerous. Or using tablets or pharma-logical therapy to suppress those symptoms. It's the smaller minority that will require more advanced therapy, but of course it's really important to know that's available.

What I always say to the patients, when we're managing rhythm disturbances, is: "Always start at the bottom of the ladder. Start with a treatment that has the least impact on the patient, has the least risk to the patient, and if that is sufficient to manage the symptoms, to mitigate the risk, then that is adequate for that individual."

If that treatment isn't successful, or additional things are required, then you start to escalate up that treatment ladder. But to go straight to the top of the ladder with, for example procedures that may be invasive and also have some risk without trying the other things that are lower risk, wouldn't be the right way to go. 

If you require expert cardiology treatment, arrange an appointment with Dr Kelly via his Top Doctors profile.