BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 7. - Arrhythmias
RADIO 4
THURSDAY 07/04/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTOR:
PETER WEISSBERG
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Unless you are exercising or feeling听anxious then your heartbeat should be steady and in the range of 60-80 beats a minute. A heart rate that's very fast, very slow or irregular may be a sign of an underlying medical condition that needs to be checked out. The occasional missed beat, funnily enough, may signify nothing at all but sustained cardiac arrhythmias, as they're called, can make you feel very unwell with symptoms including dizziness, shortage of breath and possibly chest pain. Now many arrhythmias occur as a complication of an underlying heart condition but they may be triggered by a thyroid problem and certain medicines and sometimes they simply occur out of the blue. There are various ways of bringing the heartbeat back into normal rhythm, there are thousands of people alive and well today thanks to pacemakers for example, the latest lightweight implantable devices are incredibly sophisticated.
So if you have this condition and you're wondering what new treatment might help you to continue to lead an active life without fear of triggering an attack then call us now. The number 08700 100 444 or you can e-mail checkup@bbc.co.uk to put your questions to cardiologist Professor Peter Weissberg, he's medical director of the British Heart Foundation. You're very welcome Peter. Let's go straight to our first call, we have a lot of people waiting to talk to you today. Mike Pearce is on the line, he's in Worcestershire, and he's worried about palpitations. What are these palpitations that you feel Mike?
PEARCE
Well I'll give you a brief potted history. I'm 64, not overweight, I train, cholesterol level's okay, I keep fit but a couple of years ago I got a racing heart and palpitations and it went on for about an hour and a half, it was quite frightening, and then a few days later it happened again. I went to the GP, he gave me an ECG, that was okay, referred me to a specialist who confirmed that I had an acid reflux and a mild Barrett's Oesophagus for which I now have an endoscopy annually just to check on it. I also have annually a 24 hour heart monitor on. I'm only showing slight abnormalities, arrhythmia, I think they're called, the specialist said it's nothing to worry about, I don't get any pain but on occasions when I've had bad palpitations you do feel a bit faint but normally I can control it to a degree. It does happen sometimes at night, especially if I lie on one side and I'm just wondering whether there are any ways of controlling it or this laser treatment that maybe Tony Blair had.
MYERS
Okay, so it sounds as though you're wondering whether to worry because it sounds as though you've been checked out and been told not to worry but I guess if these feelings come on it is rather concerning. Is there anything then that Mike could do Professor?
WEISSBERG
Well I think the first point to make is that most rhythm disturbances like this are intermittent and it's a little bit like the rattle in a car when you go to the garage, when you get there it's gone and it starts as soon as you drive off again. And that's one of the problems with our 24 hour taping investigation because if you don't have the symptom while the tape's on then it won't show anything abnormal. There are very commonly people who have short bursts of rhythm disturbance of the sort that you describe that make you feel just as you describe. I think the first and the most important message to take home is that these things are rarely life threatening, they're usually a nuisance and so whether you actually need to do anything about it or not is not as important as just learning that they're not going to carry you off, if you like.
PEARCE
What is the connection between an oesophageal problem that causes the heart to trigger a palpitation?
WEISSBERG
I doubt if there's any direct link between those, it's just that when people are investigated for heart rhythm disturbances we look into all sorts of issues and if there's any question of chest discomfit or anything associated with that then we investigate that and I think that's probably just an incidental finding. I think as the programme goes on you'll probably hear more about a condition atrial fibrillation, which occurs very commonly and more commonly as one gets older, and this is a disturbance whereby the heart suddenly races, somewhat erratically, for anything from seconds to hours to days and maybe even permanent in some people. And that can be distressing when it occurs.
PEARCE
And there's certainly no pain or anything like that and I do run, I swim, I do all the usual things ...
MYERS
Is Mike doing the right thing to actually keep active?
WEISSBERG
Yes I think so, I think generally speaking if you're not getting symptoms such as breathlessness or chest pain then one can assume that your heart is probably inherently relatively healthy.
MYERS
Mike, take some reassurance from that, thanks for your call. It raises this question about keeping fit and Max has e-mailed to say that he's a fit 59 year old. Now in fact he keeps fit by running but he says he takes his heart rate to around 175 for up to an hour, that seems quite fast to me, and his friends have said that by exercising above his 100% range he risks developing an arrhythmia - one of these heart disturbances - and yet other people have said that it's not a problem as long as he feels good while he's exercising. So who's correct?
WEISSBERG
Oh I think it's perfectly reasonable for somebody who is in good health without any underlying heart condition to exercise to the extent that they feel comfortable and not to be too worried about what the actual heart rate they're achieving is. It's - 170 is not a particularly high heart rate for somebody who's exercising very vigorously. We do, when we test people in hospitals, set a maximum heart rate that we allow them to achieve but that's really as a safety measure in patients that we know inherently are probably going to have heart disease, that's why they're there, that's rather different from taking somebody who's fit and healthy otherwise, who's a regular training athlete.
MYERS
Let's go to Lesley Meaker, who's missing a heartbeat, presumably not permanently Lesley?
MEAKER
No, thank goodness.
MYERS
What's the story?
MEAKER
Good afternoon to you. I've started to experience what feels like my heart missing a beat or sometimes beating double time. We do have an inherent heart condition on my mother's side of the family - angina - which has led to heart by-pass and on mother's case angioplasty. I do keep a check on my cholesterol levels, which is, at the last count, 4.6, I watch what I eat and I do take regular daily exercise. My last full medical was two years ago. Is this something that I should start to be concerned about?
MYERS
Actually Lesley you sound like an example to us all, with the preventive work that you're doing on yourself. But Professor Peter Weissberg, what about this missing a beat, is it significant?
WEISSBERG
No, I think this is probably the commonest symptom that people get related to their heart rhythm. In fact if we do an ECG when somebody thinks they're missing a beat what's happened is they've actually put in an extra heartbeat but very, very early after the previous beat, so that the heart doesn't have time to fill between the two beats and so you don't - you're not aware of that beat and then there's a bit of a gap before the next normal beat comes along, which is often heavier or more forceful than the previous beats and that's felt as a thump in the chest and it may come as couples, triplets or in runs like that. That is extremely common, generally does not imply any form of underlying heart disease whatsoever. The problem that runs in the caller's family is coronary artery disease, now of course there is a predisposition in families to this but I don't think the fact that she's missing the odd heartbeat implies that she's necessarily got the problem with the coronary arteries that the rest of her family members have.
MYERS
Again reassurance, thank you very much for that, thank you for your call Lesley. What about the connection - anything in the heart may make people worry that if it's not all tickety boo - going as it should - you could end up with a heart attack. And having said that I'd like to read this e-mail, someone who would prefer not to be named, and that's fine, but her husband's brother recently died suddenly, he was only in his thirties, and the inquest concluded he'd died from sudden cardiac death due to a momentary fatal arrhythmia of the heart with no other disease or injury. That's a tragic story, so what is the connection between these heart arrhythmias and in this case a tragic outcome - a sudden death?
WEISSBERG
Well I think the first thing to say is that the commonest cause of sudden cardiac death is in somebody who's got established coronary artery disease and they have a heart attack which destabilises the heart rhythm and unless somebody can defibrillate them with one of these defibrillating machines straightaway then that converts into a sudden death. But that is a rhythm disturbance that's triggered by the underlying problem with the coronary arteries and that tends to happen in the elderly population or middle aged to elderly. Now there are a few rare instances of people who are born with abnormalities of the way their heart cells deal with particular irons - calcium and sodium - and these people are predisposed to having a fatal cardioarrhythmia out of the blue. And unfortunately the first one ever knows about this is often when a young person in a family dies suddenly as a consequence of this.
MYERS
Sometimes on the squash court.
WEISSBERG
Sometimes on the squash court and it can be at any time. Now there are two possible reasons for this, one is that they may have what's called a cardiomyopathy - an inherent muscle disease that affects them and possibly other members of the family. The other possibility is that they have one of these iron channel problems which doesn't affect the heart muscle itself but it can often be picked up by subtle changes on an ECG. So that the take home message for anybody who's had a sudden premature unexplained death in the family of this nature is that the rest of the family members ought really to be screened by an expert cardiologist to see whether there are any of these subtle changes in their ECGs or on their hearts when they do an echocardiogram, for instance, a very simple test to do to see whether there are other family members at risk. And in fact this is the subject in the latest chapter in the National Service Framework for Coronary Heart Disease for the NHS, which deals specifically with this - that doctors should be more aware of looking after family members of patients who've had a sudden cardiac death.
MYERS
Let's go to another caller now, waiting patiently in Kings Lynn, Pat - Pat your question please.
PAT
Oh good afternoon. I have recently been diagnosed as having atrial fibrillation. Parosismal atrial fibrillation I believe.
WEISSBERG
Paroxysmal I think.
PAT
Oh sorry. Yes. Now I'm very curious to know more about the condition and in fact I've learned something from your programme so far, already. But basically I'd like to know what causes it. I have been told that it's usually as a result of high blood pressure but I've never had any high blood pressure problems. I try to eat as healthily as possible and take as much exercise as I can. Can it - is it just down to age? I'm 73 years old. Or I wondered whether - I was very ill a couple of years ago and I had a condition diagnosed as polymyalgia, was put on a high steroid dose and actually this problem with palpitations first hit me then while I was on the high dose of steroids and I wondered if it could have - if this condition that I'm suffering from now could be a follow on from that.
MYERS
And just before I get Professor Peter Weissberg to give you some of the answers to what are very intriguing questions can I just get a sense from you what it feels like when you have this paroxysmal atrial fibrillation?
PAT
Very alarming.
MYERS
Very alarming.
PAT
Yes, I'm having it now actually as I speak to you.
MYERS
Oh I'm sorry.
PAT
No that's quite alright because I have been put on medication - Adizem and warfarin - and they - just over the past three weeks - and they have seemed to help but this week, as it turns out, all these palpitations seem to have returned ...
MYERS
Okay, well you relax and listen while the Professor does the work now because I mean you've been able to offer quite a lot of reassurance, it seems to me, about these heart arrhythmias but I mean this does sound quite worrying. What's the answer?
WEISSBERG
Well yes well I think the first thing to say that Pat's in very good company because up to 1% of the population at large have atrial fibrillation and up to 5% of people over the age of 65. So I think that partly answers her question - is this just something that comes with age - the answer is largely yes. There are some specific underlying heart conditions which can predispose people to getting this but most people get it just as a matter of ageing.
MYERS
And what's happening in the heart when ...?
WEISSBERG
And what's happening is that normally the heart beats as a consequence of a pacemaker at the top chamber of the heart and it's a bit like the Christmas lights that trickle down to the rest of the heart and the whole heart beats as a consequence. What happens in atrial fibrillation is the upper chamber starts to beat chaotically and so the lower chambers don't know how to follow and so as a consequence the lower chambers, which are doing most of the pumping of the heart, pump erratically, irregularly and not forcefully enough - they don't have time to fill. And people who get this condition feel dizzy, light headed, short of breath, unwell when they change from a normal rhythm into atrial fibrillation. And as I said it's very common. In somebody who gets paroxysmal atrial - paroxysmal just means you get attacks of it. And in a way that's - the unfortunate thing is that you're having the attack of atrial fibrillation and going back to the normal rhythm - you might be surprised to hear that if you were to stay in atrial fibrillation for any length of time that combination of tablets that you're on would regulate the rhythm of your heart to the point that you would cease noticing that you're in atrial fibrillation and go about a perfectly normal day to day activities in atrial fibrillation. Unfortunately people who keep chopping and changing backwards and forwards are the ones that are in most difficulty. And again I stress this isn't life threatening but it's a heck of a nuisance.
MYERS
So what can you do to try and stop that happening?
PAT
Yes can I control it in any way?
WEISSBERG
I don't think there's anything you can do personally. The tablets you're on - the Adizem tablets, they're designed to try to stop you having attacks of atrial fibrillation...
PAT
And they have been until just recently.
WEISSBERG
Well there are other tablets that you might want to talk to your doctor about or your cardiologist about that they might want to swap you on to that might be more effective than the Adizem but keeping you out of atrial fibrillation. But I do have to say it's a difficult disturbance to treat. I should also make the point for you and others that the reason that you're on warfarin is not to treat the arrhythmia itself, the warfarin doesn't have an effect - doesn't have any effect on the heart rhythm. What it does is it reduces any risk there might be of you having a blood clot throwing off from your heart when you go into this rhythm disturbance because there is no doubt there is an increased risk of having small blood clots and that, as I'm sure you've been told, can lead to a stroke and that's why - that's why patients in atrial fibrillation are routinely treated now with warfarin.
PAT
Yes, which I think is why the palpitations when they come are so alarming because one begins to think about all these things.
WEISSBERG
No, I don't think you need be alarmed that you're going to have a stroke. You're on warfarin, that'll stop you having the stroke, you'll just feel as you do - a little alarmed and breathless and you'll probably find that as time passes it becomes easier to live with. But you do have a problem if you keep chopping and changing backwards and forwards. But there are alternative medications that you might want to discuss with your doctor.
MYERS
Pat, thank you very much for that. You raise this interesting point, or I think it comes from Pat partly, that palpitations - the feeling of being - your heart racing - you may or may not have an arrhythmia but you could be a bit confused, I would imagine, because if you're anxious - we've all had it, we've felt that fluttering of the heart or shortness of breath - do you find that many people end up in your clinic really perhaps with anxiety attacks or simply in a state about their health and thinking that they've got a really significant problem and in fact you're able to reassure them that they haven't?
WEISSBERG
Yes I'd say probably the majority of the patients that I see in my clinics who are referred for a possible rhythm disturbance turn out to have either no rhythm disturbance or one of these benign rhythm disturbances like the ectopic beats we discussed earlier on, which people are of course aware of and quite rightly are alarmed by but needn't be once they've been reassured that that's what they are.
MYERS
We'll go to Jamie Stephenson, he's calling from Devon and we're on the subject of atrial fibrillation, I think that's something that you may have been diagnosed with already and are interested in some other treatment other than medical treatment, what's your actual question Jamie please?
STEPHENSON
What are - a lot of different success rates are claimed for the ablation and other procedures for curing atrial fibrillation, can you summarise what are the risks involved in those ablation procedures and what on average actually are the likely success rates?
MYERS
Thank you. Can you start though Peter by explaining what ablation is and whether you can cure atrial fibrillation using these?
WEISSBERG
Yes, because I should do that by talking about other rhythm disturbances other than atrial fibrillation. There are some very rather simpler rhythm disturbances that are caused by, if you like, an electrical short circuit in the heart. And we've known now for several years that if you contract those down with little electrical monitoring electrodes in the heart and damage them, usually by high frequency sound waves or radio frequency waves, then you can cure that person of the tendency to the rhythm disturbance. What's been learnt more recently is that in some patients with atrial fibrillation or a slightly different version of it called atrial flutter where the heart is beating regularly but too fast, then the electro physiologist can track down the area of the heart that's responsible for this and do an ablation procedure to stop the rhythm disturbance and cure it permanently. At the moment I have to say for people with, what I would call, standard atrial fibrillation, in other words it's just come on as they've got older and there is no very obvious reason why it's happened ablation is in its infancy at the moment for this condition. There are some experts that are beginning to do it more and more now in people like that but I think it's got a little way to go. In terms of safety I think it's a very safe technique, like any technique that's putting wires into the heart there are small risks associated with it but I think the problem is for atrial fibrillation at the moment one can't guarantee a very high success rate just yet, although we may not be far off being able to do that.
MYERS
So right to ask about the risks and consequences, the risks may be not so high but if it doesn't work then it's been a small risk taken for no good reason.
WEISSBERG
No good reason, yeah.
MYERS
Okay thank you, I hope that's answered your question Jamie. We've got another AF question - atrial fibrillation - from David Lewis in Milton Keynes. David, what's your question please?
LEWIS
Thank you. I was diagnosed with paroxysmal atrial fibrillation some time ago and the medication that I was on ceased to be working at all. So I went into hospital and they carried out this pulmonary vein isolation ablation procedure ...
WEISSBERG
Yes, this is the one I've just been talking about.
LEWIS
Yes, and after seven hours they gave up because they couldn't make it work. So I've now been requested to go back to have a pacemaker fitted and apparently they're going to possibly destroy the natural pacemaker and I wondered what the dangers are to me for that.
WEISSBERG
Well thank you for coming on because you've really just illustrated the point I made a moment ago that the success rate for ablating atrial fibrillation is still not as high as we would like yet and I think we've got to learn a bit more about it before we can offer it to everybody as a routine. What happens in an ablation of the sort that you're talking about is if it turns out that one can't stop the upper chambers of the heart from fibrillating - that's this sort of very rapid chaotic beating - then what you can do is interrupt the pathway - I likened it to sort of fairy lights running down through the heart, if you take one of those bulbs out so that the current can't go down from the top to the bottom what tends to happen is that the upper chambers carry on fibrillating quite happily but the lower chambers start to go at their own pace and don't follow them. Now the good news of that is that they stop beating too fast but if you leave the lower chambers to their own devices they'll beat far too slowly - often at about 30 or 40 beats per minute - which isn't enough to keep somebody fit and happy. And so the way we get round that is to give them a pacemaker which drives their heart - the lower chambers, the important chambers of the heart - at the right rate for what they happen to be doing and we let the atria get on and fibrillate as much as they wish to and that, in effect, cures the problem.
MYERS
So does that sound as though it would be the right procedure in that case for our caller?
WEISSBERG
Well I think it depends entirely on the level of symptoms, he has to discuss that with his cardiologist, but it's not an uncommon procedure for somebody who's getting distressing symptoms from paroxysmal atrial fibrillation.
MYERS
Okay, thank you very much for the call and thank you for explaining that Professor. I'd like to take an e-mail now and it's Richard who says he's an otherwise healthy male of 53 years old and has had a first attack of atrial fibrillation, that was three years ago, he's on medication, that seems to control it quite well. However, it appears that "even a small glass of alcohol sets my palpitations off" and he'd like to know about the effects of caffeine and alcohol and whether increasing the dosage of his medication could allow him the occasional pint?
WEISSBERG
Well first of all without knowing what medication he was on I wouldn't advise anybody increasing the dose of their medication without discussing it with their doctor. Unfortunately there are some people whose hearts are exquisitely sensitive to the effects of alcohol and atrial fibrillation can occur and does occur even in very young people, we've often had students in after their finals who've been on a bender the night before and got into atrial fibrillation - it's a temporary phenomenon and they usually spontaneously go back to a normal rhythm. But there are just a few people whose hearts are exquisitely sensitive to the effects of alcohol. And I don't think I would be tempted to up the dose of my medication to increase the amount of alcohol one can take because the alcohol can have other detrimental effects on the heart other than just the rhythm.
MYERS
And I guess you're not suggesting though that it's alcohol or caffeine that actually cause these arrhythmias in the first place?
WEISSBERG
Well certainly those who are susceptible to the effects of alcohol will have episodes of atrial fibrillation triggered just by taking the alcohol - there's a definite relationship.
MYERS
There is, indeed. Okay we'll take a very quick last call, it will have to be quick, can we go to Harold.
COTTAM
Hello, Harold Cottam yes.
MYERS
Yes hello Harold, very quickly if we may, your quick question for the Professor.
COTTAM
Yes mine is roughly related to some of the comments on caffeine in the sense that I suffered from atrial fibrillation a few months ago, had some shock treatment and some drugs and I'm now entirely clear and I'm off the drugs et cetera. But nobody can tell me what might trigger again, I've asked about coffee, I've asked about alcohol, I was told if I lead a normal life it shouldn't bother me.
MYERS
If anyone can tell you the Professor can, very quickly.
WEISSBERG
Well I think it's very difficult to know what actually triggers these things. It's not necessarily the case that caffeine will do it, I think it's a matter of trial and error. If I were you though I would not be too heavy handed with either alcohol or caffeine because you're one of the lucky ones - the cardioversion worked and you're back in normal rhythm, so I don't think I'd chance my arm.
MYERS
We'll leave it at that, I'm very sorry, we always try to squeeze in too much but thanks very much. And thanks to Professor Peter Weissberg for his advice today. Thanks to everyone who rang in. More information on the website or on our help line 0800 044 044. This is the last in the current series but we'll be back in the summer. Until then goodbye.
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