Palpitation

tall-bushes-profiling-the-blue-skyWhat is palpitation?

Normally our heart is beating regularly at a rate between 60-100 per minute. But we are not aware of it. In certain circumstances, we become aware of our own heart beat. This is known as palpitation. Very often palpitation is just a manifestation of anxiety. When you are stressed or with exercise, the heart races and we become of our heart beating fast. Though most often palpitation is harmless, in some situations it could be a manifestation of a dangerous disease. For example, abnormal heart rhythms can cause palpitation. Very fast rhythms can be regular or irregular. Sometimes it may not be continuous palpitation, but feeling of an occasional flutter in the chest. This is due to transient irregularity in the heart rhythm, which is often of not much significance.

Serious forms of palpitation occurs in those with severe heart disease – either electrical or structural. Structural abnormalities of the heart which damage the heart muscle or heart valves can cause paliptation due to extra load which it gives the heart. Electrical disorders of the heart often produce either very fast rhythms or very slow rhythms, both of which can be life threatening if severe.

One of the simple tests to analyse the heart rhythm in case of palpitation is an ECG. Structural damage to the heart can be assessed by ultrasound imaging of the heart known as echocardiography. Both these tests are commonly done for evaluation of heart disease. Other more advanced tests are needed only in selected cases. If the palpitation is only occasional, it can be recorded by long term ECG monitoring known as Holter monitoring (typically 24-48 hours) or event monitoring (one week to three months). If still longer recording is needed, we have implantable loop recorders – small devices which can be implanted under the skin under local anaesthesia, which can record electrical abnormalities of the heart for up to 3 years. These devices have wireless options which can relay the signals to a device at home which in turn can transmit it to a central server by mobile networks. The central server could be even located in another continent!

Compression only CPR

leaves-in-plentyWhat is CPR?

CPR stands for cardiopulmonary resuscitation given for victims of cardiac arrest. It has two components – chest compression to replace the pump function of the heart and artificial breaths – mouth to mouth or mouth to nose breaths or using a device known as Ambu bag. Ambu bags though available with rescue teams, is not available to lay rescuers on the spot. Hence many potential lay rescuers may hesitate to start CPR, being afraid of transmission of infection from the unknown victim. This hesitation can be avoided by compression only CPR.

What is compression only CPR?

Compression only CPR is usually meant for lay rescuers, in which chest compressions are provided till an AED (automatic external defibrillator) is available or emergency medical service arrives on scene. By providing chest compressions, circulation is achieved, to give enough blood with oxygen to the brain to maintain its viability for a short period. It has been shown to be much superior to lack of CPR and nearing the efficacy of conventional CPR if the duration needed is short. This is because blood in the heart contains sufficient oxygen at the time of most cardiac arrests in adults. This is not the case in drowning and most cardiac arrests in children, where artificial breathing is needed from the beginning.

How useful is compression only CPR?

Efficacy of compression only CPR performed by lay rescuers in adult victims is comparable to conventional CPR performed by them as per recent studies. In children conventional CPR is better. But if the lay rescuer is unwilling to perform conventional CPR (chest compression with rescue breaths), they may perform compression only CPR as it is definitely better than no CPR. Initiation of any form of CPR is associated with a better prospect of survival for the victim.

Cardiac arrest

beautiful-gardenWhat is cardiac arrest?

Cardiac arrest is nothing but sudden stoppage of the functioning of the heart. It is different from heart attack which is abrupt loss of blood supply to a region of the heart muscle. Heart attack can lead to cardiac arrest in some of the victims. Though both are medical emergencies, cardiac arrest is equivalent to death unless immediate measures are taken to swing heart back into action. This is usually done by chest compressions and artificial breathing (cardiopulmonary resuscitation or CPR – Basic life support or BLS), to be soon followed by electrical countershock (defibrillation) delivered by a device known as defibrillator, to correct the abnormal rhythm of the heart which caused the cardiac arrest.

How soon should CPR be started?

CPR should be started as soon as possible. The time window for successful CPR is very narrow. Irreversible brain damage can occur if blood circulation stops more than 4 minutes as the brain is very much dependent on oxygen supplied by the blood. Even with CPR, it is difficult to maintain good blood circulation to the brain to sustain it for a long period. Usually CPR provides only about one fourth of the normal blood supply. Hence the time window available to us is about 12 minutes with CPR, unless advanced cardiac life support (ACLS) is available.

What is AED?

AED is short for automatic external defibrillator. AED is an electronic device being deployed more and more in public places to treat victims of cardiac arrest. It is also known as public access defibrillation. AED has two electrode patches which can be applied to the chest. It will sense the cardiac rhythm and interpret it using a built in computer algorithm. If a rhythm which can be shocked back to normal (ventricular fibrillation or tachycardia – fast rhythms of the heart) are detected, the devices prompts a shock delivery. Everyone should clear off the victim when the shock is being delivered. If it is not a shockable rhythm, the device gives audio prompts to continue CPR.

What is ROSC?

ROSC is the acronym for return of spontaneous circulation. Once ROSC is achieved, further care is known as post resucitation care or post cardiac arrest care. This is aimed at minimizing the brain injury caused by the period of lack of oxygen supply to the brain during cardiac arrest.

Use of mobile phone positioning system for initiating bystander CPR — Cardiophile MD

bamboo-bushes-in-a-garden

It is well known that the earlier cardiopulmonary resuscitation (CPR) is initiated, the better the outcome. Practical limitations are common in the setting of out of hospital cardiac arrest (OHCA). Bystander initiated CPR is the best way to start CPR at the earliest. Leveraging the widely available mobile phones with positioning systems in place has […]

via Use of mobile phone positioning system for initiating bystander CPR — Cardiophile MD

Electrophysiology study

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Electrophysiology study is an advanced evaluation of heart rhythm disorders. It is usually resorted to in cases where simple medications are not effective in controlling the rhythm abnormalities. Generally it is done without any sedation or general anaesthesia as it is not very painful. Local anaesthesia is given at the sites where the blood vessels are punctured to introduce small electrodes into the various chambers of the heart for recording the electrical activity of the heart internally. Each electrode has multiple recording poles – bipolar with two recording poles, quadripolar with four recording poles, decapolar with ten recording poles and duo-decapolar with 20 electrode poles.

The signals from the electrodes reach a junction box from where it reaches recorder which also displays multiple simultaneous channels on a screen. The signals can be electronically archived on a hard disc or printed on a calibrated recording paper. By analysing the sequence in which signals arrive at each electrode, the pattern in which the signals are conducted within the heart can be assessed. This gives valuable information on the origin of the heart rhythm disorder. The information gathered will guide further treatment in the form of medications or catheter ablation. Catheter ablation is the procedure by which a small electrode delivers an energy to produce localized damage a disease focus, curing the rhythm abnormality. Most commonly used source of energy is radiofrequencywhile cooling with a cryo probe and microwave energy  are other options.

Heart rhythm disorders (Arrhythmia)

Disorders of heart rhythm are technically known as cardiac arrhythmia. Rhythm disorders can be irregularity in the rhythm or change in the heart rate (increase or decrease). Commonest irregularity in the heart rhythm is due to abnormal beats originating from the lower chambers known as ventricular ectopic beats (VPB or VPC – ventricular premature complexes). Increase in heart rate can be due to physiological causes like exercise or due to simple disease states like fever. A decrease in heart rate can occur during deep sleep and when the body temperature falls below normal (hypothermia). There are several disease states which can reduce heart rate like a decrease in the function of the thyroid gland (hypothyroidism) and complete heart block. In complete heart block, the signals generate by the natural pacemaker of the heart, namely sinoatrial node, does not get conducted down to the lower chambers of the heart. The study of heart rhythm disorders is known as cardiac electrophysiology.

Disorders of the heart rhythm are initially documented by an electrocardiogram (ECG), which the technique used to record the electrical activity of the heart using multiple electrodes attached to the body. The device used to record the ECG is known as the electrocardiograph. ECG machines were very huge to begin with, when they were invented in the beginning of twentieth century. But now they are quite compact and portable, enabling recording at the bedside.

Heart rhythm disorders can be further documented by long term recorders like Holter monitors and event monitors. Continuous ECG monitoring for evaluation of cardiac arrhythmia is now commonplace in intensive care units and operating rooms.

Apart from recording of the electrical activity from the body surface as discussed, above, it is also possible to record electrical signals from within the heart using electrodes introduced into the heart chambers through the blood vessels. This procedure is known as electrophysiology study, and is used for getting advanced details regarding heart rhythm disorders for making important treatment decisions.

Electrical system of the heart

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Electrical system of the heart ensures its rhythmic contractions at normal rate of 60-100 per minute. The signal generator of the heart is known as the sinoatrial node (SA node) and the relay station is known as the atrioventricular node (AV node). Signal conduction between the nodes is through internodal pathways and that from the AV node into the ventricles through the bundle of His and its branches.

SA node

SA node is the natural pacemaker of the heart which controls the heart rate. It is in turn under the control of the brain by the autonomic nervous system. SA node increases and decreases its rate in relation to the physiological need of the body. When we take rest, the rate is low and it increases gradually with progressive exertion. Heart rate increases with emotional stress as well. SA node is located in the upper part of the right atrium (upper chamber of the heart), near the entry of the superior vena cava (blood vessel draining deoxygenated blood from the upper part of the body).

Internodal pathways

There are three signal pathways within the right atrium which connects the SA node to the AV node. One of them gives a branch to the left atrium (left upper chamber of the heart) for giving electrical signals to that chamber.

AV node

AV node is situated at the junction of the upper and lower chambers of the heart (AV junction), almost in the middle, at the lower part of right atrium. It delays the signals coming from the SA node so that contraction of the upper chambers are fully over before the lower chambers start contracting.

Bundle of His

Bundle of His is the electrical conductions system of the heart which crosses the AV junction and passess into the wall between the right and left lower chambers (ventricles) of the heart. It divides into two bundle branches – right and left for each ventricle. Left bundle further divides into two divisions, one of which goes to the front region and the other to the back region of the left ventricle (left anterior and left posterior fascicles).

Purkinje fibres

The bundle branches divide further into numerous small branches which take the electrical signals to all the muscle cells of the ventricles. These tiny branches are known as Purkinje fibres.

When the electrical system of the heart fails, the heart beats slow down and the person can get a black out. If the slowing is due to a permanent cause, an artificial electronic pacemaker is implanted under the skin and connected to the heart by a lead wire to restore the heart rhythm. If the cause is temporary (reversible), a temporary external pacemaker is used instead, which can be removed after the spontaneous rhythm of the heart is restored.