Conversations for Confidence: Expert Answers About Heart Rhythm Disorders

Do you ever feel like your heart races, flutters, or even skips a beat? If so, you're not alone. The Centers for Disease Control and Prevention predicts more than 12 million people nationwide will have atrial fibrillation (AFib), the most common heart rhythm problem, by 2050.

In some cases, irregular heartbeats or palpitations are harmless. Other times, they can increase your risk for major cardiovascular problems like stroke. So, it's important to know what that fluttery or fast heartbeat means and what treatment options are available.

In a recent webinar, heart rhythm experts from The Christ Hospital Health Network shared details about these disorders to help you protect your heart. Together, Daniel Pelchovitz, MD, FCC, FHRS, a cardiac electrophysiologist and service line medical director for The Christ Hospital Heart and Vascular Institute; Karam Ayoub, MD, a heart rhythm specialist; and Jessica Otis, DNP, APRN, FNP-BC, a cardiac electrophysiology nurse practitioner, offered valuable insights and answered questions.

Here's what they want you to know.

What Are Palpitations and When Should You Take Them Seriously?

Most of the time, you don't notice your heartbeat. Sometimes, though, one (or more) can feel "off." That's a palpitation. Everyone experiences them differently, but they're commonly described as a:

• Butterfly fluttering
• Pounding in the chest
• Skipped beat

When to Bring It Up with Your Doctor

If you have a history of infrequent palpitations that go away quickly, there's likely no need to worry. But if your irregular heartbeats are new, happen more often and last longer, or you experience other symptoms, it's time to see your provider, Dr. Pelchovitz says.

"Some people have a skipped beat here and there. That's probably pretty normal," he says. "But if you're passing out, getting lightheaded, or already have cardiac disease, we can get a little more concerned."

Talk to your doctor if you have any of these red flag symptoms:

• Chest pain
• Dizziness or lightheadedness
• Fainting
• Feeling like you may pass out
• Shortness of breath

What Causes Irregular Heartbeats

Knowing more about how your heart's electrical system works can help you understand why your palpitations happen, Dr. Ayoub says.

Like any other electrical system, your heart has a control station (in the top right side) and a relay station (in the middle). Cells in your heart continuously send the signals that control your heartbeat in a specific pattern. Palpitations happen when that pattern is disrupted for any reason.

"Sometimes, patients are born with an extra electrical pathway, and that extra wire affects how electrical signals move in the heart," Dr. Ayoub says. "Or there is a group of cells that are glitchy, and they fire irregularly."

Can Anxiety Be the Cause?

If your heartbeat kicks up or skips when you're nervous, it's not surprising. There is a clear link between your emotions and your physical self, Dr. Pelchovitz says. During stressful times when you feel anxious, you may feel more palpitations. But for most of those people who have a propensity for arrhythmias, there's almost always an underlying physiological reason that contributes to your irregular heartbeat.

"A lot of people, particularly younger people, are diagnosed with anxiety when actually they have a heart rhythm abnormality," he says. "Family members may dismiss it as a racing heart or feeling anxious, but something physical is causing that irregular heartbeat."

AFib, PVCs, and SVT: What's the Difference?

Several heart rhythm disorders can cause palpitations. Here's how the three most common conditions differ.

Atrial Fibrillation (AFib)

AFib creates a quivering, irregular heartbeat. Typically, it first appears as an on-and-off condition. However, AFib is a chronic, progressive condition. That means your episodes may be infrequent initially,but they will occur more often over time.

The abnormal rhythm that triggers AFib starts in the top chambers of your heart. The longer you delay treatment, the harder AFib is to treat. So, it's important to talk to your doctor to get the early care you need.

Premature Ventricular Contractions (PVCs)

PVCs are heartbeats that happen too fast. The extra beats (contractions) that force your heart to squeeze too soon happen in the bottom chamber of your heart.

Unlike AFib, PVCs don't always get worse over time. In some patients, it may improve on its own. But Dr. Ayoub says there isn't a way to predict which patients will experience worsening PVC and who will get better.

Supraventricular Tachycardia (SVT)

SVT is a fast, irregular heartbeat that stems from the top portion of your heart. Most people who have SVT are born with it, Dr. Ayoub says. Typically, it's caused by an extra electrical pathway that creates two competing relay stations in your heart rather than one.

"You might think that two is better than one, but that's not the case here," Dr. Ayoub says. "In a way, they will fight against each other, and that can result in an abnormal heart rhythm."

The Connection Between AFib and Other Heart Conditions

It's important to remember that AFib rarely occurs by itself. It may link to other heart problems like congestive heart failure, cardiomyopathy, or valve disease, Dr. Ayoub says. But it's often impossible to know which condition appeared first.

"It's always a question whenever a patient comes in," he says. "I usually refer to the chicken and the egg: What caused what in this situation?"

If you have more than one heart condition, it's important to work with your provider to create a customized care plan that meets all your health needs.

"We typically approach any heart conditions at the same time, and we manage them at the same time," he says. "Usually, focusing on the other medical conditions can help manage the atrial fibrillation."

Diagnosing Heart Rhythm Problems

Heart rhythm diagnosis and treatment is a journey. You take the first step when you notice that something feels off or unusual with your heart, Dr. Ayoub says.

"We always start with the basics," he says. "Once we get the results, we can decide what subsequent orders or tests are needed for further evaluation."

Initial Medical Tests Your Provider May Recommend

• Electrocardiogram (EKG): This first-line test involves placing 12 leads (electrical sensors) around your chest and upper body to record your heart rhythm. It can detect underlying rhythm problems and identify where your symptoms are coming from.
• Cardiac monitor: This patch, placed on your chest, continuously records your heart rhythm over several days or weeks. It can catch symptoms an EKG doesn't capture because they appear less frequently.

How Smartwatches and Wearables Can Help

If you're concerned about palpitations or an irregular heartbeat, Dr. Pelchovitz says smartwatches and other wearable technologies can help you monitor your condition. But he cautions that you shouldn't rely on them too much.

Watches and wearables do a great job of capturing symptoms that only pop up every few weeks or months. An EKG taken in a doctor's office will likely miss those signs.

"If you have a watch on your wrist when you have palpitations, that watch can take an EKG. Suddenly, you have a diagnosis," he says. "I love watches for making a diagnosis in patients with intermittent symptoms. But I also get concerned that people may overuse them."

Dr. Pelchovitz says he recommends these devices for most patients who've undergone treatment because they can help monitor your progress and improvement. Your watch or wearable can tell you if any lingering symptoms are related to AFib. But if you're asymptomatic, resist the temptation to check yourself for AFib all the time. You'll inevitably get a false result that says you're experiencing AFib even when you're not, he says.

Heart Rhythm Disorder Treatments

After your diagnosis, meeting with your care team is the first step to developing a customized care plan for your heart rhythm disorder. A wide range of procedures exist to treat your condition. In most cases, providers start with the simplest options - medication and lifestyle changes - to reduce your symptoms. If those options don't work, they may recommend an advanced procedure.

Lifestyle Changes and Medication

Otis says medication and lifestyle behavior changes are typically the starting point for your care. To help control your symptoms, your provider may prescribe:

• Anti-arrhythmic medications to stabilize your heart rhythm
• Beta blockers or calcium channel blockers to treat symptoms when they occur
• Rate-controlling medications to manage your heart rate

She says addressing your stress level can also be beneficial.

"Often, just calming the nervous system can lead to improvement," she says. "Adopting behaviors that help you relax can be enough to help you come out of an episode with palpitations or an irregular heartbeat."

Other helpful lifestyle modifications include:

• Drinking enough water
• Exercising frequently
• Limiting alcohol
• Maintaining a healthy weight
• Managing high blood pressure
• Treating sleep apnea

Ablation for AFib

Medication often isn't enough for long-term AFib control. Most patients need an outpatient procedure called an ablation. Along with the lifestyle modifications listed above, this front-line treatment can help keep your heart in rhythm for longer periods of time. It's designed to stop cells in your pulmonary veins from sending the abnormal signals that trigger irregular heartbeats.

"We like to address AFib early because our success rates are much higher when we get it in the earlier stages, and our patients have longer lasting relief as a result," Dr. Pelchovitz says.

An ablation typically takes a few hours. During this time, you'll be under general anesthesia. That means you'll sleep through the ablation and won't feel or remember anything. To complete the procedure, your provider places IVs in your groin veins and threads a catheter (a long, thin tube) through those veins to your heart.

Ablation can treat three types of AFib:

• Paroxysmal AFib: This is the earliest stage of AFib where irregular heartbeats occur every few weeks or months. Treatment is typically 75-85 percent effective after one ablation.
• Persistent AFib: This type of AFib causes symptoms that may not stop on their own. Ablations are usually 60-65 percent effective after one year and often require a second procedure later.
• Permanent AFib: This irregular heart rhythm always exists and does not respond to treatment.

An ablation is also a common treatment option for PVC and SVT.

Types of Ablations

There are three types of ablation procedures. Each is highly effective, Dr. Pelchovitz says. Your provider will recommend the best procedure based on your symptoms.

They may suggest:

• Radiofrequency ablation: This traditional approach uses the tip of the catheter to trace a precise line around the cells and tissue in your pulmonary veins that send abnormal signals. Then, it burns those small spots to eliminate those signals.
• Cryoablation: This approach inflates a balloon at the tip of the catheter to freeze the abnormal tissue around all four pulmonary veins at the same time.
• Pulsed field ablation: Instead of using heat or cold, this new approach uses electrical pulses to stop abnormal signals. It's a more targeted technique that reduces potential damage to surrounding tissue and structures, like your esophagus.

Recovery

After an ablation, most people go home the same day and return to normal activities after a week of taking it easy, Dr. Ayoub says. Still, full healing takes roughly three months. During this time, it's normal to feel some irregular heartbeat or palpitations. That doesn't mean your procedure failed, but you will need a care plan to handle symptoms when they show up.

"After an ablation, we typically continue all the same medicines a patient takes for maintenance, including any anti-arrhythmic or rate-controlling medication, as well as blood thinners," Otis says. "We continue it for three months because it helps suppress those recurrences. After that timeframe, we evaluate the true outcome of the procedure."

Cardioversion

Cardioversion is a short-term treatment option for the type of AFib that starts and does not stop until there's an intervention. It's a quick plan of action that slows a fast heart rate and resets a normal rhythm.

"Cardioversion is essentially a way to reboot or restart the heart," Dr. Ayoub says. "It pauses the abnormal signals while we figure out what to do next."

Providers use conscious sedation to keep you relaxed and comfortable during this procedure. Then, they use pads to deliver controlled electrical shocks through your chest wall to stop the abnormal signals.

Recovery is usually much faster than procedures like an ablation, Dr. Ayoub says. Patients cannot drive for at least eight hours to a day while the sedation wears off, but can typically resume their daily activities by the next day.

Pacemakers

If you have a heart rate that's too slow or can't tolerate medications used to treat AFib, your doctor may suggest a pacemaker. Depending on how much they're used, these battery-powered devices can last for ten to 15 years, Otis says.

To place one, your provider makes a two-inch incision under your collarbone and creates a pocket. The pacemaker sits between your skin and muscle and connects to your heart by leads that run through your vein. It sends mild electrical signals to your heart to keep the rhythm steady.

"For a short period of time after the procedure, there are some weight and motion restrictions with the affected side to keep those leads from getting dislodged," Otis says. "Post-op care will be discussed with your physician so you feel prepared to head home."

Stroke Prevention

AFib stops your heart from squeezing fully with every beat. As a result, blood can pool and create clots in your heart's left atrial appendage. If these clots travel to your brain, they can cause a stroke.

"The biggest risk of atrial fibrillation is not actually the heart rhythm itself or the symptoms," Dr. Pelchovitz says. "Instead, it's the risk of stroke."

Watchman Device

While most AFib treatments focus on correcting an irregular heart rhythm, the Watchman device goes a step further. A small device about the size of a quarter, this implant closes off the left atrial appendage (LAA), where most stroke-causing clots pool during AFib, stopping blood clots from entering the bloodstream. This reduces the likelihood of AFib's most dangerous .

Most patients take blood thinners like Eliquis or Xarelto to avoid this problem. Watchman is an effective solution for people who can't tolerate those medications.

To implant a Watchman device in your heart, physicians access a single vein through the groin. After the procedure, patients need to lay flat for a couple hours to allow the access site time to heal well.

"Recovery for the Watchman device is typically faster and easier on the body than an ablation, "Dr. Ayoub says. "Just take it easy for that first week. We don't expect to see or have much symptoms in the chest."

Left Atrial Clip

Left atrial clips are another technique that helps reduce your stroke risk. Instead of an implant, providers place the clip on the outside of your . This device is most used for:

• Patients with AFib who need open heart surgery for another reason
• Patients with no AFib history who undergo surgery for a condition that has a high likelihood of developing AFib (such as mitral valve disease)

The Christ Hospital Difference

At The Christ Hospital Health Network, our electrophysiology program is the largest and most comprehensive in Greater Cincinnati. Our dedicated teams take a patient-centered approach to delivering complete heart rhythm disorder care.

"When you come to Christ, you'll meet experts who exclusively manage your specific condition, all day, every day - we take a little bit more time with each patient to be a bit more holistic," Dr. Pelchovitz says. "We think about how this disease process affects you and your overall medical care rather than just treating the disease process."

If you have a heart rhythm disorder, the electrophysiology team at The Christ Hospital Health Network is here for you. To schedule an appointment or get a second opinion, call 513-790-6884 or fill out this form to request a call back.