Arrhythmias: Frequently Asked Questions

Brian Olshansky, MD,  is associated with the University of Iowa Health Care, where he is a cardiologist, director of cardiac electrophysiology and professor of medicine. His clinical expertise is in managing cardiac arrhythmias.

Can atrial fibrillation ever just go away?
Yes, some people only have one episode of atrial fibrillation. Generally, when someone only has one episode of atrial fibrillation, it is due to some precipitating event such as pericarditis, alcohol or some acute illness, which might cause vomiting, for example, the flu. Most people who have no obvious cause for atrial fibrillation are likely to have another episode sometime in their life. It is unclear when that episode would be. Some people have frequent episodes on a daily basis; others will have one every few years.
I saw your chat the other day on atrial fibrillation. I'm 37 years old, in perfect health, skinny and extradordinarily cold intolerant. I have noticed my heart beating with extra and fast beats almost daily. Could this be a sign of atrial fibrillation and should I be evaluated for this?
Yes, you should have a further evaluation for this problem. There are various causes for noticing your heart beating. Some people have this due to some extra beats in their heart that are from the upper or lower chambers. Other people have rhythm disturbances including atrial fibrillation and a rhythm disturbance known as supraventricular tachycardia. You should definitely have an evaluation, including a Holter monitor to evaluate the cause for this sensation of extra and fast beats.
How important is cardiac rehabilitation in the prevention of a second heart attack?
A heart attack is a condition where an artery in the heart blocks off and this causes heart muscle damage. Frequently, this is due to cholesterol deposits and damage in the blood vessels. It is a good sign if you survived the first heart attack as most people do with medical therapy but it should be a wake-up call to help illuminate the potential triggers for the problem. There are various risk factors for heart attacks including high cholesterol, lack of exercise, smoking, high blood pressure, diabetes and recently a condition whereby there is inflammation found in the blood vessel wall. Exercise treatment, cessation of smoking, lowering cholesterol, improving the diabetes will all help prevent second heart attacks. Proper cardiac rehab, when the exercise is performed appropriately, can be highly effective in improving the long-term prognosis.
What are the early warning signs of a heart attack?
It is important to recognize that many people who have had heart attacks had no warning whatsoever. This especially concerns people who have diabetes where upwards of 50 percent of heart attacks were not recognized or were not associated with any warning signs. If there are warning signs, they include the following sensations: episodes of chest discomfort, often a squeezing sensation in the center of the chest, sometimes the discomfort is felt in the left arm, especially radiating towards the 5th finger. There can also be numbness in the arm. There can be associated nausea, shortness of breath, dizziness, sweating or loss of energy.
Are cardiac rehab programs safe?
Cardiac rehabilitation programs vary from place to place, but properly performed, it can be very safe. It is performed in various stages starting with a very easy stage of a small amount of exercise. As the individual undergoing rehabilitation continues in the program, an expert in the area would gradually increase the patient's exercise intensity and time. Properly performed, this can have a great impact on ability to function, exercise and to improve the long-term prognosis. To enter most rehabilitation programs, a treadmill test is generally required. Certainly, rehab is not meant for everyone with a heart problem/attack. This needs to be prescribed by a doctor to make sure the heart condition is otherwise stable.
Does taking aspirin really help if you take it during a heart attack?
Yes, aspirin has a profound effect. If there are warning signs of a heart attack, it would make sense to take a regular aspirin, even a baby aspirin and chew it well because the effects can be immediate and profound. Aspirin has multiple effects on the heart. Aspirin prevents blood clot formation. It prevents further damage from small blood clots that have formed and long-term, aspirin has an anti-inflammatory effect on the blood vessels. Recently, there has been evidence that a new measurement known as high sensitivity, C reactive protein can be the cause for heart attacks and can predict heart attacks up to 30 years in advance. C reactive protein is a better predictor of heart attacks than cholesterol and is better than any other single measurement. Aspirin lowers C reactive protein levels.
If one were on medication for atrial fibrillation for a number of years, would it ever be wise to discontinue the medication to see if the arrhythmia is no longer present?
Atrial fibrillation can resolve over time, and it might be reasonable to discontinue the medication if the rhythm has been stable for a long time, either 6 months to a year and if the rhythm disturbance was infrequent and not severe. Atrial fibrillation severity differs from patient to patient. If someone has multiple and frequent episodes of atrial fibrillation that are poorly tolerated, but a medication is begun and the episodes go away, it would not make sense to stop the medication. However, for the patient who has only occasional episodes and appears to have a controlled rhythm on a medication for a period of time, it might be reasonable to stop the medication and see if the rhythm problem has resolved or requires treatment. Some people have greater risks of the side effects of the medications for atrial fibrillation than benefits from the atrial fibrillation medication.
Are there any conditions that make a person pre-disposed to heart attacks?
Yes. The conditions that are important are smoking, high blood pressure, diabetes, positive family history where mothers, fathers or brothers had heart disease at a relatively early age, and then some recent interesting new factors such as C reactive protein and homocysteine. There are other potential risk factors for heart attacks including, interestingly enough, drinking soft water. There are also triggers for heart attacks. Recently it has been found that shoveling snow can be a risk factor for a heart attack, for example.
How do the medications that lower blood pressure help prevent heart attacks or do they?
Yes they do. A heart attack, once again, is where there is a blocked blood vessel that creates damage to the muscle in the heart because not enough blood supply gets to the heart. The medications that lower the BP, lower the need for blood to the heart because the heart does not have to work so hard. Some of the medications that are given for lower BP such as beta-blocker medication also have a direct effect on the heart.
Are having heart palpitations an early warning sign of cardiac problems?
Yes, heart palpitations can be a serious, potentially life-threatening problem coming from the lower chambers of the heart. On the other hand, a heart palpitation may be due to a benign cause. It can be difficult to distinguish one from the other by the way palpitations feel. The best thing to do if you have palpitations, is to have an assessment of what that heart rhythm problem is. This can be done by a Holter monitor or an Event monitor. A Holter monitor is a monitor that has a tape recorder in it and it records all of the heart beats for a period of 24 to 48 hours. An Event monitor is given for approximately one month. If someone has this device and feels the palpitations, they can record that episode and send it over the telephone line to a hospital/clinic to have the rhythm problem evaluated.
Has anyone shown biofeedback to be effective in managing atrial flutter/fibrillation?
This has not yet been shown with any degree of certainty but there are reasons to suspect that conditions like atrial fibrillation may respond well to biofeedback or even meditation. In some patients, atrial flutter/fibrillation are due to increases in stress. Ways to reduce this stress can eliminate atrial fibrillation. This will not work for everyone of course, but some people will have atrial fibrillation when they are overactive, with alcohol, playing sports and others will have it even after eating a big meal or with no potential cause. Some people have atrial fibrillation due to underlying heart problems. People who would benefit most, I suspect, would be those who have a normal heart and have short-lived episodes of atrial fibrillation.
My husband has atrial fibrillation and is on medication and monitored monthly. He insists he is not aware of any heart flutters or whatever to alert him to this problem. Are there any indications he can be aware of, or that I can watch for, that would alert us to a possible immediate problem to be dealt with?
Many older people with atrial fibrillation are completely unaware of its presence. Regarding possible problems, the issues really revolve around several factors: first, making sure the heart rate is under control, that is less than 100 beats a minute at rest; second, that the blood is properly thinned. I cannot think of any particular things for you to watch to offset the possibility of a problem.
What is the difference between a stroke and a heart attack?
A heart attack is due to a blocked blood vessel that supplies blood to the heart and when it blocks up, it causes damage to the heart. A stroke is when there is damage to the brain and it often is caused by a blood clot that plugs up a blood vessel that supplies blood to the brain. The risk for stroke does not appear to be related to cholesterol but strokes are also associated with high blood pressure as are heart attacks.
What are heart palpitations?
Heart palpitations are the sensation of an irregular rapid or slow beat in the heart. For one type of heart rhythm disturbance known as supraventricular tachycardia, palpitations can feel as though the heart is racing, about to burst through the chest. Other palpitations are less severe as they occur with atrial fibrillation and supraventricular tachycardia.
I've read recently that people can experience mini-heart attacks and not even know that they had a problem. What are the long-term effects, if any, of this?
This is quite a concern because in someone who has this problem, they might not be aware that they have a heart problem. Yet, they may have serious blockages in their arteries that may lead to a serious heart attack or even cardiac arrest that can lead to death.
Can a doctor tell if a person has had one of these mini-heart attacks?
Yes, most of the time a doctor can discover the problem of small heart attacks based on the electrocardiogram or a nuclear medicine test.
If heart palpitations could be a sign of heart problems, can an ECG detect this?
Yes, an electrocardiogram could detect the cause for a heart palpitation if the heart rhythm is existing at the time. Some people have palpitations intermittently, while other people have intermittent episodes of heart palpitations. So, they may require other forms of diagnostic testing to discover the cause for their palpitations. One type of method to evaluate palpitations is to use a test called an Event monitor. In this case, the patient has leads attached to the chest and whenever there is a rapid rhythm, the patient pushes the button, saves the episode, and calls that in over the phone. Some people do not wear the monitors all of the time, but attach them when feeling the palpitations.
My father occasionally complains of chest pain, I want to bring him to his doctor, but he says "it's not that kind of chest pain." Are there different kinds of pain not related to an impending heart attack?
Yes, there are but the one thing to keep in mind is that some people who are having impending heart attacks have no pain whatsoever and the quantity and quality and severity of the pain can vary tremendously from individual to individual. It is unlikely that any person can know for sure that the pain "is not that kind of chest pain." On the other hand, chest pain can be caused by a whole variety of different problems. This includes problems with lungs, gallbladder, esophagus and several others.
How does stopping smoking help prevent heart attacks?
Smoking is one of the worst things you can do for your heart. It releases toxins, which damage your blood vessel walls and lead to ultimate blood clots in the heart. Smoking also increases blood pressure and it increases heart rate, the work on the heart. It restricts the blood vessels in the heart so it decreases the amount of blood to the heart. Smoking has been associated with a marked increase in death from heart disease, especially coronary artery disease, blocked blood vessels. The effects of stopping smoking can be profound and rapid, a complete reduction in risk from smoking cessation requires many months/years before the risk increases to what it would be if the individual did not smoke.
I've read there are new guidelines for CPR, that mouth to mouth is not really necessary, and that the important part is the chest compressions. Is there any truth to this?
There are new guidelines for CPR. Some find mouth-to-mouth resuscitation distasteful but part of the resuscitation requires ventilation to the patient, that is somehow getting air to the lungs and also pumping on the chest to help push blood around through the circulation. While mouth-to-mouth itself is not necessary, some form of getting air to the lungs (ventilation) is required.
I have been diagnosed with atrial fibrillation and my heart also skips beats. Are these problems related and how concerned should I be in regard to my heart skipping beats.
Atrial fibrillation can feel as though the heart is skipping beats but these could also be two separate problems. It is possible that at times your heart is in atrial fibrillation and other times it is in normal rhythm. It could be that the skipped beats represent extra beats, which are triggering atrial fibrillation. Recently there has been evidence that extra beats which feel as though they are skipped beats, beats that come from pulmonary veins and parts of the upper chambers of the heart, can trigger atrial fibrillation and now there are curative measures that relieve these skipped beats that cause atrial fibrillation. Skipped beats can also be caused by a rhythm disturbance in the lower chambers of the heart. It is best to consult your doctor to determine which problem exists. By itself, if skipping of heart beats were the only problem, what this would generally tend to indicate is a rhythm abnormality in the lower chambers in the heart and it may be a tip off that there are other underlying problems in the heart. This can also be adequately evaluated by your doctor. Lanoxin is a commonly used medication for atrial fibrillation as it keeps the heart rate slow or well-controlled in most situations.

Brian Olshansky, MD, Professor of Internal Medicine,
Division of Cardiology
University of Iowa Hospitals and Clinics