Heart palpitations can occur as a symptom of heart rhythm disorder (arrhythmia) as can be the result of elevated blood pressure, fear, anxiety, stress conditions, excessive caffeine or alcohol intake. Frequent palpitations that affect daily life must be evaluated by a physician. The main goal is to find out what causes palpitation and to treat it.

What is heart palpitation?
Palpitation is a general name given to the uncomfortable feeling that you are aware of your own heart beating. Strong heartbeats, skipping beats or increased heart rate (rapid heartbeats) manifest as palpitations. Defined complaints may vary depending on the cause of the palpitations. For example, palpitations may still occur in someone who feels strong heartbeats in the form of palpitations, even the heart rate is normal (between 60 and 100 beats per minute) and regular. This condition can be seen in patients with high blood pressure and anxiety disorders.

On the other hand, extra beats that fall between normal beats can cause a feeling that the heart misses a beat or will stop in between. In this condition, called extrasystole, the heart beats are at a normal rate and are regular. However, an extra beat that intervenes causes the aforementioned condition. This is the most common type of palpitations seen in the society. Another type of palpitations is the occasional acceleration of the heart rate. Especially when the heart beats per minute exceed 150 beats per minute, the person feels very disturbing palpitations. The person describes the condition as "the bird is fluttering in my heart, I feel like my heart is beating in my neck, my heart is going to come out of my mouth."

What causes heart palpitations?
Palpitations are not always indicative of heart disease. Palpitations may occur when blood pressure increases, in situations of fear, anxiety, stress, after drinking a lot of tea and coffee, or following alcohol intake. Palpitations can be seen even without a heart problem in cases of anemia, pregnancy, overactive thyroid gland. Every person can feel palpitations once in a while. However, the frequent palpitations that affect daily life should be evaluated by a physician. The main goal here is to find out whether palpitation is associated with heart disease and to treat it.

In palpitations that are not related to heart disease, the underlying condition (such as elevated blood pressure, anemia, and thyroid disease) needs to be corrected. Palpitations occurring with anxiety disorders are tried to be soothed by drugs called beta-blockers. Palpitations that cardiologists should treat are palpitations that may be associated with rhythm disorders and heart disease.

What is tachycardia?
Tachycardia is that heart beats at a faster rate than normal and that the patient feels palpitations in the meantime. It can be the result of the acceleration of normal rhythm of the heart, as well as it may occur as a result of more serious rhythm disorders. Tachycardia should be evaluated by a specialist and treatment should be planned.

Heart palpitations can be a sign of which heart diseases?
Some rhythm disorders that cause palpitation can occur on congenital basis. Having a congenital background does not mean that rhythm disorders are seen soon after birth. If there is a background, arrhythmia may occur with the effect of other factors in later life. On the other hand, even if there is no congenital basis, there may also be rhythm disorders due to underlying heart disease. For example, arrhythmias can occur in heart failure or develop after a heart attack as a result of damage to the heart muscles. Ventricular arrhythmias, especially seen on this basis, can be life-threatening.

It is necessary to treat it properly with medication, pacemaker or ablation method. Another common rhythm disorder seen in the community is atrial fibrillation. Although palpitations are a common complaint in the upper chamber of the heart (atrium) originated rhythm disorder, the main danger is the stroke caused by blood clot originating from the heart and traveling into the brain. In terms of this risk, the patient must be evaluated by a specialist and medication or interventional treatments (such as atrial fibrillation ablation, left atrial appendage closure) should be planned.

What is heart arrhythmia?
Palpitations related to heart disease are rhythm disorders. With regular functioning, the heart beats between 60 and 100 times per minute and the degradation of this harmony causes rhythm disturbance (arrhythmia). These palpitations occur with disorders in the electrical system of the heart.

Causes of heart arrhythmia
It is often caused by a number of foci that generate excessive electrical stimulation or an abnormal electrical pathway in the heart. This condition may occur due to congenital reasons right after the birth or after as part of the heart disease process. Some of the congenital heart rhythm disorders form complaints later in life. In other words, with congenital predisposition, the emergence of arrhythmia can be developed in the 20’s, 30’s or even in the advanced ages.

Non-congenital rhythm disorders often develop on the basis of heart attack, heart failure or structural heart disorders. Sometimes it may not be determined precisely weather the arrhythmia is associated with congenital or non-congenital reasons. In the end, no matter how, the type of arrhythmia should be diagnosed, determined, and treated.

Symptoms of heart arrhythmia
Most often symptoms of heart arrhythmia are palpitations and fainting Palpitations manifest itself in the form of rapid beating, skipping a beat or uneven beating of the heart. Fainting is a loss of consciousness which usually happens when decrease in heart rate. Sometimes arrhythmia can be detected occasionally doing routine electrocardiogram (ECG) with no symptomatic manifestations of itself.

What are the types of palpitations due to arrhythmia?
Palpitations due to rhythm disorders are composed of many subgroups. In some, a focus of arrhythmia in heart suddenly starts to issue pathologic impulse, and the heart rate suddenly accelerates to 170-180 beats per minute. . In some, essentially extra beats, or contractions, which interrupt the normal regular rhythm of the heart in response to an impulse in some part of the heart and cause skipped heartbeats called extrasystole. Sometimes there are more chaotic manifestations and heart rate can beat very fast and irregular at the same time.

In other words, we define a disease group with rhythm disorder, under which there are dozens of subgroups with different diagnosis and treatment. Therefore, it is not possible to determine rhythm disorders risks and treatment without classification its type. Hence, it is not possible to treat rhythm disorders as a single disease according to the complaint, risk and treatment.

What causes heart arrhythmia?
The most common complaints are palpitations and fainting, which impair the quality of life and cause intense concern in the patient. Sometimes these complaints can result in sudden death or heart failure. In some special rhythm disorders (such as atrial fibrillation), paralysis may develop as a result of blood clot in the brain.

What are the risks of heart arrhythmia?
While the arrhythmia describes a group of conditions that affect the heart's natural rhythm, the risks differ according to their subgroups. Although some have severe complaints, the life-threatening risk is extremely low. However, another may be at risk of death. There is no firm relationship between the severity of the complaint and the magnitude of the risk. However, it should be noted that there may be a life-threatening risk in rhythm disorders that occur after heart failure or heart attack. Degree of the possible risk can be evaluated according to arrhythmia type classification. At this stage, the diagnostic procedures should be performed to determine the type of arrhythmia.  

Measures to be undertaken to ease the arrhythmia
Treatment of main heart disease should be done. Avoiding stress, smoking, alcohol, caffeine or certain drugs can be beneficial for treatment.

Diagnosis of arrhythmia
Unfortunately, rhythm disorders in form of attacks sometimes cannot be recognized during the medical examination. In other words, the patient describes occasional palpitations, but when it comes to the examination there might be no signs of heart rhythm disorder, and the physician cannot diagnose any abnormalities. This phenomena is frequently encountered by physicians dealing with palpitations and arrhythmia.

In this case, a number of diagnostic tools are used. Prolonged ECG observation method is one of the important diagnostic tools in cardiology. In this method, called holter, heart beats are recorded for 24-48 hours with a special device connected to the patient. The patient continues her/his daily life with the device attached on. At the end of the period, the device is removed. All recorded heartbeats are evaluated by doctor and the type of rhythm disorder can be diagnosed. If the patient has no rhythm problems during this monitoring period due to rare palpitations (once per week or month), the necessity might occur to extend the observation period and use special devices that can record heartbeats for 1-2 weeks. However, if the diagnosis is still problematic the interventional procedures might be required. The part of this invasive process that is carried out for the purpose of diagnosis is called electrophysiological study (EPS).

Treatment of heart arrhythmia
In many cases, drug treatment may be enough in arrhythmia treatment. However, in cases who do not want to use drugs or where drug therapy is ineffective, treatment is possible with procedures such as ablation and pacemaker.

What is the difference between electrophysiological study (EPS) and ablation?
Electrophysiological study (EPS) and ablation are the diagnostic and treatment parts of the same process. Just like coronary angiography to detect stenosis in the heart vessels and balloon-stent procedures to treat it. Coronary angiography is a procedure for the diagnosis of stenosis in the heart vessels, and the electrophysiological study is a procedure to detect disorders of electrical system of the heart. While the stenosis in the heart vessels are opened and treated by balloon-stent method, disorders in the electrical system of the heart are treated by ablation method.

What is ablation treatment?
In the ablation process, the focus or foci responsible for rhythm disturbance in the heart are destroyed by radiofrequency waves by means of plastic-coated, thin, and flexible tubes called catheters.The destroyed focus is several millimeters and is responsible for arrhythmia. This can take between ten minutes and an hour, as this involves searching for a focus several millimeters in the heart.

Radiofrequency ablation treatment
One of the ablation methods described above is the name of the procedure of destroying the tissue by heating/burning with high frequency radio waves. Another method called cryoablation, is a process that destroys by cooling/freezing.

Is there pain after ablation?
The patient does not feel pain during the standard ablation process. Because there are no nerves in areas where ablation is mostly performed in the heart.

Electrophysiological study is basically a painless procedure. Only local anesthetic is applied at the insertion site in the groin area and there may be some discomfort during vascular access. Some patients may feel slight sensation of a touch as catheters move through the vein. There is no pain in the continuation of the procedure, but palpitations are felt during the process of forming the rhythm disorder. The standard ablation process is basically painless procedure performed in the continuation of electrophysiological study. Rarely, there may be pain that lasts few seconds while ablating some special regions. Light sedatives can be applied in both procedures to ensure the comfort of the patient.

Risks of ablation treatment
Electrophysiological study (EPS) being interventional diagnostic procedure considered to have the lowest risk rate among others in the field of interventional cardiology. Its risk is acknowledged to be even lower than risk of coronary angiography. Since there is also a treatment component in the ablation process, the risk may be a little higher. But even considering it, the procedure has relatively low risk. Since rhythm disorders can consist of dozens of causes, the area studied within the heart is different in the ablation process. Risk degree may depend on the area of application. Your doctor should inform you about risks concerning the ablation. In general, electrophysiological study and standard ablation procedures are low-risk procedures. However, one should realize that ultimately these interventional procedures are needed due to the diagnostic.

Do you need to be hospitalized for the interventional procedures?
Electrophysiological study is a diagnostic process that is often used in mostly venous veins. After the procedure, which lasts in average for 10-30 minutes, the catheter is removed, the bleeding control is monitored and within a few hours that the patient is discharged.

Ablation is a treatment method. Although the procedure is similar to electrophysiological study, it may be necessary for the patient to stay in the hospital for 12-24 hours for bleeding control and safety reasons. If there is no problem with the inguinal veins after discharge, patient can immediately return to daily life and work.

In which cases ablation is performed?
If you complain about palpitations, if you are not diagnosed with the cause of your complaint, if you do not benefit from drug treatment or do not want to use medication, you can safely have electrophysiological study and ablation by consulting your physician. Your physician will guide you on whether you need this procedure and whether you will benefit from the procedure.

Treatment after ablation
Full treatment is usually provided after ablation and no drug treatment is required. In some severe rhythm disorders, it may be necessary to continue supportive drug treatment after ablation.

Prof. Erdem DIKER, M.D.
Head of Department of Cardiology, Bayındır Söğütözü Hospital

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