Cardiac arrhythmias are a common story, more common than you might think. Many sufferers do not talk about it, leading to the mistaken impression that it is a rare condition. In fact, everyone has noticed that their heart beats unrhythmically, strongly, or beats much too quickly. This can be a cause for concern, especially if such conditions occur more frequently. Weekly, especially many young people come to my practice to get examined in this regard.
The challenge in diagnosing such heart conditions is that there isn’t just “one” type of cardiac arrhythmia; there are many different types. They can vary from completely harmless and normal to truly dangerous. The causes are various mechanisms, which can then have very different therapeutic consequences, from no treatment to cardiac catheterization. Nevertheless, the harmless causes are significantly more common.
What symptoms do patients experience?
Rhythm disturbances can last for a very short time, i.e. just 1 to 2 seconds. Then it is most likely a simple extrasystole. These can be perceived as irregular heartbeats, a brief pause in the heart rhythm, or a strong heartbeat felt in the throat. They can occur singularly or in groups over an extended period. Other arrhythmias can last for several minutes to hours. During such episodes, it is important for the doctor to assess how the patient is feeling. If the issue lies only in the perception (“palpitations, skipping beats, pauses, or stabbing sensations”), and induces maybe fear or panic, or if the arrhythmia is truly so severe that the patient experiences circulatory problems such as dizziness, shortness of breath, or even syncope? The faster the heart rate during the arrhythmia, the more likely circulatory problems are to occur. This brings us to a central issue of arrhythmias: the heart rate (which is equal to the pulse rate) during the arrhythmia.
How fast is the pulse?
If the cardiac arrhythmia only lasts 2 seconds, then the heart rate does not change, but if it lasts for several seconds or minutes, then it is important for the cardiologist to know how quickly the arrhythmia occurred. Experience shows that this is a point that patients cannot answer because they are very preoccupied with their subjective perception at that moment, and usually fear or panic arises. The patient typically perceives the event as dramatic and is convinced that it must have been “very fast.” Indeed, in such situations, the heart rate can reach frequencies of over 200 beats per minute (dangerous), but it can also be the case that the actual heart rate is only 150 beats per minute (fast but not dangerous) or even just 90 beats per minute (harmless).
Therefore, it is important for the patient, despite the fear, to try to measure the heart rate. In the simplest case, you look at your watch (or watch on your cell phone) for 60 seconds, place your finger on your carotid artery and count your pulse beats. This can be difficult at very high frequencies, but at least you know that it is actually very fast. Alternatively, you can use a heart rate monitor that shows your pulse automatically, or you may have a blood pressure monitor at home that, in addition to the blood pressure on the display, also shows the pulse (= heart rate) as a third value. With this information you can then say very roughly whether it is a dangerous (i.e. very fast) cardiac arrhythmia or not (slow). The question of whether the cardiac arrhythmia begins suddenly (i.e. “like turning on a switch”) or begins slowly and slowly subsides again can play a role in the correct classification.
The seizure ECG
Unfortunately, even knowing about heart rate still doesn’t give us enough information to be able to say exactly which cardiac arrhythmia is present. There are still numerous options. And to resolve this you need a so-called “seizure ECG”. An ECG that is recorded (and documented in some way) exactly during the cardiac arrhythmia.
After such an attack, it is not enough to go to the doctor and have an ECG done if the normal heartbeat has returned in the meantime. And unfortunately, this is often the critical point when making a diagnosis, since the cardiac arrhythmia usually occurs completely unexpectedly and unpredictably for the patient and in such moments there is hardly a doctor waiting for you in the next room with an ECG. When you finally go to the doctor, the nightmare is over again and you have nothing tangible, often not even information about how fast your pulse really was (see above!). However, a visit to the doctor can still be worthwhile.
Examination at the doctor
If you see a cardiologist or internist, you should of course have your heart examined. With a normal resting ECG and a heart ultrasound (echocardiography). Even if the cardiac arrhythmia is most likely not present in the resting ECG, you can at least determine whether the ECG graph is normal or not. In rare cases, it is also possible to find indications of the causes of the cardiac arrhythmia in the resting ECG (for example in the so-called WPW syndrome). Then you do a cardiac ultrasound. The structure and function of the heart are checked. If both the resting ECG and the cardiac ultrasound are normal, it can be said with a relatively high degree of probability that the whole problem is not caused by another serious heart disease and that the next heart palpitations can be overcome well. However, if any abnormalities are found during these two examinations, then these are probably related to the cardiac arrhythmia and of course need to be further clarified.
Record with what?
When it comes to the question of what you want to use to record your cardiac arrhythmia, you don’t need a doctor, just information about what type of devices (devices) are generally available for this purpose. And there has been a lot since the American chemist Norman Holter was the first to transmit an ECG wirelessly in 1954. His ECG transmission device in the form of a backpack, which weighed 45 kg at the time (but was mobile), was extremely innovative, but ultimately also somewhat impractical. And you probably weren’t very anonymous when you were there.
Modern 24-hour ECG devices (so-called Holter ECGs) are more practical; they are about the size and weight of a cell phone and record every heartbeat (and therefore every arrhythmia) precisely and noiselessly over 24 hours. Problem solved!? Unfortunately, usually not! Because most patients don’t have their arrhythmia every day. And even if you have it on average 6 out of 7 days a week – which I can confirm from reasonable experience – there is a very good chance that you will not have the arrhythmia on the exact day you wear the device. This time another American is responsible for this, namely the engineer Edward Murphy, who aptly summarized this incredible law of things that can go wrong in “Murphy’s Law” (but that’s another story).
In any case, in every practice you will first be offered a 24-hour ECG in the context of arrhythmias and hope that it occurs that day and can be recorded on the recorder. It will be offered to you mainly because there has been no alternative for decades, all practices are well equipped with it and there is good health insurance reimbursement for the doctor.
Here’s a tip: either have the “marking button” shown on the device in order to mark the exact moment of the (subjectively perceived) arrhythmia for the doctor (“this was exactly where my problem was”) – so everything can be clearly assigned in the ECG – or you can write down a mini log and record exactly what time the problem occurred. Then you can later compare it with the timeline of the recording and see what exactly was visible in the ECG at time X. However, if an arrhythmia could not be recorded on the 24-hour ECG because, for example, it only occurs once a month (and such cases are unfortunately the majority), then you should not stop the investigation here, but rather actively move the matter forward . But how?
Alternatives to the 24-hour ECG
That depends on how long the arrhythmia lasts, but also how often it occurs. We agreed above that if the frequency is 1x/week or less, a 24-hour ECG will most likely result in failure. A newer device is the so-called event recorder. Also about the size of a cell phone, it usually doesn’t require any wiring and can be rented for several weeks. So you always have it with you, whether in your coat, in your handbag or on your nightstand. Such devices are now also available for purchase as “home ECGs”. When the arrhythmia finally returns, the device is switched on and, depending on the system, an ECG is recorded over 30 seconds to 2 minutes using the hands or by placing it directly on the chest. It is advisable to hold still to prevent camera shake; if the arrhythmia lasts longer, several recordings should be made. Once you have everything safely in the box, the data will be sent to the doctor or the device will be returned and the doctor can now most likely correctly assign your arrhythmia and initiate the right therapy.
For arrhythmias that last longer than 20 minutes, you can consider going to the nearest doctor or outpatient clinic (if your circulation permits) to have an acute attack ECG recorded. If it is so bad that you no longer dare to go out, emergency services can be called. In all cases: have a copy of the ECG strip given to the cardiologist or at least take a photo of the ECG with your cell phone!
For arrhythmias that occur extremely rarely (for example, only once a year) and are associated with serious consequences (such as fainting spells – syncope – with head injuries), an implantable variant of the event recorder, called a loop recorder, may also be considered. The loop recorder is about the diameter of a pencil but only a third of its length. The device can then be pushed (“implanted”) into the subcutaneous fat through a mini-incision in the skin in the area of the heart. The loop recorder then sits there and continually records your heartbeat. If the arrhythmia has occurred, you can go to the clinic the next day and easily read the ECG at the time of the arrhythmia. If this is successful and the mechanism is clarified, the device can be easily removed again.
But there is also an easier way: the iWatch
In principle, the iWatch can replace all of these devices. Happy is the person who decided on an iPhone over the South Korean Android model when the time came. Because Apple is currently ahead here. But Huawei also offers a usable system.
What exactly is that about? For several years now, heart rate monitors have not only been a popular gadget for marathon runners, but are also used by almost all amateur athletes to extensively measure training and all sorts of other life situations and to map them using the GPS tool that is usually attached. There is hardly a situation in life in which we do not know exactly our pulse, be it in a deep sleep, at the supermarket checkout or while roller skating.
The pulse helps us with arrhythmias. However, there is no ECG on such heart rate monitors. But we need that. In addition to the optical pulse sensor (the green flashing light on the back of the watch – an app that is approved as a medical product), the iWatch now has 2 additional electrical sensors. One is also on the back of the watch, the other is in the “Digital Crown”, i.e. the brass rotary knob on the side of the iWatch. If you place the finger of your other hand there, the circuit closes and the watch produces an ECG of surprisingly good quality over 30 seconds. The app required for this is pre-installed on the watch (iWatch 4 and 5) or on the corresponding iPhone (model 6 or higher).
The ECG can be written at any time and as often as desired with virtually no delay. If you are satisfied with the recording, you can easily convert the data into a PDF and, if desired, send it immediately by email. The only requirement: you have to afford the watch (in addition to your iPhone) and of course you have to wear it at all times. This means you are independent of all recording devices and can take action yourself at any time if necessary. The app was actually developed for a specific cardiac arrhythmia called “atrial fibrillation,” which is common and mostly affects older people. This particular arrhythmia can most likely be recognized and diagnosed by the watch itself. This does not apply to other arrhythmias. But it does not matter. Once you have identified the problem, simply consult your doctor and will most likely be able to identify the arrhythmia and discuss treatment options.
Priv.Doz. Dr. Stefan Pfaffenberger is a specialist in internal medicine and cardiology, a specialist in all problems relating to the heart, circulation and blood pressure.
