Keeping the BEAT:
Advanced Treatment for Heart Arrhythmia
“For about a year, I had been short of wind and it was getting worse,” says Andrew Wahl, a retired electrician from Brandon, Wisconsin. The 70-year-old chalked it up to his asthma. Then last February, a couple of fainting spells landed him in an emergency room in Fond du Lac. There, testing confirmed a serious heart problem. “We’re sending you down to Froedtert,” Wahl remembers the doctor telling him. “You need them.”
His diagnosis? An arrhythmia. Abnormal heartbeat.
Arrhythmias affect millions of people in the United States, more than lung cancer, breast cancer and HIV. Most often it is harmless, but a certain kind of rhythm problem, ventricular arrhythmia, is the number one cause of sudden cardiac death. According to physicians at Froedtert & Medical College, arrhythmias are often undiagnosed and sometimes misdiagnosed. For many, the result is needless discomfort and worry. For some, it means going about unaware of a condition that could abruptly take their life.
There are two basic kinds of abnormal heart rhythm: Atrial rhythms originate in the two upper chambers of the heart (the atria). They account for roughly 80% of cases and are generally benign. Ventricular rhythms affect the two lower chambers of the heart (the ventricles). About 20% of arrhythmias fall into this group. These rhythm problems can be very serious.
“A Peculiar Organ”
When the heart is functioning normally, electrical impulses originating from special cells cause the heart to contract. The result, simply, is a heartbeat.
James Roth, MD, a Medical College of Wisconsin cardiologist and electrophysiologist, says rhythm problems occur when the normal electrical flow of the heart is altered. “The heart is a peculiar organ,” he says. “Each cell has the potential for electrical activity. Unlike most organs, all the cells in the heart are ‘wired together,’ so if a single cell fires prematurely, a wave will travel over the heart.” The result is rapid heartbeat. Abnormal electrical flow can also cause the heart to beat too slowly or beat in an irregular pattern.
Dr. Roth, who is director of the Froedtert & Medical College Arrhythmia Management Program, says many patients complain of palpitations. In most cases, he says, the rhythm is benign. “If you have an irregular rhythm, but your heart tests normally, it usually doesn’t get worse. If the symptoms don’t bother you, they aren’t a problem.”
Some patients are symptom-free, but are found to have a rhythm problem in the course of other cardiac exams. James Kleczka, MD, Medical College of Wisconsin cardiologist, and medical director of Cardiology Inpatient Services and Cardiac Intensive Care, says many general cardiology patients also have arrhythmias. “All of our patients are continuously monitored, so when a rhythm problem happens, it shows up immediately.”
In general, Dr. Roth says, if you have heart disease you should be concerned about any rhythm problem. Fainting, he adds, should always be evaluated. The combination is especially dangerous: “Anyone with a heart condition who passes out should go to the emergency room immediately.”
Easy to Miss, Often Simple to Diagnose
The signs of arrhythmia can be easy to miss. “It’s not unusual for somebody who has a rhythm disorder to be mislabeled as having panic attacks,” says Dr. Roth. “We have ‘healed’ some cases just by treating the abnormal rhythm — they were not panic attacks at all.”
Still, there is a real link between arrhythmias and the emotions. Earlier this year, a study reported in Circulation (a professional magazine for cardiologists) showed that hostile men were 30 percent more likely to develop a certain atrial arrhythmia than other men. Marilyn Ezri, MD, a Medical College of Wisconsin cardiologist and arrhythmia specialist, agrees stress can cause rhythm problems. Fatigue, she notes, can also signal the condition. “Doctors need to be tuned to the possibility that ‘lack of energy’ could be a rhythm problem, as opposed to just depression.”
Arrhythmia: A Family Affair
If there is a history of arrhythmia or sudden cardiac death in your family, talk about it with your doctor. According to James Roth, MD, screening could save you and other members of your family:
“I saw a woman about five years ago who had a cardiac arrest and was resuscitated. She had long QT syndrome (a heart rhythm disorder). It turned out her sister had died suddenly 10 years earlier and her father died suddenly at the age of 40. So, we screened the family. Through genetic testing, we identified two more people who had the condition.”
Lee Biblo, MD, Medical College of Wisconsin cardiologist, believes general practitioners are getting better at identifying potential rhythm problems. Besides palpitations and fainting, possible symptoms can include lightheadedness and dizziness. Doctors should also be aware of possible arrhythmias in children.
Diagnostic tools for arrhythmias are all non-invasive or minimally invasive. Some patients leave the hospital with a portable heart monitor — when you feel a symptom, you just press a button and the unit captures an EKG “snapshot.” Other patients go home wearing a Holter monitor that continuously records the heart’s rhythm for 24 hours. Still others undergo electrophysiologic (EP) testing. “EP testing is a catheter procedure that permits us to make measurements in the heart and actually reproduce the rhythms to figure out the rhythm problem,” says Dr. Roth. When the diagnosis is in, managing an arrhythmia becomes more straightforward.
If you suspect you have an arrhythmia, Dr. Roth has a very reassuring message. “For certain forms of heart disease, the best we can do is help patients manage the condition,” he says. “Heart rhythm problems, in contrast, are all treatable in one way or another and the success of treatment is very high.”
For benign rhythm problems, physicians normally try simple medications. In addition, keeping high blood pressure, high cholesterol and other conditions associated with heart disease under control can help prevent heart damage that leads to or exacerbates an arrhythmia.
If a rhythm doesn’t respond to simple medications or is life-threatening, doctors try to cure it with a procedure known as ablation. First, EP testing locates the tissue that is the source of the abnormal electrical impulse. Physicians then guide an electrode-tipped catheter into the heart and eliminate the source with a burst of radio frequency energy.
Until recently, it was hard to use ablation to cure very complex rhythm problems — those associated with heart disease or prior heart surgery. Now, Froedtert & Medical College arrhythmia specialists use a sophisticated technique called computerized electro-anatomical mapping. “With this system, we can cure rhythms associated with very advanced heart disease, and that’s a major advance,” says Dr. Roth.
The basic idea is to map the scars on a patient’s heart. Dr. Roth explains: “Rhythm problems from heart disease occur largely because of scar tissue. Whereas normal tissue conducts electrical impulses, scar tissue doesn’t. Impulses can’t go through scar tissue, they have to go around. Once an impulse travels around in a loop, it will keep looping around that area over and over again, perhaps at rates of several hundred beats per minute, and it won’t stop.”
Using a catheter probe, doctors take electrical readings throughout the heart chamber. When enough readings are collected, the system generates a 3D scar tissue map of the heart. Then it is simply a matter of using an ablation catheter to block off any loop pathways.
Implant Converts Lethal Event into Non-Event
Despite the advances, ablation is still not an option for some patients with significant heart disease. “In those cases, we use an implantable defibrillator,” says Dr. Roth. “It prevents the most serious complication, which is the possibility of dying suddenly.”
That is the complication Andrew Wahl faced when he was transported from Fond du Lac to Froedtert & Medical College last February. Following consultation and testing, his doctors decided he should have a defibrillator. After waiting two weeks for an infection to clear up, they implanted the device. Ideally, Wahl will never need it.
“Most of the time, a defibrillator does nothing but monitor the heart rhythm,” says Dr. Roth. If the heart accelerates to a dangerous rate, the device delivers a strong electrical shock. “The shock converts what would have been a life threatening or even lethal event into basically a non-event,” he says. “Patients might feel dizzy; they receive a shock, and within seconds they feel better.”
Roth says defibrillator events should be infrequent—occurring less than once a year.
Back in Action
With his brand-new defibrillator, Andrew Wahl is back home and almost as busy as ever. “My daughter and I went to the village rummage sale the other Saturday,” he relates. “Afterwards, she said, ‘You surprised me, you’re walking a lot better now and not running out of wind like you did last summer.’”
Wahl attributes his recovery to his implant, a healthier diet and taking things a bit easier. Recent activities include digging mud out of a ditch and building a large playhouse for his granddaughter. Although welding is now off limits, Wahl still keeps up with his main hobby, restoring antique tractors. “My wife and son frown on me using the big sledge hammer to loosen engine parts.”
“I didn’t realize how serious I was,” Wahl says, reflecting on his experience with arrhythmia. “All in all, if anybody were to ask me where they should go for anything serious, I would answer ‘Go to Froedtert.’”